What are the risks of stroke in the postpartum period?

From the Guidelines

After experiencing a stroke during pregnancy, patients should be on a comprehensive treatment plan that prioritizes blood pressure control, lifestyle modifications, and regular follow-ups to minimize the risk of recurrent stroke and improve long-term outcomes. The risk of stroke is approximately tripled in pregnant and postpartum individuals compared to young adults of similar age, with the highest-risk time point being the early postpartum period 1.

Key Considerations

• Blood pressure should be maintained below 140/90 mmHg using pregnancy-safe medications like labetalol or nifedipine if needed 1.
• Lifestyle modifications are crucial, including a heart-healthy diet, regular physical activity as tolerated, smoking cessation, and limiting alcohol consumption.
• Regular neurological follow-ups every 3-6 months in the first year post-stroke are essential, along with monitoring by a high-risk obstetrician for any future pregnancies.
• Preconception counseling is strongly recommended for future pregnancies, and anticoagulation therapy may be considered depending on stroke etiology.

Management and Prevention

• The mechanisms of pregnancy-associated stroke are diverse, and the sequelae can be catastrophic 1.
• Additional risk factors for maternal stroke include older age, migraine, assisted reproductive technology, obesity, heart disease, infections, and SLE 1.
• Evidence supports BP control as critical for the prevention of maternal morbidity, including fatal and nonfatal stroke 1.
• Patients with hypertensive disorders in pregnancy (HDP) represent a particularly high-risk group for maternal stroke, and intracerebral hemorrhage (ICH) is a leading cause of death in these individuals 1.

Treatment and Follow-up

• Antiplatelet therapy such as low-dose aspirin (81-100mg daily) may be considered indefinitely, unless contraindicated, as part of a comprehensive treatment plan.
• The risk of recurrent stroke is highest in the first year after the initial event, with pregnancy itself being a hypercoagulable state that increases stroke risk due to hormonal changes, increased blood volume, and changes in blood vessel reactivity 1.
• Early intervention and adherence to the treatment plan significantly improve long-term outcomes and reduce recurrence risk.

From the Research

Strokes in Pregnancy Afterwards

• The risk of ischemic stroke is elevated especially from the third trimester until 6 weeks postpartum 2.
• Pregnancy and the postpartum period confer an increased risk of stroke, with the risk appearing to be increased for all strokes during the puerperium and for hemorrhagic strokes during pregnancy 3.
• The common independent vascular risk factors for stroke, such as hypertension, diabetes, hyperlipidemia, and smoking, may also be present to contribute to the risks conferred by pregnancy 3.
• Ischemic stroke during pregnancy or the puerperium is a devastating disease during a crucial period in life and warrants a specific approach, with current practice mainly based on expert opinion due to a lack of randomized controlled trials and high-quality observational studies 2.

Management of Strokes in Pregnancy

• MRI is the most accurate and well tolerated diagnostic option, but low-dose CT-head is a valid alternative 2.
• Reperfusion therapies should not be withheld from a pregnant woman with moderate-to-severe stroke when benefits outweigh the risk 2.
• Aspirin up to 150 mg daily is considered well tolerated during pregnancy and lactation period 2.
• Acute stroke in pregnancy can be devastating, and obstetric care providers should have an understanding of the presentation and management of stroke, particularly in the initial period when the window of opportunity for therapy is critical 4.

Clinical Presentation and Management

• Patients presenting within 4.5 hours of symptom onset and with an initial normal head CT scan are candidates for alteplase (tissue plasminogen activator [tPA]) 4.
• Blood pressure control is paramount when administering tPA, with a recommended range of 140-160/90-110 mm Hg during tPA treatment 4.
• Pregnancy should not be a contraindication for mechanical thrombectomy in carefully selected patients 4.
• Supportive therapy should include aggressive treatment of fever, avoidance of hypotonic maintenance fluids, and maintenance of normal serum sodium levels 4.