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Stroke in Obstetric Patients: a Series of 34 Cases
Abstract Number: T 3
Abstract Type: Original Research
BACKGROUND: Stroke, a leading cause of maternal morbidity and mortality, is implicated in at least 6.3% of maternal deaths in the US and 10% of all maternal deaths in the UK. Although pregnancy-related stroke (PRS) appears to be increasing, there are few data on its risk factors, presentation, and outcomes.
METHODS: We conducted a billing data query and identified 34 patients with PRS from Massachusetts General Hospital (2000-2011). Pre-specified data elements were collected from patients’ medical records including demographics, co-morbidities, presentation, clinical trajectory, and outcomes.
RESULTS: Sixteen patients (17 events) suffered acute ischemic stroke. Subtypes included cardioembolic (8), cryptogenic (6), and arterial dissections (3). Risk factors included patent foramen ovale (6), diabetes mellitus (3), prothrombotic mutations (3), central venous sinus thrombosis (1), and hypertension (4). Five acute ischemic stroke patients had preeclampsia; four were severe. Half (8/16) of the ischemic stroke patients came to medical attention > 4.5 hrs after symptom onset, outside of the traditional window for intravenous tissue plasminogen activator treatment; none received this therapy. Presenting symptoms included headache (10), focal neurologic deficits (11), and aphasia (6). Nine occurred in the antenatal period and six occurred postpartum. One death occurred in this group, and six were discharged to rehabilitation facilities. Hemorrhagic stroke occurred in 18 patients with intracerebral hemorrhage (7) and/or subarachnoid hemorrhage (11) (2 aneurysms, 2 arteriovenous malformations, and 1 posterior reversible encephalopathy syndrome). The overall median presenting blood pressure was 144/84 (7 had SBP>150 mmHg, 3 had DBP>105mmHg). 4/18 hemorrhagic stroke patients had preeclampsia, and median presenting blood pressure was 160/77. The majority (13/18) of these patients presented in the postpartum period. Headache severity and frequency were higher in this cohort compared to ischemic stroke. Hemorrhagic stroke patients had longer average intensive care unit and overall lengths of hospital stay (6.8d vs. 3.5d and 14d vs. 11d, respectively). There were no deaths in the hemorrhagic group.
CONCLUSION: Our review of 34 patients with PRS suggested importance for earlier diagnosis and consideration of thrombolytic therapy in obstetric patients with ischemic stroke. Hemorrhagic stroke patients demonstrated a propensity for post-partum presentation. Median presenting blood pressure in patients with hemorrhagic stroke was 144/84 and 160/77 in those with co-existing preeclampsia. Prompt recognition and treatment of PRS could potentially reduce the incidence of such cases.
1. Berg CJ, et al. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol 2010;116:1302-1309
2. De Keyser, et al. Intravenous Alteplase for Stroke: Beyond the Guidelines and in Particular Clinical Situations. Stroke 2007;38:2612-8