Cerebrovascular disorders complicating pregnancy
- Men-Jean Lee, MD
Men-Jean Lee, MD
- Associate Professor
- University of Hawaii
- Susan Hickenbottom, MD, MS
Susan Hickenbottom, MD, MS
- Adjunct Associate Professor of Neurology
- University of Michigan
- Section Editors
- Jose Biller, MD, FACP, FAAN, FAHA
Jose Biller, MD, FACP, FAAN, FAHA
- Section Editor — Stroke
- Professor of Neurology and Neurological Surgery
- Chairman Department of Neurology
- Loyola University Chicago
- Stritch School of Medicine
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
Cerebrovascular disease during pregnancy can be distilled into two major categories: thrombosis/ischemia (including arterial and venous infarction) and hemorrhage (including intracerebral and subarachnoid hemorrhage). Normal physiologic changes associated with pregnancy, combined with pathophysiologic processes unique to pregnancy, predispose women to develop stroke during pregnancy and the puerperium.
This topic review will focus on the relationship between pregnancy and cerebrovascular disorders. Other neurologic disorders complicating pregnancy are discussed separately. (See "Neurologic disorders complicating pregnancy".)
Pregnant or recently pregnant women develop stroke (incidence 11 to 34 per 100,000 deliveries) more frequently than their nonpregnant counterparts (annual incidence, 10.7 per 100,000 women of reproductive age) [1-3]. Approximately 10 percent of strokes occur in the antepartum period, 40 percent occur proximate to delivery, and 50 percent occur postpartum and after discharge . Although data are inconsistent, the incidence of stroke during the antenatal period alone, excluding stroke during the puerperium, may be similar to the incidence in nonpregnant women of childbearing age .
Taken together, pregnancy and the postpartum period are associated with a marked increase in the relative risk and a small increase in the absolute risk of ischemic stroke and intracerebral hemorrhage, with the highest risk during the puerperium [2,5-9]. This was illustrated in a review of female hospital discharges from central Maryland and Washington, DC in 1988 and 1991 that determined the magnitude of the effect of pregnancy (including spontaneous and induced abortions) on stroke risk . The following observations were made:
●For cerebral infarction, the relative risk was 0.7 during pregnancy (a nonsignificant difference) but increased to 8.7 in the postpartum period (within six weeks of a live birth or stillbirth).
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- Risk factors
- Preeclampsia, eclampsia, and HELLP
- Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome
- Postpartum angiopathy
- Cerebral venous thrombosis
- Hypercoagulable state
- DIAGNOSTIC EVALUATION
- MECHANISM-SPECIFIC TREATMENT
- Treatment of preeclampsia, eclampsia, and HELLP
- Treatment of TTP or HUS
- Treatment of postpartum angiopathy
- Acute ischemic stroke
- - Acute reperfusion therapy
- Secondary prevention of ischemic stroke
- Cerebral venous sinus thrombosis
- Intracranial hemorrhage
- - Delivery
- MANAGEMENT ISSUES
- Anticoagulation during pregnancy
- Stroke remote from term
- Stroke near term
- FUTURE PREGNANCY
- Stroke risk in future pregnancy
- SUMMARY AND RECOMMENDATIONS