Stroke and Cerebrovascular Disease in Pregnancy

Adverse Pregnancy Outcomes and Chronic Hypertension in the Era of Prevention: A Contemporary, Retrospective Cohort Study Using Data from the National Inpatient Sample Database

OBJECTIVE

 Chronic hypertension is a known risk factor for the development of preeclampsia and obstetrical morbidity. However, recent risk estimates, particularly in the era of use of low-dose acetylsalicylic acid for preeclampsia prevention, are lacking. This study aimed to estimate the association between chronic hypertension and preeclampsia and other adverse pregnancy outcomes in a contemporary cohort of births spanning the period, since the introduction of a low-dose acetylsalicylic acid protocol. The secondary outcome was to estimate trends in preeclampsia and preterm birth among patients with chronic hypertension during the study period.

STUDY DESIGN

 A retrospective, population-based cohort study was conducted using the National Inpatient Sample Database to identify individuals discharged from hospitals in the United States following obstetrical delivery from 2014 to 2019. Pregnancies complicated by chronic hypertension were identified using ICD 9/10 (International Classification of Diseases 9th and 10th editions) codes. Multivariable logistic regression models were used to estimate the adjusted odds ratios for the association between chronic hypertension and adverse pregnancy outcomes compared with pregnancies not complicated by chronic hypertension. Temporal trends in preeclampsia and preterm birth among patients with chronic hypertension were estimated over the study period.

RESULTS

 Among 4,451,667 obstetrical delivery-related admissions, 139,556 (3.1%) included pregnancies complicated by chronic hypertension. Of these, 27,146 (19.4%) admissions included pregnancies with superimposed preeclampsia, compared with 222,351 (5.2%) of admissions that included pregnancies with preeclampsia without prior diagnosis of chronic hypertension. Pregnancies complicated by chronic hypertension were associated with 3.29 times the odds of preeclampsia compared with pregnancies without chronic hypertension (95% confidence interval: 3.22-3.36), but the odds of preeclampsia (p-value for linear trend <0.0001) and preterm birth (p-value for linear trend = 0.0001) in this subgroup decreased over the study period.

CONCLUSION

 While the odds of preeclampsia are increased among pregnancies complicated by chronic hypertension, the odds of preeclampsia in this population have decreased over time.

KEY POINTS

· Pregnancies complicated by chronic hypertension are at significantly higher odds of preeclampsia.. · Recent guidelines have recommended low-dose acetylsalicylic acid for preeclampsia prevention in these pregnancies.. · In a nationwide cohort, the odds of preeclampsia among these pregnancies are decreasing over time..

Incidence and Predictors of Stroke in Australian Adults With Congenital Heart Disease (2000-2017)

BACKGROUND

Adults with congenital heart disease (CHD) are at increased risk of stroke but high-quality population level data on stroke incidence in these patients are scant.

METHODS AND RESULTS

A retrospective whole-population Western Australian cohort of adult patients with CHD aged 18 to 64 years was created and followed from January 2000 to December 2017 using linked hospital data. Stroke incidence rates within the adult cohort with CHD were calculated and compared with the general population via direct standardization. A nested case-control design assessed predictors of ischemic and hemorrhagic stroke within the cohort. Among 7916 adults with CHD, 249 (3.1%) incident strokes occurred at a median age of 47 years; 186 (2.3%) ischemic, 33 (0.4%) hemorrhagic and 30 (0.4%) unspecified strokes. Ischemic and hemorrhagic stroke incidence was, respectively, 9 and 3 times higher in adults with CHD than the general population. Absolute risk was low with annual rates of 0.26% (ischemic) and 0.05% (hemorrhagic). Highest rates were observed in adults with shunt and left-sided lesions. Predictors of ischemic stroke in adults with CHD included recent cardiac surgery, left-sided valve repair/replacements, shunt lesions, and traditional risk factors (hypertension, infective endocarditis, peripheral vascular disease, and tobacco use). Mental health disorders and increasing Charlson's comorbidity scores were strongly associated with higher risk of ischemic and hemorrhagic stroke. The CHA2DS2VASc score was associated with ischemic stroke incidence.

CONCLUSIONS

This study provides the first population-based stroke incidence estimates for adults with CHD in Australia, showing elevated stroke risk across different CHD lesions. It highlights the potential clinical importance of managing comorbidities, especially mental health.

Obstetric and perinatal outcomes in women with cerebrovascular accident vs. transient ischemic attack: an evaluation of a population database

PURPOSE

Cerebrovascular accidents (CVAs) and transient ischemic attacks (TIAs) are uncommon neurologic events in women of childbearing age. We aimed to compare pregnancy, delivery, and neonatal outcomes between women who suffered from a CVA and those who experienced a TIA.

METHODS

A retrospective population-based cohort study was performed using the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample. Included were all pregnant women who delivered or had a maternal death in the US between 2004 and 2014. We compared women with an ICD-9 diagnosis of a CVA before or during pregnancy to those diagnosed with a TIA before, during the pregnancy, or during the delivery admission. Pregnancy and perinatal outcomes were compared between the two groups, using multivariate logistic regression to control for confounders.

RESULTS

Among 9,096,788 women in the database, 898 met the inclusion criteria. Of them, 706 women (7.7/100,000) had a CVA diagnosis, and 192 (2.1/100,000) had a TIA diagnosis. Women with a CVA, compared to those with a TIA, had a higher rate of pregnancy-induced hypertension (aOR 3.82,95%CI 2.14-6.81, p < 0.001); preeclampsia (aOR 2.6,95%CI 1.3-5.2, p = 0.007), eclampsia (aOR 13.78,95% CI 1.84-103.41, p < 0.001); postpartum hemorrhage (aOR 4.52,95%CI 1.31-15.56, p = 0.017), blood transfusion (aOR 5.57,95%CI 1.65-18.72, p = 0.006), and maternal death (54 vs. 0 cases, 7.6% vs. 0%), with comparable neonatal outcomes.

CONCLUSION

Women diagnosed with a CVA before or during pregnancy had a higher incidence of myriad maternal complications, including hypertensive disorders of pregnancy, postpartum hemorrhage, and death, compared to women with a TIA diagnosis, with comparable neonatal outcomes, stressing the different prognoses of these two conditions, and the importance of these patients' diligent follow-up and care.

Pharmacotherapeutic options for the treatment of hypertension in pregnancy

INTRODUCTION

Hypertensive disorders of pregnancy affect approximately one in 10 pregnancies and are associated with increased risk of adverse fetal, neonatal and maternal outcomes. There is strong evidence that effective treatment of hypertension (blood pressure ≥ 140/90 mmHg), and enhanced monitoring throughout pregnancy reduces these risks.

AREAS COVERED

This article provides a contemporaneous review of treatment of hypertension in pregnancy with antihypertensive agents. We completed a systematic search and review of all meta-analyses and systematic reviews of studies comparing antihypertensives for treatment of pregnancy hypertension in the last five years. We provide a clinically focused summary of when to treat hypertension in pregnancy and which antihypertensive agents can be offered. Special scenarios reviewed include treatment-resistant hypertension and pre-pregnancy antihypertensive optimization.

EXPERT OPINION

Several antihypertensives are considered safe and are known to be effective for treatment of hypertension in pregnancy. Given the current uncertainty as to which antihypertensive(s) are superior for treatment of hypertension in pregnancy, women should be counselled and offered a range of antihypertensive options in keeping with evidence on clinical effectiveness, local context and availability of antihypertensive(s), potential side effect profile, and women's preference. Further research is required to help guide clinical decision making, and move toward personalized treatment.

Approach to Altered Mental Status in Pregnancy and Postpartum

The evaluation and diagnosis of altered mental status in the pregnant or postpartum patient largely parallels the approach used for any other patient; however, there are several critical differences including that some neuroobstetric diagnoses require emergent delivery of the fetus. Being familiar with the physiological changes and medical complications of pregnancy and delivery is therefore essential. This review first addresses pregnancy-specific disorders that may result in altered mental status, such as the hypertensive disorders of pregnancy and pregnancy-related metabolic and endocrinopathies. The focus then shifts to the complex physiologic changes in pregnancy and how these changes contribute to the distinct epidemiology of pregnancy-related cerebrovascular complications like intracranial hemorrhage, ischemic stroke, and reversible cerebral vasoconstriction syndrome. Medical disorders that are not unique to pregnancy, such as infections and autoimmune conditions, may present de novo or worsen during pregnancy and the peripartum period and require a thoughtful approach to diagnosis and management. Finally, the unique nervous system complications of obstetric anesthesia are explored. In each section, there is a focus not only on diagnosis and syndrome recognition but also on the emergent treatment needed to reverse these complications, bearing in mind the unique physiology of the pregnant patient.

Long-Term Mortality, Recovery, and Vocational Status After a Maternal Stroke: Register-Based Observational Case-Control Study

BACKGROUND AND OBJECTIVES

Maternal stroke is a rare event with an increasing incidence. Data on the long-term prognosis after a maternal stroke are limited. We aimed to examine long-term mortality, recovery, vocational status and morbidity after a maternal stroke in a population-based setting including a comparison with matched, stroke-free controls.

METHODS

In this register-based study with hospital chart validation, we included all women with a maternal stroke in Finland in 1987-2016 who survived the first year after the event. The recovery of the cases was assessed from the hospital charts by modified Rankin scale (mRS). Three controls matched by delivery year, age, and parity were selected for each case. All deaths until 2022 were identified from the Register for Causes of Death. Data on vocational status were obtained from Statistics Finland and morbidity from the Hospital Discharge Register and patient charts until year 2016.

RESULTS

The study included 235 women with a maternal stroke and 694 matched controls. The median follow-up time was 17.5 years (interquartile range [IQR] 9.6-25.4) for mortality and 11.8 years (IQR 3.8-19.8) for vocational status and subsequent morbidity. Mortality among cases was 5.5% and among controls, 2.4% (age-adjusted odds ratio [OR] 2.3, 95% [CI] 1.1-4.9). At the end of the follow-up, 90.3% of the cases were independent in daily activities (mRS ≤2). In 2016, fewer women with a maternal stroke were working compared with controls (65.9% vs 79.1%, OR 0.5, 95% CI 0.4-0.7) and were more often receiving a pension (18.2% vs 4.9%, OR 4.4, 95% CI 2.7-7.3). Cerebrovascular events (age-adjusted OR 8.6 95% CI 4.4-17.1), cardiac diseases (age-adjusted OR 3.3, 95% CI 1.4-7.7), and major cardiovascular events were more common among cases during the follow-up (age-adjusted OR 7.6 95% CI 3.1-18.7).

DISCUSSION

Despite having higher overall mortality and higher cardiovascular morbidity, the majority of the maternal stroke survivors recovered well. As expected, the vocational status of cases was inferior to that of controls, but most women were working at the end of the follow-up. Our study provides important information on the prognosis and sequalae after a maternal stroke to help in patient counseling and to improve secondary prevention.

Temporal changes in pre-existing health conditions five years prior to pregnancy in British Columbia, Canada, 2000-2019

BACKGROUND

Pre-existing health conditions increase the risk of obstetric complications during pregnancy and birth. However, the prevalence and recent changes in the frequency of pre-existing health conditions in the childbearing population remain unknown.

OBJECTIVES

To estimate the temporal changes in the prevalence of pre-existing health conditions among pregnant women in British Columbia, Canada.

METHODS

We carried out a population-based cross-sectional study of 825,203 deliveries in BC between 2000 and 2019 and examined 17 categories of physical and psychiatric health conditions recorded within 5 years before childbirth. We also undertook age-period-cohort analyses to evaluate temporal changes in pre-existing health conditions.

RESULTS

The prevalence of any pre-existing health condition was 26.2% (n = 216,214) with overall trends remaining stable during the study period. Between 2000 and 2019, the prevalence rates of anxiety (5.6%-9.6%), bipolar (1.6%-3.4%), psychosis (0.7%-0.8%), and eating disorders (0.2%-0.3%) increased. The prevalence of hypertension increased sharply from 0.06% in 2000 to 0.3% in 2019. Diabetes mellitus and stroke rates increased, as did the prevalence of systemic lupus, multiple sclerosis, and chronic kidney disease. Advanced maternal age was strongly associated with both psychiatric and circulatory/metabolic conditions. A strong birth cohort effect was evident, with rates of psychiatric conditions increasing among women born after 1985.

CONCLUSIONS

In British Columbia, Canada, 1 in 4 mothers had a pre-existing health condition 5 years prior to pregnancy. These findings underscore the need for multi-disciplinary care for women with pre-existing health conditions to improve maternal, foetal, and infant health.

The impact of sex on epidemiology, management, and outcome of spontaneous intracerebral hemorrhage (sICH)

OBJECTIVE

Data on sex differences in spontaneous intracerebral hemorrhages are limited.

METHODS

An automated comprehensive scoping literature review was performed using PubMed and Scopus. Articles written in English about spontaneous intracerebral hemorrhage and sex were reviewed.

RESULTS

Males experience spontaneous intracerebral hemorrhage more frequently than females, at younger ages, and have a higher prevalence of deep bleeds compared to females. Risk factors between sexes vary and may contribute to differing incidences and locations of spontaneous intracranial hemorrhage. Globally, females receive less aggressive care than males, likely impacting survival.

CONCLUSIONS

Epidemiology, risk factors, and treatment of spontaneous intracranial hemorrhage vary by sex, with limited and oftentimes conflicting data available. Further research into the sex-based differences of spontaneous intracranial hemorrhage is necessary for clinicians to better understand how to evaluate and guide treatment in the future.

Transient ischemic attack and pregnancy, delivery and neonatal outcomes-An evaluation of a population database

OBJECTIVE

Transient ischemic attack (TIA) is rare in women of reproductive age. We aimed to compare perinatal outcomes between women who suffered from a TIA to those who did not.

METHODS

A retrospective population-based cohort study utilizing the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS). All women who delivered or had a maternal death in the US (2004-2014) were included in the study. Pregnancy, delivery, and neonatal outcomes were compared between women with an ICD-9 diagnosis of a TIA to those without.

RESULTS

Overall, 9 096 788 women met the inclusion criteria. Of these, 203 women (2.2/100000) had a TIA (either before or during pregnancy). Women with TIA, compared to those without, were more likely to be older than 35 years of age, white, in the highest income quartile, be insured by private insurance and suffer from obesity and chronic hypertension. Patients in the TIA group, compared to those without, had a higher rate of pregnancy-induced hypertension (aOR 2.5, 95% CI: 1.55-4.05, P < 0.001), pre-eclampsia (aOR 3.77, 95% CI: 2.15-6.62, P < 0.001), eclampsia (aOR 28.05, 95% CI: 6.91-113.95, P < 0.001), preterm delivery (aOR 1.78, 95% CI: 1.03-3.07, P = 0.039), and maternal complications such as deep vein thrombosis (aOR 33.3, 95% CI: 8.07-137.42, P < 0.001). Regarding neonatal outcomes, patients with a TIA, compared to those without, had a higher rate of congenital anomalies (aOR 7.04, 95% CI: 2.86-17.32, P < 0.001).

CONCLUSION

Women with a TIA diagnosis before or during pregnancy had a higher rate of maternal complications, including hypertensive disorders of pregnancy and venous thromboembolism, as well as an increased risk of congenital anomalies.

Effects of prior reproductive losses on risk of cardiovascular diseases within six months of a first live birth

Objective

There is emerging evidence suggesting that pregnancy loss (induced or natural) is associated with an increased risk of cardiovascular diseases (CVD). This prospective longitudinal study investigates the effect of prior pregnancy losses on CVD risk during the first six months following a first live birth.

Methods

Medicaid claims of 1,002,556 low-income women were examined to identify history of pregnancy losses, CVD, diabetes, and hyperlipidemia prior to first live birth. The study population was categorized into five groups: A: women with no pregnancy loss or CVD history prior to first live birth; B: women with pregnancy loss and no CVD prior to first live birth. C: women with a first CVD diagnosis after a first pregnancy ending in a loss and before their first live birth. D: women with CVD prior to first live birth and no history of pregnancy loss. E: women with both CVD and pregnancy loss prior to their first live birth.

Results

After controlling for age, race, state of residence, and history of diabetes and hyperlipidemia, the risk of CVD in the six-month period following a first live birth were 15%, 214%, 79% and 129% more common for Groups B, C, D and E, respectively, compared to Group A.

Conclusions

Pregnancy loss is an independent risk factor for CVD risk following a first live birth, both for women with and without a prior history of CVD. The risk is highest when CVD is first diagnosed after a pregnancy loss and prior to a first live birth.

Severe maternal morbidity surveillance, temporal trends and regional variation: A population-based cohort study

OBJECTIVE

To quantify temporal trends and regional variation in severe maternal morbidity (SMM) in Sweden.

DESIGN

Cohort study.

POPULATION

Live birth and stillbirth deliveries in Sweden, 1999-2019.

METHODS

Types and subtypes of SMM were identified, based on a standard list (modified for Swedish clinical setting after considering the frequency and validity of each indicator) using diagnoses and procedure codes, among all deliveries at ≥22 weeks of gestation (including complications within 42 days of delivery). Contrasts between regions were quantified using rate ratios (RRs) and 95% confidence intervals (95% CIs). Temporal changes in SMM types and subtypes were described.

MAIN OUTCOME MEASURES

Types and subtypes of SMM.

RESULTS

There were 59 789 SMM cases among 2 212 576 deliveries, corresponding to 270.2 (95% CI 268.1-272.4) per 10 000 deliveries. Composite SMM rates increased from 236.6 per 10 000 deliveries in 1999 to 307.3 per 10 000 deliveries in 2006, before declining to 253.8 per 10 000 deliveries in 2019. Changes in composite SMM corresponded with temporal changes in severe haemorrhage rates, which increased from 94.9 per 10 000 deliveries in 1999 to 169.3 per 10 000 deliveries in 2006, before declining to 111.2 per 10 000 deliveries in 2019. Severe pre-eclampsia, eclampsia and HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome (103.8 per 10 000 deliveries), severe haemorrhage (133.7 per 10 000 deliveries), sepsis, embolism, disseminated intravascular coagulation, shock and severe mental health disorders were the most common SMM types. Rates of embolism, disseminated intravascular coagulation and shock, acute renal failure, cardiac complications, sepsis and assisted ventilation increased, whereas rates of surgical complications, severe uterine rupture and anaesthesia complications declined.

CONCLUSIONS

The observed spatiotemporal variations in composite SMM and SMM types provide substantive insights and highlight regional priorities for improving maternal health.

Evaluation of stroke in pregnant and non-pregnant women of reproductive years: A multicenter ambispective cohort study in a low- to middle-income country

Objective

Early recognition of stroke symptoms and risk factors is important for timely intervention to improve outcomes. This study aimed to investigate differences in stroke frequency, risk factors, and presentation in pregnant and non-pregnant women of reproductive years.

Methods

This multicenter ambispective cohort study, conducted from 4th August 2021 to 4th March 2023, examined strokes in women of reproductive years at the neurology outpatient/emergency department of five busiest/referred neuro-medical facilities in Karachi, Pakistan, where patients from across the nation are assessed. In all, 1210 patients were enrolled via consecutive or convenient sampling retrospectively from January 2017 to August 2021 and prospectively from August 2021 to March 2023. Pregnancy-related and non-pregnancy-related stroke occurrence and characteristics were compared using the chi-square/Fischer's exact test.

Results

56% were non-pregnancy-related strokes and 44% were pregnancy-related strokes with non-pregnancy-related strokes approximately equal throughout the reproductive years (15-24 years = 34%, 25-34 years = 25%, 35-45 years = 41%) and pregnancy-related stroke between 15 and 35 years (82%). In the non-pregnancy-related stroke, arterial stroke dominated (96.4%); while in pregnancy-related stroke, arterial stroke accounted for 61.4% and venous stroke for 38.6% of cases. Middle cerebral artery was a typical stroke site (66%). Infarction was the most significant CT/MRI finding (PRS = 89%, NPRS = 66%), with pregnancy-related stroke hemorrhagic stroke occurring in only 11% of cases and non-pregnancy-related stroke comprising one-third (34%). The most prevalent etiologies were eclampsia in pregnancy-related stroke (32%), hypertension in non-pregnancy-related stroke (40%), and cardiac problems among both groups (25%:33%). Weakness and headache were the common clinical manifestations among both groups. In the pregnancy-related and non-pregnancy-related stroke groups, the initial presentation of stroke resulted in severe disability for 91% and 75%, respectively. With timely treatment, the outcome improved significantly. The mortality rate was 7% for the pregnancy-related stroke group and 4% for the non-pregnancy-related stroke group.

Conclusions

Our findings show that stroke is prevalent among reproductive-year women, posing a significant mortality risk if not adequately recognized and treated. Awareness, research, and screening of stroke risk factors and their often-overlooked early presentation (i.e., headache and weakness) in reproductive years are essential to reducing stroke occurrence among reproductive-year women.

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.

Dynamic Prognosis Prediction for Patients on DAPT After Drug-Eluting Stent Implantation: Model Development and Validation

BACKGROUND

The rapid evolution of artificial intelligence (AI) in conjunction with recent updates in dual antiplatelet therapy (DAPT) management guidelines emphasizes the necessity for innovative models to predict ischemic or bleeding events after drug-eluting stent implantation. Leveraging AI for dynamic prediction has the potential to revolutionize risk stratification and provide personalized decision support for DAPT management.

METHODS AND RESULTS

We developed and validated a new AI-based pipeline using retrospective data of drug-eluting stent-treated patients, sourced from the Cerner Health Facts data set (n=98 236) and Optum's de-identified Clinformatics Data Mart Database (n=9978). The 36 months following drug-eluting stent implantation were designated as our primary forecasting interval, further segmented into 6 sequential prediction windows. We evaluated 5 distinct AI algorithms for their precision in predicting ischemic and bleeding risks. Model discriminative accuracy was assessed using the area under the receiver operating characteristic curve, among other metrics. The weighted light gradient boosting machine stood out as the preeminent model, thus earning its place as our AI-DAPT model. The AI-DAPT demonstrated peak accuracy in the 30 to 36 months window, charting an area under the receiver operating characteristic curve of 90% [95% CI, 88%-92%] for ischemia and 84% [95% CI, 82%-87%] for bleeding predictions.

CONCLUSIONS

Our AI-DAPT excels in formulating iterative, refined dynamic predictions by assimilating ongoing updates from patients' clinical profiles, holding value as a novel smart clinical tool to facilitate optimal DAPT duration management with high accuracy and adaptability.

Stroke risk in multiple sclerosis: a critical appraisal of the literature

Observational studies suggest that the occurrence of stroke on multiple sclerosis (MS) patients is higher compared to the general population. MS is a heterogeneous disease that involves an interplay of genetic, environmental and immune factors. The occurrence of stroke is subject to a wide range of both modifiable and non-modifiable, short- and long-term risk factors. Both MS and stroke share common risk factors. The immune mechanisms that underlie stroke are similar to neurodegenerative diseases and are attributed to neuroinflammation. The inflammation in autoimmune diseases may, therefore, predispose to an increased risk for stroke or potentiate the effect of conventional stroke risk factors. There are, however, additional determinants that contribute to a higher risk and incidence of stroke in MS. Due to the challenges that are associated with their differential diagnosis, the objective is to present an overview of the factors that may contribute to increased susceptibility or occurrence of stroke in MSpatients by performing a review of the available to date literature. As both MS and stroke can individually detrimentally affect the quality of life of afflicted patients, the identification of factors that contribute to an increased risk for stroke in MS is crucial for the prompt implementation of preventative therapeutic measures to limit the additive burden that stroke imposes.

Pregnancy-associated stroke and the recurrence of stroke and other complications in subsequent pregnancies: Population-based retrospective cohort study

OBJECTIVE

To examine the outcomes of the subsequent pregnancies from women with a previous pregnancy-associated stroke (PAS) in comparison to matched controls.

DESIGN

Population-based retrospective cohort study.

SETTING AND POPULATION

All women with a PAS in Finland 1987-2016 (n = 235) and controls (n = 694).

METHODS

We identified all subsequent deliveries and induced and spontaneous abortions for women with a previous PAS and their matched controls from the Medical Birth Register and the Hospital Discharge Register until 2016. The number, course and outcomes of the subsequent pregnancies were compared. Patient records were studied for PAS recurrence.

MAIN OUTCOME MEASURES

PAS recurrence and pregnancy complications.

RESULTS

Women with a previous PAS had fewer subsequent deliveries: 73 (31.1%) women had 122 deliveries in all, whereas 303 (47.3%) of the controls had 442 deliveries (age-adjusted odds ratio [OR] 0.54, 95% CI 0.38-0.76). Hypertensive disorders of pregnancy (HDP) (17.2% versus 5.7%, age-adjusted OR 4.0, 95% CI 1.7-9.3), especially chronic hypertension (age-adjusted OR 5.9, 95% CI 1.5-24.7), and any diabetes during pregnancy (24.6% versus 14.5%, age-adjusted OR 2.0, 95% CI 1.1-3.8) were more common in cases. Regarding HDP, the difference between groups was explained by underlying factors such as index pregnancy HDP (multivariable OR 2.4, 95% CI 0.8-6.7). PAS recurred in four cases (5.5%).

CONCLUSIONS

Subsequent pregnancies of women with a history of PAS are more often complicated with hypertensive disorders of pregnancy and any diabetes during pregnancy. PAS recurrence risk is considerable.

Acute headache in pregnant and post-partum patients: A clinical review

BACKGROUND

Headaches during pregnancy and the post-partum period may be due to either an exacerbation of a pre-existing neurological presentation, a new pregnancy-related process, or a non-pregnancy related condition. Key physiologic changes during pregnancy and the post-partum period contribute to the vulnerability of this patient population and the increased risk of complications.

OBJECTIVE OF THE REVIEW

Review causes of headaches in pregnant and post-partum patients as well as neuroimaging techniques performed.

DISCUSSION

Headaches are a common complaint for pregnant and post-partum patients. For pregnant patients, a range of serious causes must be considered including cerebral venous thrombosis, posterior reversible encephalopathy syndrome and stroke. Primary headaches are responsible for most post-partum headaches, however other causes also include pre-clampsia, cerebral venous thrombosis and post-dural headache. Determining the optimal imaging technique in this vulnerable population remains a challenge given the scarce guidelines.

CONCLUSION

The greatest difficulty while evaluating pregnant and post-partum patients presenting with an acute headache in an emergency setting is to determine whether the headache is due to a primary disorder such as migraines or is secondary to an underlying, sometimes serious pathology. The following review explores evidenced-based diagnosis of headache in this particular setting.

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.

Etiology and risk factors of ischemic stroke during pregnancy and puerperium: A population-based study

INTRODUCTION

Ischemic stroke (IS) is an uncommon, but potentially life-changing, complication of pregnancy. The aim of this study was to analyze the etiology and risk factors of pregnancy-associated IS.

PATIENTS AND METHODS

We collected a population-based retrospective cohort of patients diagnosed with IS during pregnancy or puerperium in Finland from 1987 to 2016. These women were identified by linking the Medical Birth Register (MBR) with the Hospital Discharge Register. Three matched controls were selected from MBR for each case. The diagnosis and temporal relationship of IS to pregnancy, and clinical details were verified from patient records.

RESULTS

A total of 97 women (median age 30.7 years) were identified as having pregnancy-associated IS. The most common etiologies based on TOAST classification were cardioembolism in 13 (13.4%), other determined in 27 (27.8%) and undetermined in 55 (56.7%) patients. Fifteen patients (15.5%) had embolic strokes of undetermined sources. The most important risk factors were pre-eclampsia, eclampsia, gestational hypertension, and migraine. IS patients had more frequently traditional and pregnancy-related stroke risk factors than the controls (OR 2.38, 95% CI 1.48-3.84) and the risk of IS multiplied with the number of risk factors (4-5 risk factors: OR 14.21, 95% CI 1.12-180.48).

DISCUSSION AND CONCLUSION

Rare causes and cardioembolism were frequent etiologies for pregnancy-associated IS, but in half of the women, the etiology remained undetermined. The risk of IS increased with the number of risk factors. Surveillance and counseling of pregnant women, especially with multiple risk factors, is crucial for the prevention of pregnancy-associated IS.

In-hospital outcomes and recurrence of stroke during pregnancy and puerperium

BACKGROUND

There are limited data regarding the best management and outcomes of acute stroke during pregnancy and the puerperium.

METHODS

Pregnancy-related hospitalizations with age > 18 years were identified from the Nationwide Readmissions Database 2016-2018. The study cohort consisted of all patients with acute stroke and a 5% random sample of the remaining non-stroke hospitalizations. Logistic regression and survival analyses were used to compare the in-hospital outcomes and readmissions in patients with and without acute stroke.

RESULTS

There were 11,829,044 pregnancy-related hospitalizations, of which 4057 had acute stroke. The mean ± SD age of the study cohort was 29.0 ± 5.7 years. Among patients with acute ischemic stroke, 60 (3.7%) patients received intravenous thrombolysis and 112 (6.8%) patients underwent endovascular thrombectomy. Among patients with intracranial hemorrhage, 205 (10.5%) patients underwent ventriculostomy and 18 (0.9%) patients underwent decompressive craniotomy. Patients with stroke had longer length of stay (mean: 10.7 vs 2.7 days), higher in-hospital mortality (4.6% vs 0.0001%) and were less likely to discharge home (73.0% vs 98.6%). Non-elective readmission within 90 days of discharge occurred in 14.8% of patients with stroke versus in 3.9% of patients without stroke. Readmissions due to cerebrovascular events occurred in 2.3% of patients with stroke versus in 0.007% of patients without stroke within 1 year of discharge, with mean ± SD time to readmission 66.2 ± 78.0 days.

CONCLUSION

Stroke is a serious complication of pregnancy, associated with high morbidity and mortality. Recurrence of stroke occurs in a small proportion of patients, and the risk is highest during the initial 3 months.

Identifying Targets to Improve the Management of Severe Hypertension in Pregnancy and Postpartum

OBJECTIVES

To 1) define quality indicators for severe hypertension (sustained systolic blood pressure [BP] ≥160 mm Hg or diastolic BP ≥110 mm Hg) management, 2) describe care gaps, and 3) identify process issues in severe hypertension management at our tertiary care centre.

METHODS

Pregnant and postpartum individuals diagnosed with a hypertensive disorder of pregnancy from 2018 to 2019 were identified. A retrospective cohort of patients with severe hypertension was constructed, and data were collected through chart review. Severe hypertension management was assessed according to defined quality indicators. Clinical characteristics were compared between participants with and without time-to-target BP within 60 minutes. Process issues were examined for each severe hypertension occurrence.

RESULTS

Of 608 participants with a hypertensive disorder of pregnancy, 90 (15%) experienced severe hypertension. Median time-to-target BP was 76 minutes (interquartile range 47-123 minutes), and target BP (<155/105 mm Hg) was achieved within 60 minutes in 31/90 (34%) participants. Appropriate antihypertensives for severe hypertension were used in 55/90 (61%), and time-to-treatment initiation was within 30 minutes in 42/54 (78%). Chronic hypertension and oral labetalol use were associated with delays in achieving target BP. Process issues related to severe hypertension management included inappropriate treatment (n=35/90; 39%), failure to recognize severe hypertension as an emergency (n=21/90; 23%), and delayed treatment initiation (n=12/54; 22%).

CONCLUSION

We defined quality indicators for severe hypertension management. Time-to-target BP within 60 minutes was achieved in a minority of patients, and chronic hypertension was associated with delayed severe hypertension resolution. Process issues in severe hypertension management were described.

Maternal Health Outcomes After Pregnancy-Associated Stroke: A Population-Based Study With 19 Years of Follow-Up

BACKGROUND

Pregnancy-associated stroke carries high short-term morbidity and mortality, but data on subsequent maternal outcomes are limited. We evaluated long-term maternal health outcomes after pregnancy-associated stroke.

METHODS

In this retrospective cohort study, we used administrative data to identify pregnant adults aged ≤49 years with stroke between 2002-2020 in Ontario, Canada and 2 comparison groups: (1) non-pregnant female patients with stroke and (2) pregnant patients without stroke. Patients who survived the index admission were followed until 2021. After propensity score matching, we used Cox regression with a robust variance estimator to compare pregnant patients with stroke and the 2 comparison groups for the composite outcome of death and all-cause non-pregnancy readmission. Where proportional hazard assumption was not met, we reported time-varying hazard ratios (HR) with 95% CIs by modeling the log-hazard ratio as a function of time using restricted cubic splines.

RESULTS

We identified 217 pregnant patients with stroke, 7604 non-pregnant patients with stroke, and 1 496 256 pregnant patients without stroke. Of the 202 pregnant patients with stroke who survived the index stroke admission, 41.6% (6.8 per 100 person-years) subsequently died or were readmitted during follow-up. Median follow-up times were 5 years (pregnancy-associated stroke), 3 years (non-pregnant stroke), and 8 years (pregnant without stroke). Pregnant patients with stroke had a lower hazard of death and all-cause readmission compared with non-pregnant patients with stroke at 1-year follow-up (HR, 0.64 [95% CI, 0.44-0.94]), but this association did not persist during longer-term follow-up. Conversely, pregnant patients with stroke had higher hazard of death and readmission compared with pregnant patients without stroke at 1-year follow-up (HR, 5.70 [95% CI, 3.04-10.66]), and this association persisted for a decade.

CONCLUSIONS

Stroke during pregnancy is associated with long-term health consequences. It is essential to transition care postpartum to primary or specialty care to optimize vascular health.

Preeclampsia and the Kidney: Pathophysiology and Clinical Implications

Preeclampsia and other hypertensive disorders of pregnancy are major contributors to maternal morbidity and mortality worldwide. This group of disorders includes chronic hypertension, gestational hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension, and eclampsia. The body undergoes important physiological changes during pregnancy to allow for normal placental and fetal development. Several mechanisms have been proposed that may lead to preeclampsia, including abnormal placentation and placental hypoxia, impaired angiogenesis, excessive pro-inflammatory response, immune system imbalance, abnormalities of cellular senescence, alterations in regulation and activity of angiotensin II, and oxidative stress, ultimately resulting in upregulation of multiple mediators of endothelial cell dysfunction leading to maternal disease. The clinical implications of preeclampsia are significant as there are important short-term and long-term health consequences for those affected. Preeclampsia leads to increased risk of preterm delivery and increased morbidity and mortality of both the developing fetus and mother. Preeclampsia also commonly leads to acute kidney injury, and women who experience preeclampsia or another hypertensive disorder of pregnancy are at increased lifetime risk of chronic kidney disease and cardiovascular disease. An understanding of normal pregnancy physiology and the pathophysiology of preeclampsia is essential to develop novel treatment approaches and manage patients with preeclampsia and hypertensive disorders of pregnancy. © 2023 American Physiological Society. Compr Physiol 13:4231-4267, 2023.

Stroke in Women: A Review Focused on Epidemiology, Risk Factors, and Outcomes

Stroke is a particularly important issue for women. Women account for over half of all persons who experienced a stroke. The lifetime risk of stroke is higher in women than in men. In addition, women have worse stroke outcomes than men. Several risk factors have a higher association with stroke in women than in men, and women-specific risk factors that men do not have should be considered. This focused review highlights recent findings in stroke epidemiology, risk factors, and outcomes in women.

Incidence and Time Trends of Pregnancy-Related Stroke Between 2010 and 2018: The Nationwide CONCEPTION Study

BACKGROUND AND OBJECTIVES

Despite the potentially devastating effects of pregnancy-related stroke, few studies have examined its incidence by type of stroke. We aimed to study the nationwide incidence rates and recent temporal trends for all types of pregnancy-related stroke and to compare these incidences with stroke incidence in nonpregnant women.

METHODS

We conducted a study of 6,297,698 women aged 15-49 years who gave birth in France between 2010 and 2018 with no history of stroke before pregnancy by collecting data from the French National Health Insurance Information System database. Poisson regression was used to estimate the incidence by types of strokes for the different pregnancy periods and the incidence rate ratio of stroke in pregnant vs nonpregnant French women.

RESULTS

Among the 6,297,698 women, 1,261 (24.0 per 100,000 person-years) experienced a first ever stroke during, antepartum peripartum, or the first 6 weeks of postpartum. Of the pregnancy-related strokes, 42.9% were ischemic (IS), 41.9% were hemorrhagic (with similar proportion of intracerebral and subarachnoid hemorrhage), and 17.4% were cerebral venous thrombosis (CVT). Compared with nonpregnant women, incidence rates of stroke were similar during pregnancy for IS (adjusted incidence risk ratio [IRR] 0.9 [0.8-1.1]), slightly higher for all hemorrhagic strokes (IRR 1.4 [1.2-1.8]), and considerably increased for CVT (IRR 8.1 [6.5-10.1]). Pregnancy-related stroke incidence rose between 2010 and 2018 for IS and HS but was stable for CVT.

DISCUSSION

The risk of pregnancy-related CVT was more than 8-fold higher than that observed in nonpregnant women. The incidence of pregnancy-related IS and HS is increasing over time, and efforts should be made for prevention considering treatable cardiovascular risk factors and hypertensive disorders in pregnant women.

An Opportunity to Better Address Hypertension in Women: Self-Measured Blood Pressure Monitoring

More than 56 million women in the United States have hypertension, including almost one in five women of reproductive age. The prevalence of hypertensive disorders of pregnancy is on the rise, putting more women at risk for adverse pregnancy-related outcomes and atherosclerotic cardiovascular disease later in life. Hypertension can be better detected and controlled in women throughout their life course by supporting self-measured blood pressure monitoring. In this study, we present some potential strategies for strengthening our nation's ability to address hypertension in women focusing on pregnancy-related considerations for self-measured blood pressure monitoring.

The Fourth Trimester: a Time for Enhancing Transitions in Cardiovascular Care

Purpose of Review

The "fourth trimester" concept, defined as the first 12 weeks after delivery (and beyond), is a critical window of time for clinicians to intervene to optimize women's cardiovascular health after pregnancy. A timely and comprehensive postpartum cardiovascular assessment should be performed in all women following delivery in order to (1) follow up medical conditions present prior to conception, (2) evaluate symptoms and signs of common postpartum complications, and (3) identify risk factors and prevent future adverse cardiovascular outcomes. In this review, we aim to discuss major maternal cardiovascular risk factors such as hypertensive disorders of pregnancy, gestational diabetes mellitus, postpartum weight retention, and postpartum depression, as well as lactation as a potential protective risk modifying factor. Additionally, we will review effectiveness of outpatient interventions to enhance transitions in cardiovascular care during the fourth trimester.

Recent Findings

A seamless hand-off from obstetric to primary care, and potentially cardiology, is needed for early detection and management of hypertension, weight, glycemic control, stress and mood, and long-term cardiovascular risk. Additionally, the use of telemedicine, blood pressure self-monitoring, remote activity monitoring, and behavioral health coaches are potentially feasible modalities to augment clinic-based care for cardiovascular risk factors and weight management, but additional studies are needed to study their long-term effectiveness.

Summary

Development of a comprehensive postpartum care plan with careful consideration of each patient's risk profile and access to resources is critical to improve maternal morbidity and mortality, reduce health disparities, and achieve long-term cardiovascular health for women. Supporting postpartum well-being of women during this transition period requires a multidisciplinary approach, especially primary care engagement, and planning should start before delivery.

Toward a Better Understanding of Sex- and Gender-Related Differences in Endovascular Stroke Treatment: A Scientific Statement From the American Heart Association/American Stroke Association

There are many unknowns when it comes to the role of sex in the pathophysiology and management of acute ischemic stroke. This is particularly true for endovascular treatment (EVT). It has only recently been established as standard of care; therefore, data are even more scarce and conflicting compared with other areas of acute stroke. Assessing the role of sex and gender as isolated variables is challenging because they are closely intertwined with each other, as well as with patients' cultural, ethnic, and social backgrounds. Nevertheless, a better understanding of sex- and gender-related differences in EVT is important to develop strategies that can ultimately improve individualized outcome for both men and women. Disregarding patient sex and gender and pursuing a one-size-fits-all strategy may lead to suboptimal or even harmful treatment practices. This scientific statement is meant to outline knowledge gaps and unmet needs for future research on the role of sex and gender in EVT for acute ischemic stroke. It also provides a pragmatic road map for researchers who aim to investigate sex- and gender-related differences in EVT and for clinicians who wish to improve clinical care of their patients undergoing EVT by accounting for sex- and gender-specific factors. Although most EVT studies, including those that form the basis of this scientific statement, report patient sex rather than gender, open questions on gender-specific EVT differences are also discussed.

Elevated cardiovascular disease risk in low-income women with a history of pregnancy loss

OBJECTIVE

Pregnancy is associated with elevated risk of cardiovascular diseases (CVD), but little is known regarding the association between CVD and specific types of pregnancy losses. The aim of this study is to investigate the effects of pregnancy loss on the risk of subsequent CVD of any type.

METHODS

This prospective longitudinal study examines medical records between 1999 and 2014 for Medicaid beneficiaries born after 1982 who lived in a state that funds all reproductive health services, including induced abortion. Unique pregnancy outcomes, history of diabetes, hyperlipidaemia or CVD (International Classification of Diseases, Ninth Revision (ICD-9): 401-459) prior to their first pregnancy outcome for each woman. Cumulative incidence rates of a first CVD diagnosis following a first pregnancy were calculated for the observed period, exceeding 12 years.

RESULTS

A history of pregnancy loss was associated with 38% (OR=1.38; 95% CI=1.37 to 1.40) higher risk of a CVD diagnosis in the period observed. After controlling for history of diabetes, hyperlipidaemia, age, year of first pregnancy, race, state of residence, months of eligibility, number of pregnancies, births, number of losses before and after the first live birth, exposure to any pregnancy loss was associated with an 18% (adjusted OR=1.18; 95% CI=1.15 to 1.21) increased risk of CVD. Our analyses also reveal an important temporal relationship between the CVD and pregnancy loss. Immediate and short-term increased CVD risk is more characteristic for women whose first pregnancy ended in live birth while a delayed and more prolonged increased risk of CVD is associated with a first pregnancy loss.

CONCLUSIONS

Our findings corroborate previous research showing that pregnancy loss is an independent risk factor for CVD, especially for diseases more chronic in nature. Our research contributes to understanding the specific needs for cardiovascular health monitoring for pregnant women and developing a consistent, evidence-based screening tools for both short-term and long-term follow-up.

Trends and outcomes for deliveries with hypertensive disorders of pregnancy from 2000 to 2018: A repeated cross-sectional study

OBJECTIVE

To analyse trends, risk factors, and outcomes related to hypertensive disorders of pregnancy (HDP).

DESIGN

Repeated cross-sectional.

SETTING

US delivery hospitalisations.

POPULATION

Delivery hospitalisations in the 2000-2018 National Inpatient Sample.

METHODS

US hospital delivery hospitalisations with HDP were analysed. Several trends were analysed: (i) the proportion of deliveries by year with HDP, (ii) the proportion of deliveries with HDP risk factors and (iii) adverse outcomes associated with HDP including maternal stroke, acute renal failure and acute liver injury. Risk ratios were determined using regression models with HDP as the exposure of interest.

MAIN OUTCOME MEASURES

Prevalence of HDP, risk factors for HDP and associated adverse outcomes.

RESULTS

Of 73.1 million delivery hospitalisations, 7.7% had an associated diagnosis of HDP. Over the study period, HDP doubled from 6.0% of deliveries in 2000 to 12.0% in 2018. The proportion of deliveries with risk factors for HDP increased from 9.6% in 2000 to 24.6% in 2018. In adjusted models, HDP were associated with increased stroke (aRR [adjusted risk ratio] 15.9, 95% CI 14.8-17.1), acute renal failure (aRR 13.8, 95% CI 13.5-14.2) and acute liver injury (aRR 1.2, 95% CI 1.2-1.3). Among deliveries with HDP, acute renal failure and acute liver injury increased; in comparison, stroke decreased.

CONCLUSION

Hypertensive disorders of pregnancy increased in the setting of risk factors for HDP becoming more common, whereas stroke decreased.

TWEETABLE ABSTRACT

While hypertensive disorders of pregnancy increased from 2000 to 2018, stroke appears to be decreasing.

Trends in the Incidence and Risk Factors of Pregnancy-Associated Stroke

Pregnancy is a female-specific risk factor for stroke. Although pregnancy-associated stroke (PAS) is a rare event, PAS leads to considerable maternal mortality and morbidity. It is estimated that 7.7–15% of all maternal deaths worldwide are caused by stroke and 30–50% of surviving women are left with persistent neurological deficits. During last decade, several studies have reported an increasing incidence of PAS. The objective of this review is to summarize studies on time trends of PAS in relation to trends in the prevalence of stroke risk factors in pregnant women. Seven retrospective national healthcare register-based cohort studies from the US, Canada, UK, Sweden, and Finland were identified. Five studies from the US, Canada, and Finland reported an increasing trend of PAS. Potential biases include more sensitive diagnostics and improved stroke awareness among pregnant women and professionals toward the end of the study period. However, the concurrent increase in the prevalence of several stroke risk factors among pregnant women, particularly advanced age, hypertensive disorders of pregnancy, diabetes, and obesity, indicate that the findings are likely robust and should be considered seriously. To reduce stroke in pregnancy, increased awareness among all medical specialties and pregnant women on the importance of risk-factor management during pregnancy and stroke symptoms is necessary. Important preventive measures include counseling for smoking cessation and substance abuse, treatment of hypertensive disorders of pregnancy, use of aspirin in women at high risk for developing preeclampsia, and antithrombotic medication and pregnancy surveillance for women with high-risk conditions. Epidemiological data from countries with a high risk-factor burden are largely missing. National and international registries and prospective studies are needed to increase knowledge on the mechanisms, risk factors, management, and future implications for the health of women who experience this rare but devastating complication of pregnancy.

The Impact of Sex and Gender on Stroke

Women face a disproportionate burden of stroke mortality and disability. Biologic sex and sociocultural gender both contribute to differences in stroke risk factors, assessment, treatment, and outcomes. There are substantial differences in the strength of association of stroke risk factors, as well as female-specific risk factors. Moreover, there are differences in presentation, response to treatment, and stroke outcomes in women. This review outlines current knowledge of impact of sex and gender on stroke, as well as delineates research gaps and areas for future inquiry.

Maternal Stroke Associated With Pregnancy

PURPOSE OF REVIEW

This article summarizes current knowledge of the epidemiology, pathophysiology, prevention, and treatment of cerebrovascular disease in pregnant and postpartum women.

RECENT FINDINGS

Stroke is a leading cause of maternal morbidity and mortality, and most fatal strokes are preventable. Adaptive physiologic changes of pregnancy, including hemodynamic changes, venous stasis, hypercoagulability, and immunomodulation, contribute to increased maternal stroke risk. The highest-risk time period for maternal stroke is the immediate postpartum period. Migraine and hypertensive disorders of pregnancy, including gestational hypertension and preeclampsia, are major risk factors for maternal stroke. Adverse pregnancy outcomes, including gestational hypertension, preeclampsia, preterm delivery, and fetal growth restriction, are important risk factors for cerebrovascular disease later in life.

SUMMARY

Many catastrophic maternal strokes could be avoided with targeted prevention efforts, early recognition of warning signs, and rapid evaluation of neurologic symptoms. Neurologists play a central role in the care of pregnant patients with cerebrovascular disease, whether acute or chronic, and should be familiar with the unique and complex physiology of pregnancy and its complications, particularly hypertensive disorders of pregnancy.

Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy: A Scientific Statement From the American Heart Association

Hypertensive disorders of pregnancy (HDP) remain one of the major causes of pregnancy-related maternal and fetal morbidity and mortality worldwide. Affected women are also at increased risk for cardiovascular disease later in life, independently of traditional cardiovascular disease risks. Despite the immediate and long-term cardiovascular disease risks, recommendations for diagnosis and treatment of HDP in the United States have changed little, if at all, over past decades, unlike hypertension guidelines for the general population. The reasons for this approach include the question of benefit from normalization of blood pressure treatment for pregnant women, coupled with theoretical concerns for fetal well-being from a reduction in utero-placental perfusion and in utero exposure to antihypertensive medication. This report is based on a review of current literature and includes normal physiological changes in pregnancy that may affect clinical presentation of HDP; HDP epidemiology and the immediate and long-term sequelae of HDP; the pathophysiology of preeclampsia, an HDP commonly associated with proteinuria and increasingly recognized as a heterogeneous disease with different clinical phenotypes and likely distinct pathological mechanisms; a critical overview of current national and international HDP guidelines; emerging evidence that reducing blood pressure treatment goals in pregnancy may reduce maternal severe hypertension without increasing the risk of pregnancy loss, high-level neonatal care, or overall maternal complications; and the increasingly recognized morbidity associated with postpartum hypertension/preeclampsia. Finally, we discuss the future of research in the field and the pressing need to study socioeconomic and biological factors that may contribute to racial and ethnic maternal health care disparities.

Severe hypertension in pregnancy

Severe hypertension in pregnancy is defined as a sustained systolic blood pressure of 160 mmHg or over or diastolic blood pressure of 110 mmHg or over and should be assessed in hospital. Severe hypertension before 20 weeks' gestation is rare and usually due to chronic hypertension; assessment for target organ damage and exclusion of secondary hypertension are warranted. The most common cause of severe hypertension in pregnancy is pre-eclampsia, which presents after 20 weeks' gestation. This warrants more rapid control of blood pressure due to the risk of haemorrhagic stroke, and intravenous antihypertensive agents may be required. Treatment is determined by licensing, availability and clinician experience, with no high-level evidence to guide prescribing. Labetalol is the agent most commonly used, both orally and intravenously, in pregnancy in the UK. Severe hypertension is a risk factor for sustained hypertension after pregnancy. Hypertension in pregnancy is associated with increased cardiovascular risk.

Stroke in COVID-19 and Pregnancy: A Case Report

Neurological manifestations add prognostic severity to the coronavirus disease (COVID-19). Here, we report a case of a pregnant patient with COVID-19 that progressed with neurological complications. Magnetic resonance imaging revealed cerebral ischemic insults associated with cortical laminar necrosis, in addition to an intraparenchymal brain hematoma. The mechanisms of vascular injury may have multifactorial origins and result in complex radiological presentations. Since stroke associated with pregnancy is one of the main causes of long-term disability in women, accurate identification of cerebrovascular events may potentially reduce sequelae.

Treatment and rehabilitation of stroke patients in India: A gendered analysis based on repeated cross-sectional national sample surveys on health, 2014 and 2019

We attempt a gendered inspection of sex differentials in care following stroke in India using data from two rounds of NSSO. While almost all men and women receive allopathic care, a higher percentage of women (51.8%) were treated in public hospitals compared to men (32.6%) in 2014 and 2017-18 (45.8% vs 41.4%). Men were preponderantly treated in private hospitals (67.4%) compared to women (48.2%) in 2014 and 2017-18 (58.6% vs 54.2%). We provide evidence that for rehabilitation, at the highest decile for expenditure, men spend more than women. This preliminary exploration is indicative of a gendered dimension in care-seeking for stroke.

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.

Team-Based Care of Women With Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 1/5

The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice. A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and delivery, and ensure close follow-up during the postpartum period when CVD complications remain common. The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should receive appropriate education and longitudinal follow-up.

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.

Stroke Incidence by Sex Across the Lifespan

BACKGROUND AND PURPOSE

We evaluated the influence of age on the association between sex and the incidence of stroke or transient ischemic attack (TIA) using a population-based cohort from Ontario, Canada.

METHODS

We followed a cohort of adults (≥18 years) without prior stroke from January 1, 2003 (cohort start date) to March 31, 2018, to identify incident events. We calculated hazard ratios (HRs), in women compared to men, of incident stroke or TIA, adjusted for demographics and comorbidities, overall and stratified by stroke type. We calculated piecewise adjusted HRs for each decade of age to evaluate the effect of age on sex differences in stroke incidence.

RESULTS

We followed 9.2 million adults for a median of 15 years and observed 280,197 incident stroke or TIA events. Compared with men, women had an overall lower adjusted hazard of stroke or TIA (HR, 0.82 [95% CI, 0.82-0.83]), with similar findings across all stroke types except for subarachnoid hemorrhage (HR, 1.29 [95% CI, 1.24-1.33]). We found a U-shaped association between age and sex differences in the incidence of stroke or TIA: compared with men, the hazard of stroke was higher in women among those aged ≤30 years (HR, 1.26 [95% CI, 1.10-1.45]), lower among those between ages 40 and 80 years (eg, age 50-59, HR, 0.69 [95% CI, 0.68-0.70]), and similar among those aged ≥80 years (HR, 0.99 [95% CI, 0.98-1.01]).

CONCLUSIONS

Overall, women have a lower hazard of stroke than men, but this association varies by age and across stroke types. Recognition of age-sex variations in stroke incidence can help guide prevention efforts to reduce stroke incidence in both men and women.

A maternal death due to the intracerebral hemorrhage caused by antiphospholipid syndrome: a case report

Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by the presence of antiphospholipid antibodies in patients with arterial or venous thrombosis or pregnancy complications. This paper reports a case of a 31-year-old woman who died after she underwent C-section for intrauterine fetal death (IUFD) at the 25th week of gestation. The patient was complaining of pelvic pressure, swelling in the lower limbs, and pain in the groin, one big toe, and both wrists. She had low platelet count, liver abnormalities, and proteinuria. After IUFD, she complained of flank pain and headache. After discharge from the hospital, the patient had constant headaches and 5 days later woke up with hemiplegia. CT scan showed cerebral hemorrhage in the right hemisphere and thrombosis in the left hemisphere. The LA and APS tests were positive. The main cause of death was hemorrhage and infarction in the brain.

Stroke in pregnancy

Stroke in pregnancy is rare and has a wide range of etiologies and implications on stroke management that differ from nonpregnant individuals. The highest risk of stroke is during the third trimester and puerperium period, where hypertensive disorders of pregnancy occur; however, stroke can occur at any point during pregnancy. In this chapter, we will provide an overview of the epidemiology of stroke in pregnancy and then review the specific etiologies of ischemic and hemorrhagic stroke as they relate to pregnant women. Finally, we discuss the process of acute stroke evaluation in pregnancy and the management of women after stroke with regard to long-term risk factors, medications, and implications in future pregnancies. Throughout the chapter, we highlight relevant guidelines from the American Heart Association and American Stroke Association and key literature on stroke in pregnancy.

The Effect of Exercise During Pregnancy on Maternal and Offspring Vascular Outcomes: a Pilot Study

The aim of this pilot study is to obtain estimates for the change in maternal cerebrovascular (primary) and offspring vascular structure (secondary) during healthy pregnancy that includes structured exercise. Eighteen pregnant women self-assigned to a moderate-intensity aerobic exercise intervention or a control group. Maternal cerebral blood flow (CBF) at the middle cerebral artery, cerebro- and peripheral-vascular function was assessed at the end of each trimester. Offspring carotid artery intima-media thickness (IMT) was measured within 12 weeks of birth. For exploratory purposes, we performed statistical analysis to provide estimates of the change for primary and secondary outcome variables. Maternal CBF reduced (− 8 cm s⁻¹ [− 14 to − 2]) with evidence of change to cerebral autoregulation (normalised gain: 0.12 %cm s⁻¹% mmHg⁻¹mmHg/% [− 0.18 to 0.40]) during pregnancy. Offspring carotid IMT was smaller in the exercise group (− 0.04 mm [− 0.12–0.03]) compared with controls. Based upon this data, a sample size of 33 and 57 in each group is required for low-frequency normalised gain and offspring IMT, respectively. This would provide 90% power to detect statistically significant (P < 0.05) between group differences in a randomised controlled trial. CBF is reduced in pregnancy, possibly due to reduced vascular resistance and altered maternal cerebral autoregulation. Maternal exercise had negligible effects on cerebrovascular adaptation to pregnancy, but we observed lower offspring carotid artery wall thickness following maternal exercise. Our directional findings and sample size estimations should be explored in a fully powered randomised control trial.

Clinical trial registration: The trial was registered on March 14th at https://register.clinicaltrials.gov (NCT03079258). Participant enrolment began on 3rd April 2016.