Diagnosis and management of women with stroke during pregnancy/postpartum

Global Temporal Trends and Projections of Stroke Among Women of Childbearing Age: An Age-Period-Cohort Analysis Based on the Global Burden of Disease Study 2021

BACKGROUND

Stroke is a major global health concern, particularly for women of childbearing age (WCBA), who face unique biological and sociodemographic risks. This study analyzes temporal trends in stroke incidence, prevalence, disability-adjusted life-year (DALY), and deaths among WCBA at global, regional, and national levels over the past three decades, using age-period-cohort (APC) modeling.

METHODS

Stroke burden data for WCBA from 1992 to 2021 across 204 countries were extracted from the Global Burden of Disease (GBD) 2021 study. An APC model assessed annual percentage changes in stroke burden (net drift), age group-specific trends (local drift), and relative risks associated with age, period, and cohort factors. Future stroke burden was projected using Bayesian APC models through 2030.

RESULTS

From 1992 to 2021, global stroke incidence cases among WCBA increased from 638,478 to 779,371, but ASIR and AS-DALYs declined. High-SDI regions consistently had the lowest stroke rates, while middle- and low-SDI regions, particularly China and India, accounted for a significant portion of global cases. Despite declines in some regions, countries like the Philippines and Pakistan exhibited rising trends. Projections to 2030 indicate a continued increase in stroke incidence cases, with higher rates expected in middle-income countries due to emerging risk factors like obesity and gestational diabetes.

CONCLUSIONS

While ASIR and AS-DALYs declined globally, rising incidence case numbers and persistent disparities highlight the need for targeted prevention and policy strategies, particularly in low- and middle-income regions, to reduce the stroke burden among WCBA.

Thrombolytic Dilemma: A Case Report of Early Puerperium Ischemic Stroke Treated With Intravenous Thrombolysis

A 25-year-old woman was admitted to the obstetrics ward when presented with a sudden onset of expressive aphasia and minor right facial palsy 48 hours after forceps-assisted delivery. The intrahospital emergency team was immediately mobilized. The patient had a blood pressure (BP) of 119/79 mmHg, heart rate of 114 bpm, O₂ saturation of 97%, and blood glucose level of 136 mg/dL. Trauma and toxic exposure were ruled out. A rapid EKG was performed with no significant changes. Assuming an acute stroke, the patient immediately underwent brain CT (approximately 15 minutes after the beginning of the symptoms), which revealed no signs of hemorrhage, an ischemic area, or masses. Brain CT angiography was then performed; however, no major brain artery obstruction was found. With brain hemorrhage ruled out and persistent neurologic deficits, the case was discussed between the emergency team doctor and the patient's obstetrician, and intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) was started approximately 45 minutes after the onset of symptoms. After treatment completion, the patient had a complete resolution of the neurological deficits. The patient remained under strict observation at the acute stroke unit (ASU), and no secondary brain hemorrhage or post-partum-related complications were noted.

ABO O gene frequency increase in the US might be causing increased maternal mortality

Maternal mortality rate has increased in the United States over the past 30 years from 16 deaths per 100,000 births to 28 deaths per 100,000 births while the rest of the world is experiencing declining rates. Increasing obesity and c-section rates in the US have been cited as contributing factors needing remediation, and because of the two to three fold difference in maternal mortality rates in non-Hispanic black women compared to white women, inequality and implicit racial bias has been targeted as well for remediation. Using an epidemiologic approach, a hypothesis here brought to bear is that US immigration policy changes over the past 50 years have brought changes in the gene pool that have caused increasing obstetric hemorrhage and other causes of maternal death. ABO gene frequencies have changed in the US during this time such that ABO O, a gene associated with hemorrhage and mortality in pregnancy, has increased in frequency in the US thus increasing population maternal mortality rate. Using mendelian randomization logic, noting the increase in ABO O gene in the US population over the past 30 years and the association of ABO O gene with both hemorrhage and lower longevity, the increase in frequency of the ABO O gene in the past 30 years in the US population might be causative of an increase in maternal mortality rate. Consequences of this hypothesis would include recognition of the role of ABO gene and thus ABO blood group in prediction of risk of obstetric hemorrhage. Thus those at risk on this basis would be under high surveillance and would have medications and treatment strategies readily available. While research on ABO gene and pregnancy has been done, much of the research is being done in countries other than the US, and given the increasing mortality in the US as well as the role that ABO gene may have in that, further research needs to be done in US populations to quantify risk for all adverse events in pregnancy related to ABO blood type including hemorrhage as well as inter-related causes including pre-eclampsia, cardiovascular disease, thromboembolic disease and infection.

Spontaneous haemorrhagic stroke complicating severe pre-eclampsia in pregnancy: a case report in a resource-limited setting in Cameroon

BACKGROUND

Spontaneous intracerebral haemorrhage is a rare complication of preeclampsia during pregnancy associated with a high morbidity and mortality. Compared with the non-pregnant women stroke rates are relatively rare during pregnancy.

CASE PRESENTATION

We report the case of a 32-year-old female Cameroonian gravida 4 para 3 who presented at 34 weeks of gestation with sudden onset of right sided hemiplegia associated with headache, blurred vision and a blood pressure of 182/126. Cerebral CT scan confirmed a left parietal spontaneous haemorrhage. Emergency caesarean delivery was done and the recovery uneventful.

CONCLUSION

This case highlights the importance of good neurological examination in pregnant women presenting with neurological symptoms as well as the place of multidisciplinary management in severe life threatening conditions.

Cerebrovascular emergencies in pregnancy

Caring for pregnant and postpartum patients with neurological disease carries specific challenges. In performing a diagnosis, it is often difficult to differentiate between true pathology and neurological symptoms resulting from normal pregnancy physiology. Treating the pregnant patient can be problematic as well. Providers need to be aware of the possible untoward effects of maternal treatments on the developing fetus, but not withhold therapies that reduce disease-related morbidity and mortality. Given the complexities of conducting trials during pregnancy, few treatments are based on high-quality data; observational data and clinical expert opinion often guide treatments. With the exception of preeclampsia/eclampsia, neurological diseases typically do not warrant early delivery in the absence of fetal distress. Multidisciplinary care, utilizing the expertise of anesthesiology, critical care medicine, emergency medicine, maternal-fetal medicine, neurology, and radiology, is essential in ensuring prompt diagnosis and treatment.

Spontaneous hemorrhagic strokes during pregnancy: case report and review of the literature

Hemorrhagic stroke is responsible for significant morbidity and mortality. Postpartum and pregnancy are risk period. Only urgent care in intensive care units may improve prognosis. We report the case of 22 years old's Morrocan, who presented to our department with an intense headache headset followed a few hours later by consciousness disorder. Clinical examination at admission has objectified a woman obsessed with a GCS 13, normotensive, the labstix is negative. A brain scan was performed showing left temporal intra parenchymal hematoma with ventricular flooding and subfalcine herniation. An external ventricular shunt was made. The patient was extubated on day 2 of hospitalization, with progressive neurological improvement. Concerning obstetrical care, the pregnancy has evolved harmoniously without any growth retardation or other abnormalities, with full-term vaginal delivery of a healthy 3kg200 baby. although Hemorrhagic stroke during pregnancy is rare, the prognosis is reserved. An adequate care in intensive care unit is required.

Etiology and management of postpartum hypertension-preeclampsia

Postpartum hypertension can be related to persistence of gestational hypertension, preeclampsia, or preexisting chronic hypertension, or it could develop de novo postpartum secondary to other causes. There are limited data describing the etiology, differential diagnosis, and management of postpartum hypertension-preeclampsia. The differential diagnosis is extensive, and varies from benign (mild gestational or essential hypertension) to life-threatening such as severe preeclampsia-eclampsia, pheochromocytoma, and cerebrovascular accidents. Therefore, medical providers caring for postpartum women should be educated about continued monitoring of signs and symptoms and prompt management of these women in a timely fashion. Evaluation and management should be performed in a stepwise fashion and may require a multidisciplinary approach that considers predelivery risk factors, time of onset, associated signs/symptoms, and results of selective laboratory and imaging findings. The objective of this review is to increase awareness and to provide a stepwise approach toward the diagnosis and management of women with persistent and/or new-onset hypertension-preeclampsia postpartum period.

Treatment of Neurocritical Care Emergencies in Pregnancy

OPINION STATEMENT: Neurologic emergencies are a major cause of morbidity and mortality in pregnant women. In part because the patient population is young, the nihilistic approach that often accompanies neurologically devastating disorders in other contexts is largely absent. A number of studies have demonstrated improved patient outcomes in the setting of aggressive care delivered by neurointensivists in a specialty-specific environment. It stands to reason that young, pregnant women who suffer from neurologically devastating disorders and who have a wide range of prognosis may also benefit from such specialized care. Close collaboration between obstetricians and neurointensivists is critical in this context. A number of unique considerations in diagnosis and management present dilemmas in the context of pregnancy, such as radiation dose from diagnostic neuroimaging, choice of pharmacotherapy for seizures, anticoagulation, and the method of delivery in the context of cerebral mass lesions and elevated intracranial pressure. Patients and their physicians are often faced with the additional challenge of balancing the relative risks and benefits of the impact of a management approach on both mother and fetus. In general, this balance tends to favor the interests of the mother, but the impact on the fetus becomes more relevant over the course of the pregnancy, especially in the third trimester. A low threshold for admission to an intensive care unit (ideally one that specializes in neurointensive care) should be used for pregnant patients. Because of the limited information regarding long-term outcomes in this population, rigid prognosis formation and early care limitations should be deferred in the immediate period. After the patient is stabilized and a plan has been charted for the remainder of the pregnancy, every effort should be made to engage patients in aggressive, urgent neurologic rehabilitation.

Spontaneous acute subdural haematoma and intracerebral haemorrhage in patient with HELLP syndrome: case report

HELLP (haemolysis, elevated liver enzymes, and low platelet count) syndrome can result in a fatal intracranial haemorrhage during the perinatal period. We report treatment of a 32-year-old primigravida who fell into a deep coma during labour with fetal distress, complicated by a spontaneous acute subdural haematoma and intracerebral haemorrhage. Simultaneous emergency operations, evacuation of the acute subdural haematoma and a caesarean section, were performed, during which a diagnosis of HELLP syndrome with disseminated intravascular coagulation was made. Both mother and infant recovered, though hemiparesis persisted in the mother. Patients with HELLP syndrome should be managed as high-risk, which requires an excellent working relationship of the physicians involved. Prompt recognition of intracranial haemorrhagic complications and neurosurgical intervention are particularly important.

Hormones and cardiovascular health in women

Cardiovascular diseases (CVDs) may have their origin before birth: the combination of being small at birth and having an overly rich post-natal diet increases the likelihood of obesity and of acquiring a specific metabolic syndrome in adulthood that carries an increased risk of CVD. The incidence of CVD and mortality is very low in women of reproductive age but rises to a significant level in older women. In this article, we discuss CVD in relation to hormonal contraception, pregnancy and polycystic ovarian syndrome (PCOS) in younger women and menopause in older women. Women with PCOS have a higher risk of diabetes and hypertension, but studies to date have not shown an effect on CVD events. Use of combined hormonal contraception has only small effects on CVD because of the low baseline incidence of myocardial infarction (MI), stroke and venous thromboembolism (VTE) among young women. Women with existing risk factors or existing CVD, however, should consider alternative contraception. In pregnancy, CVD is rare, although, in the West, it now accounts for a significant proportion of maternal mortality as the frequency of obstetrical causes of mortality has substantially declined. The frequency of VTE is 15 per 10,000 during pregnancy and the post-partum period. In older women, menopause causes a slightly higher risk of MI after allowing for age, although there is substantial heterogeneity in the results of studies on menopause and age at menopause and MI. A larger effect might have been expected, because estrogen reduces the risk of developing atherosclerosis in premenopausal women, whereas in post-menopausal women who may have established atherosclerotic disease, estrogen increases the risk of myocardial disease through the effects on plaque stability and clot formation. Recent trial results indicate that hormone treatment in menopause does not favourably affect the risk of MI, stroke or other vascular disease. Thus, prevention of CVD should rely on diet and fitness, low-dose aspirin and treatment of hypertension, hyperglycaemia and hyperlipidaemia.