Infections and Risk of Peripartum Stroke During Delivery Admissions

Pregnancy, delivery and neonatal outcomes in women with a cerebrovascular-accident history prior to delivery - Evaluation of a population database

Objective

Cerebrovascular accidents (CVA) in childbearing-age women are rare. We aimed to evaluate the association between CVA events prior to delivery and obstetrical and neonatal outcomes.

Methods

A retrospective cohort study was conducted using data from the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS) database. All pregnant women who delivered or had a maternal death in the US from 2004 to 2014 were included in the study. We performed a comparison between women with an ICD-9 diagnosis of CVA before the delivery admission and those without. Obstetrical and neonatal outcomes were compared between the two groups.

Results

In total, 9,096,788 women fulfilled the inclusion criteria. Among them, 695 women (7.6 per 100,000) were diagnosed with a CVA before delivery. Women with a history of CVA, compared to those without, were more likely to be Black, older than 35 years of age, and suffer from obesity, chronic hypertension, pregestational diabetes, and thyroid disease. Patients with a prior CVA, compared to those without, had higher rates of pregnancy-induced hypertension (aOR 6.41, 95% CI 5.03-8.39, p < 0.001), preeclampsia (aOR 7.65, 95% CI 6.03-9.71, p < 0.001), and eclampsia (aOR 171.56, 95% CI 124.63-236.15, p < 0.001). Additionally, they had higher rates of preterm delivery (aOR 1.72, 95% CI 1.33-2.22,p = 0.003), cesarean section (aOR 2.69, 95% CI 2.15-3.37, p < 0.001), and maternal complications such as a peripartum hysterectomy (aOR 11.62, 95% CI 5.77-23.41, p < 0.001), postpartum hemorrhage (aOR 3.39, 95 % CI 2.52-4.54, p < 0.001), disseminated intravascular coagulation (aOR 16.32, 95% CI 11.33-23.52, p < 0.001), venous thromboembolism (aOR 45.08, 95% CI 27.17-74.8, p < 0.001), and maternal death (aOR 486.11, 95% CI 307.26-769.07, p < 0.001). Regarding neonatal outcomes, patients with a prior CVA, compared to those without, had a higher rate of intrauterine fetal demise and congenital anomalies.

Conclusion

Women with a CVA event before delivery have a significantly higher incidence of maternal complications, including hypertensive disorders of pregnancy, and neonatal complications, such as intrauterine fetal demise and congenital anomalies. Rates of maternal death were dramatically increased, and this association requires further evaluation.

Stroke vs. Preeclampsia: Dangerous Liaisons of Hypertension and Pregnancy

Stroke during pregnancy and preeclampsia are two distinct but interrelated medical conditions, sharing a common denominator-blood control failure. Along with cardiovascular diseases, diabetes, dyslipidemia, and hypercoagulability, hypertension is undoubtedly a major risk factor associated with stroke. Even though men have higher age-specific stroke rates, women are facing higher life-long stroke risk, primarily due to longer life expectancy. Sex hormones, especially estrogen and testosterone, seem to play a key link in the chain of blood pressure control differences between the genders. Women affected with stroke are more susceptible to experience some atypical stroke manifestations, which might eventually lead to delayed diagnosis establishment, and result in higher morbidity and mortality rates in the population of women. Preeclampsia is a part of hypertensive disorder of pregnancy spectrum, and it is common knowledge that women with a positive history of preeclampsia are at increased stroke risk during their lifetime. Preeclampsia and stroke display similar pathophysiological patterns, including hypertension, endothelial dysfunction, dyslipidemia, hypercoagulability, and cerebral vasomotor reactivity abnormalities. High-risk pregnancies carrying the burden of hypertensive disorder of pregnancy have up to a six-fold higher chance of suffering from stroke. Resemblance shared between placental and cerebral vascular changes, adaptations, and sophisticated auto-regulatory mechanisms are not merely coincidental, but they reflect distinctive and complex cardiovascular performances occurring in the maternal circulatory system during pregnancy. Placental and cerebral malperfusion appears to be in the midline of both of these conditions; placental malperfusion eventually leads to preeclampsia, and cerebral to stoke. Suboptimal performances of the cardiovascular system are proposed as a primary cause of uteroplacental malperfusion. Placental dysfunction is therefore designated as a secondary condition, initiated by the primary disturbances of the cardiovascular system, rather than an immunological disorder associated with abnormal trophoblast invasion. In most cases, with properly and timely applied measures of prevention, stroke is predictable, and preeclampsia is a controllable condition. Understanding the differences between preeclampsia and stroke in pregnancy is vital for healthcare providers to enhance their clinical decision-making strategies, improve patient care, and promote positive maternal and pregnancy outcomes. Management approaches for preeclampsia and stroke require a multidisciplinary approach involving obstetricians, neurologists, and other healthcare professionals.

Stroke Around Pregnancy; Protection and Prevention!

As per recent studies, incidence of stroke is increasing in pregnant women. It is essential to be vigilant and well-versed in managing stroke in pregnancy, as both the mother and the baby are prone to stroke-related injury. In this viewpoint article, we have reviewed the current data from research publications on the incidence, prevalence, risk factors, and clinical presentation of stroke in pregnancy. Finally, we have discussed the plan of investigations and the current treatment guidelines for stroke in pregnancy.

Pregnancy-Related Stroke: A Review

Importance

The maternal risk of strokes in the United States is approximately 30/100,000 pregnancies, and strokes are the eighth leading cause of maternal death. Because of the relationship between stroke and significant neurological disability/maternal death, obstetrical health care providers must be able to identify, evaluate, diagnosis, and treat these women.

Evidence Acquisition

PubMed was searched using the search terms "stroke" OR "cerebrovascular accident" OR "intracranial hemorrhage" AND "pregnancy complications" OR "risk factors" OR "management" OR "outcome." The search was limited to the English language and was restricted to articles from 2000 to 2020.

Results

There were 319 abstracts identified, and 90 of the articles were ultimately used as the basis of this review. Presenting stroke signs and symptoms include headache, composite neurologic defects, seizures, and/or visual changes. Diagnosis is typically made with computed tomography scan using abdominal shielding or magnetic resonance imaging without contrast. Management options for an ischemic stroke include reperfusion therapy with intravenous recombinant tissue plasminogen activator catheter-based thrombolysis and/or mechanical thrombectomy. Hemorrhagic strokes are treated similarly to strokes outside of pregnancy, and that treatment is based on the severity and location of the hemorrhage.

Conclusions and Relevance

Early recognition and management are integral in decreasing the morbidity and mortality associated with a stroke in pregnancy.

Relevance Statement

This study was an evidence-based review of stroke in pregnancy and how to diagnose and mange a pregnancy complicated by a stroke.

Stroke in Pregnancy: A Multidisciplinary Approach

Pregnancy confers a substantially increased risk of stroke, especially during the third trimester and until 6 weeks postpartum. Hypertensive disorders of pregnancy and gestational hypercoagulability are important contributors to obstetric stroke. Preeclampsia and eclampsia confer risk for future cardiovascular disease. Hemorrhagic stroke is the most common type of obstetric stroke. Ischemic stroke can result from cardiomyopathy, paradoxical embolism, posterior reversible encephalopathy, reversible cerebral vasoconstriction syndrome, and dissections. Cerebral venous sinus thrombosis is a frequent complication of pregnancy.

Stroke associated with Mycoplasma hominis infection: a case report

BACKGROUND

Mycoplasmas are the smallest prokaryotic microorganisms in nature. Many cases of stroke post-Mycoplasma pneumoniae infection have been reported, particularly in the pediatric population. However, Mycoplasma hominis infection has not previously been associated with stroke.

CASE PRESENTATION

We report the case of a 36-year-old Greek woman who presented with an extensive stroke with an unspecified cause. She had a concurrent genital infection with Mycoplasma hominis for an unknown duration.

CONCLUSION

An association may exist between stroke and the immune response to Mycoplasma hominis infection.

Stroke in Pregnancy and Puerperium: Validated Incidence Trends With Risk Factor Analysis in Finland 1987-2016

OBJECTIVE

To investigate whether previously reported increasing incidence of pregnancy-associated stroke (PAS) is observed in chart-validated register data in Finland. In an exploratory analysis, we studied risk factors for PAS.

METHODS

We performed a retrospective population-based cohort study and nested case-control study in Finland from 1987 to 2016. The Medical Birth Register (MBR) was linked to the Hospital Discharge Register to identify women with incident stroke (ischemic stroke, cerebral venous thrombosis, intracerebral or subarachnoid hemorrhage) during pregnancy or puerperium. Cases were verified from patient records. Incidence of PAS over the study period in 5-year age groups and pregnancy/postpartum period was calculated per number of deliveries. Three matched controls were selected for each case from MBR to compare risk factors.

RESULTS

After chart review, 29.6% (257 of 868) of cases were PAS. The incidence of PAS was 14.5 (95% confidence interval [CI] 12.8-16.3) per 100,000 deliveries. Incidence increased from 11.1 to 25.2 per 100,000 deliveries from 1987 to 1991 to 2012 to 2016 (p < 0.0001). Incidence increased by age from 9.8 to 29.9 per 100,000 deliveries from 20 to 24 years to >40 years of age (p < 0.0001). During the early postpartum period, incidence was 5-fold greater compared to the first trimester. Maternal mortality was 6.6%. In the multivariable-adjusted model, smoking beyond 12 gestational weeks (odds ratio [OR] 1.8, 95% CI 1.2-2.7), migraine (OR 16.3, 95% CI 5.3-49.8), and hypertensive disorders of pregnancy (OR 4.0, 95% CI 2.5-6.3) were the most important risk factors for PAS.

CONCLUSION

PAS incidence is increasing, stressing the importance of careful pregnancy surveillance and risk factor management, particularly in older expectant mothers and extending to puerperium.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that smoking beyond 12 gestational weeks, migraine, and hypertensive disorders of pregnancy are associated with an increased risk of PAS.

Maternal Stroke: A Call for Action

Maternal mortality rates have been steadily increasing in the United States, and cardiovascular mortality is the leading cause of death among pregnant and postpartum women. Maternal stroke accounts for a significant burden of cardiovascular mortality. Data suggest that rates of maternal stroke have been increasing in recent years. Advancing maternal age at the time of birth and the increasing prevalence of traditional cardiovascular risk factors, and other risk factors, as well, such as hypertensive disorders of pregnancy, migraine, and infections, may contribute to increased rates of maternal stroke. In this article, we provide an overview of the epidemiology of maternal stroke, explore mechanisms that may explain increasing rates of stroke among pregnant women, and identify key knowledge gaps for future investigation in this area.

Temporal Trends in Pregnancy-Associated Stroke and Its Outcomes Among Women With Hypertensive Disorders of Pregnancy

Background

Stroke is a serious complication of hypertensive disorders of pregnancy (HDP), with potentially severe and long‐term sequelae. However, the temporal trends, predictors, and outcomes of stroke in women with HDP at delivery remain unknown.

Methods and Results

All HDP delivery hospitalizations with or without stroke event (ischemic, hemorrhagic, or unspecified) between 2004 and 2014 in the United States National Inpatient Sample were analyzed to examine incidence, predictors, and prognostic impact of stroke. Of 4 240 284 HDP delivery hospitalizations, 3391 (0.08%) women had stroke. While the prevalence of HDP increased over time, incident stroke rates decreased from 10 to 6 per 10 000 HDP delivery hospitalizations between 2004 and 2014. Women with stroke were increasingly multimorbid, with some risk factors being more strongly associated with ischemic strokes, including congenital heart disease, peripheral vascular disease, dyslipidemia, and sickle cell disease. Delivery complications were also associated with stroke, including cesarean section (odds ratio [OR], 1.58; 95% CI, 1.33–1.86), postpartum hemorrhage (OR, 1.91; 95% CI, 1.33–1.86), and maternal mortality (OR, 99.78; 95% CI, 59.15–168.31), independently of potential confounders. Women with stroke had longer hospital stays (median, 6 versus 3 days), higher hospital charges (median, $14 655 versus $4762), and a higher proportion of nonroutine discharge locations (38% versus 4%).

Conclusions

The incidence of stroke in women with HDP has declined over time. While a relatively rare event, identification of women at highest risk of ischemic or hemorrhagic stroke on admission for delivery is important to reduce long‐term sequelae.

Stroke in Pregnancy: A Focused Update

Ischemic stroke (IS) and hemorrhagic stroke (HS) can be devastating complications during pregnancy and the puerperium that are thought to occur in approximately 30 in 100,000 pregnancies. In high-risk groups, such as women with preeclampsia, the incidence of both stroke subtypes, combined, is up to 6-fold higher than in pregnant women without these disorders. IS or HS may present in young women with atypical symptoms including headache, seizure, extremity weakness, dizziness, nausea, behavioral changes, and visual symptoms. Obstetric anesthesiologists who recognize these signs and symptoms of pregnancy-related stroke are well positioned to facilitate timely care. Acute stroke of any type is an emergency that should prompt immediate coordination of care between obstetric anesthesiologists, stroke neurologists, high-risk obstetricians, nurses, and neonatologists. Historically, guidelines have not addressed the unique situation of maternal stroke, and pregnant women have been excluded from the large stroke trials. More recently, several publications and professional societies have highlighted that pregnant women suspected of having IS or HS should be evaluated for the same therapies as nonpregnant women. Vaginal delivery is generally preferred unless there are obstetric indications for cesarean delivery. Neuraxial analgesia and anesthesia are frequently safer than general anesthesia for cesarean delivery in the patient with a recent stroke. Potential exceptions include therapeutic anticoagulation or intracranial hypertension with risk of herniation. General anesthesia may be appropriate when cesarean delivery will be combined with intracranial neurosurgery.

Maternal Race/Ethnicity, Hypertension, and Risk for Stroke During Delivery Admission

Background

Racial disparities contribute to maternal morbidity in the United States. Hypertension is associated with poor maternal outcomes, including stroke. Disparities in hypertension might contribute to maternal strokes.

Methods and Results

Using billing data from the Healthcare Cost and Utilization Project's National Inpatient Sample, we analyzed the effect of race/ethnicity on stroke during delivery admission in women aged 18 to 54 years delivering in US hospitals from January 1, 1998, through December 31, 2014. We categorized hypertension as normotensive, chronic hypertension, or pregnancy‐induced hypertension. Adjusted risk ratios (aRRs) and 95% CIs were calculated using log‐linear Poisson regression models, testing for interactions between race/ethnicity and hypertensive status. A total of 65 286 425 women were admitted for delivery during the study period, of whom 7764 were diagnosed with a stroke (11.9 per 100 000 deliveries). Hypertension modified the effect of race/ethnicity (P<0.0001 for interaction). Among women with pregnancy‐induced hypertension, black and Hispanic women had higher stroke risk compared with non‐Hispanic whites (blacks: aRR, 2.07; 95% CI, 1.86–2.30; Hispanics: aRR, 2.19; 95% CI, 1.98–2.43). Among women with chronic hypertension, all minority women had higher stroke risk (blacks: aRR, 1.71; 95% CI, 1.30–2.26; Hispanics: aRR, 1.75; 95% CI, 2.32–5.63; Asian/Pacific Islanders: aRR, 3.62; 95% CI, 2.32–5.63). Among normotensive women, only blacks had increased stroke risk (aRR, 1.17; 95% CI, 1.07–1.28).

Conclusions

Pregnant US women from minority groups had higher stroke risk during delivery admissions, compared with non‐Hispanic whites. The effect of race/ethnicity was larger in women with chronic hypertension or pregnancy‐induced hypertension. Targeting blood pressure management in pregnancy may help reduce maternal stroke risk in minority populations.

Ischemic stroke and cerebral venous sinus thrombosis in pregnancy

Maternal ischemic stroke and cerebral venous sinus thrombosis (CVST) are dreaded complications of pregnancy and major contributors to maternal disability and mortality. This chapter summarizes the incidence and risk factors for maternal arterial ischemic stroke (AIS) and CVST and discusses the pathophysiology of maternal AIS and CVST. The diagnosis, treatment, and secondary preventive strategies for maternal stroke are also reviewed. Special populations at high risk of maternal stroke, including women with moyamoya disease, sickle cell disease, HIV, thrombophilia, and genetic cerebrovascular disorders, are highlighted.

Infection During Delivery Hospitalization and Risk of Readmission for Postpartum Stroke

Background and Purpose- Most cases of pregnancy-related ischemic stroke (IS) and hemorrhagic stroke (HS) occur postpartum. Infections have been identified as a trigger for strokes in young people and have been associated with strokes during delivery hospitalizations, but a temporal relationship has been difficult to establish. We hypothesized that infections diagnosed during a delivery admission would be associated with an increased risk of readmission for postpartum stroke. Methods- We conducted a retrospective cohort study using the Healthcare Cost and Utilization Project's National Readmissions Database from 2010 to 2014. Using weighted survey design Poisson regression analysis, we calculated adjusted risk ratios (aRR) and 95% CI for the association between infection during delivery admission and 30-day postpartum readmission for IS or HS. Results- Out of 17.2 million delivery admissions during the study period, 2128 were readmitted within 30 days for a stroke of any type. There were 1189 HS (intracerebral hemorrhage or subarachnoid hemorrhage) and 720 IS, and the remainder unspecified pregnancy-related stroke. Adjusting for age and comorbidities, women with delivery infections were at higher risk of readmission for postpartum stroke of any type (aRR, 1.19; 95% CI, 1.01-1.41). Women with infections had higher risk of readmission for postpartum IS (aRR, 1.75; 95% CI, 1.37-2.22), but not for postpartum HS (aRR, 0.96; 95% CI, 0.75-1.23). The effect of infection on 30-day IS readmission was larger in women without hypertensive disorders of pregnancy (aRR, 2.0; 95% CI, 1.55-2.69 in women without hypertensive disorders of pregnancy versus aRR, 1.47; 95% CI, 0.9-2.38 in women with hypertensive disorders of pregnancy, P value for interaction=0.09). Conclusions- Infection during delivery hospitalization was associated with increased risk of readmission for IS, but not HS, within 30 days postpartum, particularly in women without hypertensive disorders of pregnancy. Infection may play a role in triggering postpartum IS even in the absence of other risk factors.

Stroke in Pregnancy: An Update

Pregnancy confers a substantially increased risk of stroke in women. The period of highest risk of stroke is the peripartum/postpartum phase, coinciding with the highest risk for hypertensive disorders of pregnancy and peak gestational hypercoagulability. Hemorrhagic stroke is the most common type of obstetric stroke. Hypertensive disorders of pregnancy are important contributors to obstetric stroke and predispose women to premature cardiovascular disease. The rate of stroke associated with hypertensive disorders of pregnancy has increased in the United States. Other conditions associated with obstetric stroke include posterior reversible encephalopathy, reversible cerebral vasoconstriction syndrome, and cerebral venous sinus thrombosis.

Maternal Stroke: an Update

PURPOSE OF THE REVIEW

Maternal morbidity and mortality is rising in the USA, and maternal stroke is a major contributor. Here, we review the epidemiology, risk factors, and current recommendations for diagnosis and acute treatment of ischemic and hemorrhagic stroke during pregnancy and postpartum, focusing on recent evidence.

RECENT FINDINGS

The incidence of maternal stroke has risen in recent years, possibly due to increasing rates of hypertensive disorders of pregnancy. The risk of maternal stroke is highest in the peripartum and early postpartum period. Preeclampsia is highly associated with reversible cerebral vasoconstriction syndrome and posterior reversible encephalopathy syndrome and is also associated with long-term increased risk of stroke and vascular dementia. Hypertensive disorders of pregnancy, migraine, and infections are risk factors for maternal stroke. Limited data suggest that thrombolytics and endovascular reperfusion therapy are safe and effective in pregnant women with ischemic stroke, but few data are available regarding safety of thrombolytics in the postpartum period. New consensus guidelines are now available to assist with management of ischemic and hemorrhagic stroke in pregnancy. Many gaps remain in our understanding of maternal stroke. While risk factors have been identified, there are no prediction tools to help identify which women might be at highest risk for postpartum stroke and require closer monitoring. The risk of recurrent maternal stroke has not been adequately quantified, limiting clinicians' ability to counsel patients. The complex pathophysiology of preeclampsia and its effects on the cerebral vasculature require further targeted study. An increased focus on the prevention, recognition, and optimal treatment of maternal stroke will be critical to reducing maternal morbidity and mortality.

Pregnancy-associated stroke -a systematic review of subsequent pregnancies and maternal health

Background

Pregnancy-associated stroke is a rare but life-threatening event, with an estimated incidence of 30/100000 deliveries. Data on the risk of stroke recurrence and the risk of other adverse pregnancy outcomes are essential for adequate counselling and surveillance in subsequent pregnancies. The aim of this systematic review is to describe the implications of a pregnancy-associated stroke for the future health of these women.

Methods

We searched Ovid Medline, PubMed, Cochrane Library and CINAHL for articles published in 1980–2018. Articles including women with pregnancy-associated stroke and information on at least one of the following outcomes were included: 1) recurrence of stroke during subsequent pregnancy, 2) number and course of subsequent pregnancies and their outcomes and 3) subsequent cardiovascular health.

Results

Twelve articles were included in the review, with six providing information on subsequent pregnancies, four on subsequent maternal health and two on both. The included articles varied greatly in terms of study design, length of follow up and reported outcomes. We found 252 women with pregnancy-associated stroke for whom the outcomes of interest were reported: 135 women with information on subsequent pregnancies and 123 women with information on future health. In total, 55 pregnancies after stroke were found. In the majority of studies, the incidence of pregnancy complications was comparable to that of the general population. The risk of stroke recurrence during pregnancy was 2%. Data on subsequent health of these women were limited, and the quality of the data varied between the studies.

Conclusions

Data on subsequent pregnancies and health of women with a history of pregnancy-associated stroke are limited. Further research on this topic is essential for adequate counselling and secondary prevention.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2339-y) contains supplementary material, which is available to authorized users.

Age and Sex Are Critical Factors in Ischemic Stroke Pathology

Ischemic stroke is a devastating brain injury resulting in high mortality and substantial loss of function. Understanding the pathophysiology of ischemic stroke risk, mortality, and functional loss is critical to the development of new therapies. Age and sex have a complex and interactive effect on ischemic stroke risk and pathophysiology. Aging is the strongest nonmodifiable risk factor for ischemic stroke, and aged stroke patients have higher mortality and morbidity and poorer functional recovery than their young counterparts. Importantly, patient age modifies the influence of patient sex in ischemic stroke. Early in life, the burden of ischemic stroke is higher in men, but stroke becomes more common and debilitating for women in elderly populations. The profound effects of sex and age on clinical ischemic stroke are mirrored in the results of experimental in vivo and in vitro studies. Here, we review current knowledge on the influence of age and sex in the incidence, mortality, and functional outcome of ischemic stroke in clinical populations. We also discuss the experimental evidence for sex and age differences in stroke pathophysiology and how a better understanding of these biological variables can improve clinical care and enhance development of novel therapies.