Pregnancy-Associated Stroke in Preeclampsia

Study Questions:

Which women with preeclampsia are at highest risk for pregnancy-associated stroke (PAS)?

Methods:

Women with preeclampsia were analyzed using billing data from the New York State Department of Health inpatient database (2003-2012). Women with and without PAS were matched 1:3 based on age, race/ethnicity, and insurance. Odds ratios were calculated for predefined PAS risk factors (pregnancy complications, vascular risk factors, prothrombotic states/coagulopathies, and infections that were present on admission).

Results:

Of 88,857 women with preeclampsia admitted to New York State hospitals, 197 (0.2%) had PAS. Risk factors associated with PAS in these women were: severe preeclampsia or eclampsia (odds ratio [OR], 7.2; 95% confidence interval [CI], 4.6-11.3), prothrombotic states (OR, 3.5; 95% CI, 1.3-9.2), coagulopathies (OR, 3.1; 95% CI, 1.3-7.1), infections present on admission (OR, 3.0; 95% CI, 1.6-5.8), or chronic hypertension (OR, 3.2; 95% CI, 1.8-5.5).

Conclusions:

Women with preeclampsia are at increased risk for PAS if they also have infections, chronic hypertension, coagulopathies, or underlying prothrombotic conditions.

Perspective:

The rarity of PAS (34.2 per 100,000 deliveries) makes it a difficult condition to study. This observational study only included women with preeclampsia, accounting for about 36% of women who have PAS. Among these women, hypercoagulable states and hypertension were additive risk factors. The presence of genitourinary infection was also associated with PAS; however, in this retrospective analysis, it is impossible to be certain that the infection preceded the stroke. Urinary tract infections are common during pregnancy. Whether treating this modifiable risk factor would have a meaningful impact on the rare occurrence of PAS has yet to be studied. Other risk factors for PAS include valvular heart disease, heart failure, and congenital heart disease, which also warrant careful management during pregnancy. Although rare, PAS in young mothers can be devastating. Increased awareness, identification of risk factors, and interventions aimed at prevention are needed.


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