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Abstract
The risk of ischemic events in pregnancy and the puerperium is influenced by ethnic background and by age. African American women have a significantly higher risk than Caucasians. Furthermore, women over the age of 35 years have an increased risk of pregnancy-related stroke. Caesarean delivery has been shown to be associated with a 3–12 times increased risk of peripartum and postpartum stroke.
Known medical conditions strongly linked to stroke in pregnancy include hypertension, diabetes, sickle cell disease, thrombophilia, smoking and heart disease. Other risk factors in case series or reports are alcohol and recreational drug abuse, particularly cocaine. The presence of a lupus anticoagulant or anticardiolipin antibody is a well-recognised risk factor in pregnancy and an association with stroke in pregnancy has been shown with systemic lupus erythematosus. Other factors that may predispose to risk include multiple gestation and greater parity.
Not surprisingly, complications of pregnancy such as preeclampsia, eclampsia, hyperemesis, and disturbances in electrolyte and fluid balance are significant risk factors for stroke in the context of pregnancy.
Patients undergoing blood transfusion have been shown to have a substantially higher incidence of stroke. This seems to relate to associated medical risk factors such as treatment for sickle cell disease and treatment for postpartum haemorrhage.
An antiphospholipid syndrome can be triggered by pregnancy. This may present with stroke, which may be either arterial or venous. Diagnosis rests on the detection of one or more antiphospholipid antibodies: lupus anticoagulant, anticardiolipin antibody and anti -b2 - glycoprotein. If the diagnosis is suspected, all three antibodies should be tested for.
Women who are pregnant or in the postpartum period account for 10–25% of patients with thrombotic thrombocytopenic purpura (TTP). TTP may present with a wide variety of neurological presentations, including strokes, transient ischaemic attacks, fluctuating neurological symptoms, headaches, seizures and confusion. The diagnosis should be considered in pregnant women who develop anaemia and thrombocytopaenia. Blood film analysis may show red cell fragmentation and there may be a haemolytic pattern on laboratory analysis with elevated bilirubin, lactate dehydrogenase and increased reticulocyte count. Early diagnosis is critical as intensive treatment with plasma exchange may be life-saving.
Rarely, air embolus may result in ischemic stroke as a complication of caesarean section or following intravaginal and intrauterine gas insufflation during pregnancy. Strenuous labour, multiparity, caesarean section, increased gestational age and increased maternal age all seem to be risk factors, although the syndrome may still occur in their absence. Most cases occur during labour and around the time of delivery.
Intracranial haemorrhage has been estimated to constitute 2–7% of the total cases of neurological disorders related to pregnancy. In many cases, this relates to uncontrolled hypertension. Of the 34 cases of stroke related to pregnancy described by Jaigobin et al, 13 were haemorrhages, seven of which were subarachnoid haemorrhage (SAH). Three of these patients had rupture of an underlying cerebral aneurysm, all of which were posterior communicating artery aneurysms. Haemorrhage from either a subarachnoid bleed or intracerebral bleed occurred most commonly in the second trimester and the postpartum period.
A bleed from an underlying aneurysm occurred with equal frequency in all trimesters and the puerperium, whereas bleeding from an underlying arteriovenous malformation (AVM) occurred after the first trimester and in the postpartum period. SAH, mostly from aneurysms, accounts for 3% of all strokes. A saccular aneurysm will be responsible in approximately 85% of patients with SAH. In 10% of patients, SAH is secondary to non-aneurysmal perimesencephalic haemorrhage, which should be considered when haemorrhage on imaging is predominantly confined to the basal cisterns around the midbrain.