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Grand Rounds

Who is Most at Risk for Postpartum Stroke?

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BACKGROUND AND PURPOSE: 

  • The incidence of pregnancy-associated stroke 34/100,000 deliveries 
  • Although rare, admissions for pregnancy-associated stroke has increased 83% from 1994-1995 to 2005-2007 
  • ACOG recommends monitoring women with hypertensive diseases of pregnancy as follows 
    • For at least 72 hours postpartum AND 
    • 7-10 days after delivery or earlier if symptomatic  
  • Too et al. (Obstetrics & Gynecology, 2018) sought to assess associated risk factors and timing of postpartum stroke

METHODS: 

  • Retrospective cohort study  
  • Healthcare Cost and Utilization Project’s Nationwide Readmissions Database (2013 & 2014)  
  • Data collected on readmission for stroke within 60 days of discharge 
  • Risk was calculated using odds ratio (OR) with 95% CIs  
  • Using adjusted models for stroke readmission risk were created to odetermine  
    • Proportion of patients with stroke readmission diagnosed with hypertensive diseases of pregnancy on readmission but not during initial hospitalization 
    • Risk of stroke for patients with superimposed preeclampsia, mild preeclampsia, severe preeclampsia, and gestational hypertension 

RESULTS: 

  • Of the 6,272,136 patients included, 1505 were readmitted for postpartum stroke (24.0/100,000 deliveries, 95% CI 22.8–25.2)  
    • 214 (14.2%) cases of stroke occurred among patients with hypertensive diseases of pregnancy 
    • 66 (4.4%) with chronic hypertension  
    • 1,225 (81.4%) without hypertension 
  • When compared to women without a history of hypertension  
    • Hypertensive diseases of pregnancy were associated with increased risk of stroke (OR 1.74, 95% CI 1.33–2.27) 
    • Chronic hypertension was associated with an increased risk of stroke (OR 1.88, 95% CI 1.19–2.96) 
  • Other risk factors associated with maternal stroke included longer length of stay during the delivery hospitalization, cesarean delivery, pregestational diabetes, tobacco use, and Medicaid insurance vs private insurance
  • The majority of stroke readmission occurred within 10 days of discharge (58.4%) 
  • Median times to readmission  
    • 8.9 days for hypertensive diseases of pregnancy 
    • 7.8 days for chronic hypertension 
    • 8.3 days with neither of the above 

CONCLUSION: 

  • Patients with history of hypertensive diseases during pregnancy or chronic hypertensive diseases are at a higher risk of postpartum stroke 
  • Challenge to prevent stroke 
    • 80% of patients readmitted with stroke did not have a history of hypertension/preeclampsia during index hospitalization  
  • Majority of readmissions occurred within 10 days of discharge
  • Underlying mechanism for stroke risk unknown
    • May be secondary to BP elevation at 3–5 days after delivery secondary to fluid shifts along and impaired cerebral autoregulation
  • Results support immediate assessment of symptoms (e.g., headache or neurologic signs) 

Learn More – Primary Sources:  

Timing and Risk Factors of Postpartum Stroke 

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Related ObG Topics:

ASPRE Trial: A Combined Risk Algorithm and Use of Aspirin to Prevent Preterm Preeclampsia
Diagnosing Preeclampsia – Key Definitions and ACOG Guidelines
Aspirin Treatment for Women at Risk for Preeclampsia – ACOG, SMFM and USPSTF Recommendations
ACOG Guidance: Emergency Treatment for Severe Hypertension in Pregnancy
Are NSAIDs Associated with Persistent Postpartum Hypertension in Women with Preeclampsia?

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