Stroke in Pregnancy: A Focused Update

Eliza C. Miller, MD; Lisa Leffert, MD†

Disclosures

Anesth Analg. 2020;130(4):1085-1096. 

In This Article

Abstract and Introduction

Abstract

Ischemic stroke (IS) and hemorrhagic stroke (HS) can be devastating complications during pregnancy and the puerperium that are thought to occur in approximately 30 in 100,000 pregnancies. In high-risk groups, such as women with preeclampsia, the incidence of both stroke subtypes, combined, is up to 6-fold higher than in pregnant women without these disorders. IS or HS may present in young women with atypical symptoms including headache, seizure, extremity weakness, dizziness, nausea, behavioral changes, and visual symptoms. Obstetric anesthesiologists who recognize these signs and symptoms of pregnancy-related stroke are well positioned to facilitate timely care. Acute stroke of any type is an emergency that should prompt immediate coordination of care between obstetric anesthesiologists, stroke neurologists, high-risk obstetricians, nurses, and neonatologists. Historically, guidelines have not addressed the unique situation of maternal stroke, and pregnant women have been excluded from the large stroke trials. More recently, several publications and professional societies have highlighted that pregnant women suspected of having IS or HS should be evaluated for the same therapies as nonpregnant women. Vaginal delivery is generally preferred unless there are obstetric indications for cesarean delivery. Neuraxial analgesia and anesthesia are frequently safer than general anesthesia for cesarean delivery in the patient with a recent stroke. Potential exceptions include therapeutic anticoagulation or intracranial hypertension with risk of herniation. General anesthesia may be appropriate when cesarean delivery will be combined with intracranial neurosurgery.

Introduction

Ischemic stroke (IS) and hemorrhagic stroke (HS) are rare, yet highly morbid complications during pregnancy and the puerperium. The incidence of maternal strokes was recently estimated to be approximately 30 in 100,000 pregnancies including all subtypes.[1] In high-risk groups, such as women with preeclampsia and other hypertensive disorders of pregnancy, the incidence of maternal HS and IS combined is up to 6-fold higher than in pregnant women without these disorders.[2–5] In addition to maternal mortality, pregnancy-related stroke can lead to disability affecting a woman's ability to care for herself and her children and to be productive personally and professionally. In this focused update, we review the available data on the epidemiology, pathophysiology, risk factors, and treatment of maternal stroke and discuss the role of the obstetric anesthesiologist in the identification and peripartum management of this potentially catastrophic event.

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