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Absence of Hypertension at Presentation in Pregnancy-Related Stroke: Findings from a Large US Stroke Registry
Abstract Number: T-43
Abstract Type: Original Research
Background: Stroke accounts for 14% of maternal deaths. Our knowledge of the risk factors and etiologies of pregnancy-related stroke (PRS) is limited, as most data are derived from small, single center series or large, administrative datasets lacking clinical detail. We sought to identify the risk factors and stroke characteristics of PRS by analyzing the Get with the Guidelines® (GWTG) Stroke Registry.
Methods: GWTG-Stroke is a national, voluntary quality improvement program sponsored by the American Heart Association with over 1,700 participating hospitals and over 3 million patients enrolled. For this study, all women aged 18-44 in GWTG from 2008-2013 with PRS (defined as stroke in a woman who was pregnant or <6 weeks postpartum) were identified using a combination of medical history of pregnancy and ICD-9 codes. There were 58% identified by a principal ICD-9 diagnosis code of stroke (430, 431, 433.xx, 434.xx, 436) plus a medical history of pregnancy vs. 42% with a principal ICD-9 code for PRS (671.5x, 673.04, 674.0x). Proportions for categorical and medians for continuous variables are reported.
Results: We identified 46043 patients with stroke from 1554 sites, of whom 668 (1.5%) had PRS. There were 338 (51%) ischemic strokes (IS), 178 (27%) intracerebral hemorrhages (ICH) and 152 (23%) subarachnoid hemorrhages (SAH). Many patient and stroke characteristics differed significantly by stroke subtype (Table). Hypertension, smoking and pre-stroke therapy with antithrombotic or antihypertensive medications were common; 7.4% of IS were recurrent. About 86% of all strokes did not occur in a healthcare setting and only 27% of patients arrived by EMS. Median initial blood pressure (BP) was higher in ICH and SAH than in IS patients, and half of all patients had first-recorded post-stroke BP below the threshold for pre-eclampsia (140/90 mmHg). HS patients were more often treated at larger, academic hospitals.
Conclusions: PRS constituted 1.5% of all strokes among women aged 18-44 in a large contemporary stroke registry with roughly equal proportions of IS and HS. Most PRS occurred out of hospital, when pregnant or postpartum patients are usually not under direct medical observation. Despite the known link between hypertensive disorders of pregnancy and stroke, half of all cases presented with normal BP levels. Further research is needed to better define PRS etiology and the role of hypertension.