Targeted Prevention: How to Reduce Stroke Risk During Pregnancy

Stroke and Pregnancy: The Relevance of the Problem

Pregnancy is a period of significant physiological changes in a woman's body, which, unfortunately, can increase the risk of certain serious complications. One such complication is stroke. Although stroke during pregnancy is relatively rare, affecting approximately 30 out of 100,000 pregnancies, its consequences can be extremely severe for both the mother and the child [1].

Recent data show an alarming trend toward an increase in the number of pregnancy-related strokes, especially among women of advanced reproductive age. There is an increase in cases of ischemic stroke and cerebral venous thrombosis [1]. This growth is partly explained by natural changes in the pregnant body, such as increased blood clotting (hypercoagulability), which is a protective mechanism to prevent bleeding during childbirth, but simultaneously increases the risk of blood clot formation [1, 3].

The risk of stroke is particularly high in the peripartum period and immediately after childbirth (postpartum) [1]. For women who have already had a stroke or a transient ischemic attack (TIA) before pregnancy, an individually developed secondary prevention strategy is crucial, as pregnancy can significantly increase their risk of a recurrent event [2].

Key Risk Factors for Stroke During Pregnancy

Understanding risk factors is the foundation for effective prevention. Some conditions, characteristic of pregnancy or existing before it, can significantly increase the likelihood of developing a stroke:

• Hypertensive Disorders of Pregnancy (HDP): These include gestational hypertension, preeclampsia, and eclampsia. These conditions affect 5-8% of pregnant women worldwide and are one of the leading causes of maternal and neonatal morbidity and mortality [1, 4]. Uncontrolled high blood pressure significantly increases the risk of stroke.
• Migraine: A common neurological disease among women of childbearing age. Studies show that migraine is associated with a significantly increased risk of all types of strokes and TIAs (odds ratio 10.45), as well as ischemic stroke (odds ratio 7.14) during pregnancy and the postpartum period [3]. Migraine is also associated with other pregnancy complications, such as preeclampsia and preterm birth [5].
• Thrombophilia: Conditions in which the blood has an increased tendency to clot also increase the risk of thrombotic complications, including stroke [1].
• Diabetes Mellitus: Both gestational diabetes and type 2 diabetes, if not properly controlled, are important risk factors for cardiovascular diseases, including stroke [6].
• Maternal Age: Older maternal age is associated with an increased risk of stroke during pregnancy [1].
• Cerebral Arteriovenous Malformations (AVMs): These are abnormal tangles of blood vessels in the brain. Pregnancy can increase the risk of hemorrhage from AVMs [7].

Prevention Strategies: What Can Be Done?

Effective stroke prevention during pregnancy requires a comprehensive approach and close cooperation between the patient and physicians. It is important to begin preventive measures before conception and continue them throughout pregnancy and the postpartum period.

Before conception:

• Preconception counseling: Women with known risk factors (e.g., history of stroke/TIA, chronic hypertension, diabetes, migraine) are advised to undergo a thorough examination and receive consultation from specialists before planning a pregnancy [1, 2, 5]. This allows for the optimization of chronic disease treatment and the development of an individualized pregnancy management plan.

During pregnancy:

• Strict blood pressure control: This is one of the key prevention strategies. Regular blood pressure monitoring and timely treatment of hypertensive disorders of pregnancy significantly reduce the risk of stroke [1]. Studies show that educational programs on dietary changes, physical exercise, and recognizing warning signs of hypertension can improve clinical parameters and reduce stress in pregnant women with hypertension [4].
• Low-dose aspirin: For women at high risk of developing hypertensive disorders of pregnancy or thrombophilia, low-dose aspirin may be recommended as a preventive measure [1].
• Migraine management: If a migraine is present, it is important to discuss safe and effective treatment methods with a doctor, taking into account potential risks to the mother and fetus [5].
• Diabetes control: For pregnant women with gestational diabetes or type 2 diabetes, adding metformin to insulin can be effective for controlling blood sugar levels and reducing risks associated with diabetes [6].
• Healthy lifestyle: A balanced diet, regular moderate physical activity (e.g., walking, special leg exercises), and stress reduction methods (e.g., relaxation techniques) contribute to overall well-being and can help control risk factors [4].
• Monitoring of cerebral AVMs: In the presence of unruptured AVMs without additional risk factors for bleeding (e.g., absence of a concomitant aneurysm, normal venous drainage), conservative observation is possible. In the case of AVM rupture, active treatment is required [7].

Diagnosis and Treatment of Acute Conditions

In case of suspected stroke during pregnancy or in the postpartum period, rapid and accurate diagnosis is crucial. Modern neuroimaging methods, such as MRI and CT, can be safely used in pregnant women provided there is adequate shielding to protect the fetus [1, 7].

Advances in acute stroke treatment, including thrombolysis (clot-dissolving) and endovascular therapy (mechanical clot removal), now support their use in carefully selected pregnant and postpartum women [1]. In the case of a ruptured cerebral AVM, active treatment is necessary, which may include endovascular procedures or stereotactic radiosurgery, with radiation doses generally remaining within safe values for the fetus [7].

A key aspect of a successful outcome is immediate medical attention and coordination of a multidisciplinary team of specialists.

The Role of Medical Staff and an Interdisciplinary Approach

Reducing maternal mortality and morbidity associated with stroke requires the coordinated work of a team of specialists. This includes obstetrician-gynecologists, neurologists, cardiologists, anesthesiologists, and other experts. The presence of obstetric hospitalists who provide continuous care for laboring women and actively participate in hospital safety initiatives can significantly improve outcomes [8].

Their immediate availability allows for the prompt assessment of patients' conditions, the initiation of necessary treatment, and the coordination of the entire team's actions in cases of serious complications, such as hypertensive crisis or massive hemorrhage. This interdisciplinary approach ensures the timely identification of risk factors, effective management of chronic conditions, and a rapid response to acute situations, which ultimately contributes to the safety of the mother and child [8].

Sources

1. Pregnancy and Stroke Risk.
2. Canadian stroke best practice consensus statement: Secondary stroke prevention during pregnancy.
3. Migraine and pregnancy-related headaches as a risk factor for cardiovascular and cerebrovascular events in pregnancy: a systematic review and meta-analysis of over 94 million pregnancies.
4. A true experimental study to assess the effectiveness of holistic self-care approach on clinical parameters, psychological stress, wellbeing, among antenatal mothers with pregnancy-induced hypertension admitted in antenatal ward at SRM Medical College Hospital and Research Centre.
5. Migraine treatment in pregnancy: A survey of comfort and treatment practices of women's healthcare providers.
6. Metformin + Insulin vs. Insulin for GDM and T2DM during pregnancy: systematic review and meta-analysis.
7. The clinical characteristics and treatment of cerebral AVM in pregnancy.
8. The Role of Obstetrics/Gynecology Hospitalists in Reducing Maternal Mortality.

Important Note

The information provided in this article is for reference purposes only and cannot replace professional medical advice, diagnosis, or treatment. Always consult your healthcare provider regarding any questions concerning your health or the health of your child.