Stroke and pregnancy: etiology, timing and outcome

Background and goal

Most previous studies on stroke during pregnancy have mainly focused on incidence and risk factors. These studies have not reported details of etiology and stroke outcome. The present study focuses on the evaluation of the etiology, timing and outcome of stroke occurring during pregnancy.

Materials and methods

We conducted a retrospective analysis on all obstetric patients who have been diagnosed with stroke during pregnancy or within 8 weeks postpartum. These patients were transferred to our multidisciplinary ICU between January 1996 and December 2004. All patients were investigated with a CT scan of the brain, and MRI and/or cerebral angiography.

Results

Eighty-eight patients were included, 34 of them were excluded (incomplete investigations or nonstroke diagnosis: reversible leucoencephalopathy, cerebral abscess, etc.). Fifty-four patients with a diagnosis of stroke were identified: 30 patients with ischemic stroke (IS) and 24 patients with hemorrhagic stroke (HS). The majority of events (45 patients, 83%) occurred in the third trimester and postpartum period (P = 0.02). A specific cause was identified in 24 patients (80%) of IS and in 21 patients (87%) of HS. Causes of IS include preeclampsia/eclampsia in 11 patients, venous thrombosis and coagulopathies (deficiencies of protein C, protein S, and activated protein C resistance) in nine patients, valvular heart disease with history of prior stroke in four patients and six patients had no definable cause. The major causes of HS were preeclampsia/eclampsia in eight patients, four patients presented with hemorrhage secondary to aneurysmal rupture, three patients presented with bleeding from arterio-venous malformations (AVM), bleeding as a consequence of disseminated intravascular coagulation (DIC) occurred in two patients and seven patients had hemorrhagic events of unknown origin. Hypertensive disorders of pregnancy were the most common comorbid conditions (32%).

Nineteen deaths (35%) occurred in our study, eight patients with infarction and 11 patients with hemorrhage. Thirty-one patients left the hospital with neurologic deficits, requiring chronic care or rehabilitation.

Discussion and conclusion

The results of the present study complement the findings of previous studies on timing of stroke in pregnancy [1, 2]. We found that preeclampsia/eclampsia and intracranial vascular malformations were the major causes of stroke in pregnancy, which agrees with other findings [2, 3]. Our study shows a high mortality rate of 35%, which indicates that careful management of at-risk patients during the first postpartum weeks is warranted.