The following article is part of conference coverage from the 2019 American Academy of Neurology Annual Meeting (AAN 2019) in Philadelphia, PA. Neurology Advisor’s staff will be reporting breaking news associated with research conducted by leading experts in neurology. Check back for the latest news from AAN 2019.
PHILADELPHIA — The risk for intracerebral hemorrhage (ICH) in pregnant women was the highest during the 3rd trimester and early postpartum, according to a study presented at the 2019 American Academy of Neurology Annual Meeting, held May 4 to 10, 2019, in Philadelphia, Pennsylvania.1
Investigators conducted a crossover cohort study to determine the risk for ICH in pregnancy and during the postpartum period. The researchers identified patients with labor and delivery diagnosis using ICD-9 codes from State Inpatient Databases in New York, California, and Florida. The initial study included a 40-week pregnancy, labor, and delivery period with a 24-week postpartum period, followed by a 52-week interim and 64-week crossover period. Patients with a prior ICH were excluded. The rate of ICH during case and crossover periods were compared.
During the case period, more than 3.3 million deliveries were identified; of these, 238 patients experienced ICH. The rate of ICH during the case period vs crossover period was 8.1 vs 2.5 per 100,000 deliveries/patients, respectively, and the absolute risk difference was 5.5 and 3.2, respectively. Patients with a history of hypertension, coagulopathy, substance abuse, thrombocytopenia, or preeclampsia/eclampsia were more likely to experience ICH during the postpartum period. In addition, patients who were Black or Asian were also more likely to experience ICH postpartum.
Investigators concluded that “further investigation is warranted to characterize individuals at a greater risk of ICH during [the postpartum period].”
Neurology Advisor spoke to Eliza C. Miller, MD, Assistant Professor of Neurology in the Division of Stroke and Cerebrovascular Disease at New York-Presbyterian and Columbia University Irving Medical Center regarding the study conducted by Dr Meeks and colleagues
Eliza C. Miller, MD: “Maternal stroke is the cause of 7.4% of maternal deaths in the United States, and a leading cause of maternal morbidity. Although the increased risk for stroke during pregnancy is often attributed to a hypercoagulable state, the majority of deaths due to maternal stroke are from ICH, a fact which is often overlooked. In this observational study, Dr Meeks and colleagues used a case-crossover design in a large administrative dataset to investigate whether the risk of intracerebral hemorrhage is increased during pregnancy and postpartum, and found an increased risk for ICH in the third trimester and postpartum, particularly in Black and Asian women, and women with hypertensive disorders of pregnancy.
For me the most important benefit from this study is to raise awareness among clinicians of the importance of hypertension in causing maternal ICH. A recent Japanese study analyzed maternal deaths due to stroke, 90% of which were due to ICH, and found that more than a third of the deaths could have been prevented by more aggressive treatment, including aggressive control of blood pressure and quicker transfer to higher levels of care.2
Especially after delivery, there is a tendency to focus on the baby and forget about the mother’s risks. In my own clinical experience, I have cared for many women who suffered ICH in the postpartum period, and many of them had symptoms of severe headache for several days before they developed the hemorrhage and presented to the hospital. Some had presented to emergency departments and had been sent home without brain imaging due to low suspicion for an acute intracranial process. I believe postpartum hypertension is far more common than previously thought, and clinicians need to have a higher index of suspicion for possible warning signs for impending stroke. My own practice is when in doubt, admit the patient, monitor her blood pressure closely and get brain imaging. I am also often consulted for headaches in pregnant women, often in the setting of mild preeclampsia or gestational hypertension. Even if the brain imaging is normal, I counsel all these women on the signs and symptoms of stroke, and encourage them not to ignore their symptoms if they get worse after they go home, but to come straight to the emergency room.”
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- Meeks J, Bambhroliya A, Alex K, Sheth S, Vahidy F. Risk of intracerebral hemorrhage in pregnancy and the postpartum period: a population based analysis using a cohort–cross over design. Presented at: 2019 American Academy of Neurology Annual Meeting; May 4-10, 2019; Philadelphia, PA.
- Katsuragi S, Tanaka H, Hasegawa J, et al. Analysis of preventability of stroke-related maternal death from the nationwide registration system of maternal deaths in Japan. J Matern Fetal Neonatal Med. 2018;31(16):2097-2104.