Stroke and Pregnancy: A Potentially Deadly Combination

For most women awaiting the arrival of their baby, pregnancy is filled with celebration — although it’s often coupled with fatigue and nausea. What many don’t realize is that pregnancy places them at higher risk for stroke than they otherwise would be, not just during those nine months, but also in the weeks and months after giving birth.

Stroke is three times more common in pregnant and postpartum women than it is in nonpregnant women of the same age, according to the American Heart Association. While it is important to note that maternal stroke isn’t common, it occurs in approximately 30 of every 100,000 deliveries and one in 500 women who develop preeclampsia (which is a new onset of severe high blood pressure during pregnancy).

Higher Risk of Blood Clots

“Pregnancy increases the risk of thrombosis, or blood clots, three- to four-fold,” says neurologist Constance Katsafanas, D.O., with Marcus Neuroscience Institute at Boca Raton Regional Hospital, part of Baptist Health. Dr. Katsafanas was one of the experts who spoke recently at the Marcus Neuroscience Institute Brain & Spine Symposium, an educational meeting for physicians and other healthcare professionals highlighting the latest advances in the treatment of neurological conditions.

Constance Katsafanas, D.O., with Marcus Neuroscience Institute at Boca Raton Regional Hospital, part of Baptist Health..

 

“During pregnancy, the blood gets more sticky, and there’s good reason for that,” she explains. “When women deliver, they bleed. Coagulation is the body’s protective mechanism, and the clotting is very important. But when this clotting gets out of control, we have problems.”

In addition, during pregnancy women experience many other changes, not just their hormones. Blood volume increases as well, which means that the heart has to work harder. When this is coupled with the fact that many women become less active during pregnancy, for some this is enough to cause problems.

Medical Conditions Prior to Pregnancy

The likelihood of stroke is raised in women who have medical conditions prior to pregnancy, such as high blood pressure, or with illnesses like diabetes, pre-existing cardiovascular conditions and structural heart conditions such as a patent foramen ovale (PFO), a small hole between the left and right atria of the heart present before birth that usually closes naturally later. Black and Hispanic women are at higher risk for these underlying conditions than other groups.

Conditions such as infective endocarditis and acquired cardiac conditions, including peripartum cardiomyopathy (a form of heart failure that can occur toward the end of pregnancy or even in the months that follow childbirth), also increase the risk of stroke.

“Stroke can lead to significant long-term disability after pregnancy, and it can cause the death of mother and baby,” Dr. Katsafanas says.

She goes on to add that stroke prevention involves close monitoring of patients with known risk factors. An evaluation with a neurologist or cardiologist who specializes in maternal health or high-risk pregnancies is typically advised. Women may need to be placed on blood pressure medications or undergo other treatment to lessen their risk of stroke.

Effective Treatment Options Available

If a woman has a stroke during or following pregnancy, the positive news is that treatment options are available, and outcomes can be quite good, particularly if the patient is cared for at a comprehensive stroke center.

“Unfortunately, 58 percent of pregnant or postpartum patients with acute ischemic stroke do not receive thrombolytic therapy (clot-busting drugs) because providers wrongly believe that pregnancy excludes them,” Dr. Katsafanas says. “This is a real problem. Pregnant women were not included in the drug trials for intravenous alteplase, so initially it was considered a contraindication.”

However, the American Heart Association/American Stroke Association said in their 2018 guidelines that “IV alteplase administration may be considered in pregnancy when the anticipated benefits of treating moderate or severe stroke outweigh the anticipated increased risks of uterine bleeding.” These are decisions that it takes a trained neurologist to make in order to weigh the risks and benefits.

Some women with ischemic strokes, which account for about 87 percent of all strokes, are also candidates for endovascular thrombectomy. In a minimally invasive procedure, doctors thread a thin catheter through an artery to the point of the blockage and remove the clot, restoring blood flow to the brain. This, like clot-busting medications, must be done quickly to save as much brain as possible.

One of the reasons that strokes are becoming more common in pregnant women is because more women are holding off pregnancy until they are older. Despite that, they are more likely to have a good outcome. “The one thing these women have going for them is that they are younger than the average stroke patient and younger brains typically do better. We have favorable outcomes for about 80 percent of these women,” Dr. Katsafanas says.

Signs of High Blood Pressure During Pregnancy

During pregnancy, all women should have their blood pressure regularly checked and if their BP readings equal or exceed 140/90 on two separate occasions they should be evaluated and treated. Also, expectant mothers should be aware of any signs of high blood pressure, including:

• Severe headaches
• Sudden weight gain or swelling of the face and/or extremities
• Upper stomach pain
• Vision changes, including temporary loss of vision, blurred eyesight or sensitivity to light
• Blood in the urine
• Shortness of breath

If you’re thinking of getting pregnant or are currently expecting and you have a history of high blood pressure, an existing cardiac condition or another condition that puts you at high risk of stroke, speak to your OB/GYN or primary care physician about what that means for you and your baby. If you experience any signs of high blood pressure during pregnancy or following delivery, seek medical care right away.