Grand Rounds

Who is Most at Risk for Postpartum Stroke?

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

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

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

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)

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