Maternal Morbidity - CVA Resources

Spontaneous subarachnoid hemorrhage due to ruptured berry aneurysm and arteriovenous malformation accounted for 4.4 per cent of all maternal deaths in the State of Minnesota from 1950 to 1973. This catastrophic entiity ranked eighth in frequency regarding all causes of death and third among the nonobstetric causes. An analysis of the 37 deaths among 1,763,824 live births is presented. These 37 patients had delivered 96 infants and had 10 spontaneous abortions prior to current pregnancy. This suggest that pregnancy per se has no appreciable effect upon the occurrence of the hemorrhage. Five of these died in association with labor and delivery, or during a 1 day period-three during labor, one during vaginal delivery, and one only 1 hour postpartum. This is equivalent to 35 per week. On the other hand, 15 occurred during pregnancy (underlivered) (0.4 per week) and 17 during the first 3 months post partum (1.4 per week). These data seem to indicate that labor and delivery increase the risk of spontaneous subarachnoid hemorrhage. The neurologic state of these 37 patients was bad from the very onset of the hemorrhage. Rapid irreversible coma occurred in 34 (76 per cent). Of these 34, 24 (74 per cent) were dead within the first 24 hours and 32 (94 per cent) were dead within the first 4 days following the onset of the hemorrhage.

Intracranial hemorrhage (ICH) from an intracranial aneurysm or arteriovenous malformation is a grave complication of pregnancy and is responsible for 5 to 12% of all maternal deaths. We critically analyzed 154 cases of verified ICH during pregnancy from an identified intracranial lesion, including 2 patients treated at our institution and 152 cases previously reported in the literature in English. Aneurysms were responsible for ICH in 77% of patients, and arteriovenous malformations in 23%. Hemorrhage occurred antepartum in 92% of patients and postpartum in 8%. Women with angiomatous hemorrhage were younger than those with aneurysmal hemorrhage; however, in contrast to previous reports, we found no differences between angiomatous and aneurysmal hemorrhage with respect to parity or gestational age at the time of the initial hemorrhage. Hypertension and/or albuminuria were present at some time during the pregnancy in 34% of patients with documentation, which sometimes made it difficult to differentiate angiomatous or aneurysmal ICH from that associated with eclampsia. In a logistic regression analysis, surgical management of aneurysms, but not arteriovenous malformations, was associated with significantly lower maternal and fetal mortality, independent of other covariants. For those patients with a lesion not operated on, cesarean delivery afforded no better maternal or fetal outcome than did vaginal delivery. We conclude that the decision to operate after ICH during pregnancy should be based upon neurosurgical principles, whereas the method of delivery should be based upon obstetrical considerations. The perioperative and anesthetic management of the pregnant patient with a neurosurgical complication is discussed.

Although pregnancy-associated stroke is uncommon, the risk of stroke is greatly increased above the low baseline rate in young patients during late pregnancy and, even more so, during the puerperium. Stroke is a major contributor to the serious morbidity and mortality of pregnancy. The physiological hormonally mediated changes in circulation, vascular tissue structure, and coagulability, and the pathological state of pre-eclampsia–eclampsia contribute to this increased risk of stroke. Pregnancy-associated strokes are roughly evenly divided among hemorrhagic strokes, mainly from rupture of aneurysms and arteriovenous malformations (AVMs); ischemic strokes, mainly from late pregnancy and postpartum cerebral venous thrombosis; and strokes associated with pre-eclampsia–eclampsia, with a contribution from cardioembolism, especially in populations at risk from a high rate of underlying rheumatic valvular heart disease. Awareness of the types of stroke to expect during pregnancy will facilitate early diagnosis. This article discusses the pathogenesis of pregnancy-associated stroke, its epidemiology, and some diagnostic and therapeutic issues unique to pregnancy.

Cerebral arteriovenous malformations infrequently complicate pregnancy.We sought to determine the neurologic, obstetric, and ethical significance of such malformations.We present the clinical course of 2 pregnant women with arteriovenous malformations who experienced cerebral hemorrhage and a loss of capacity for decision making.We also review the neurologic and obstetric significance of arteriovenous malformations in pregnancy. Various treatment options with concern for pregnancy and the prognosis for arteriovenous malformations are outlined. The ethical issues involved for pregnant patients whose decisional capacity is compromised as a result of cerebral injury are explored. A review of persistent vegetative state and brain death (death by neurologic criteria) occurring in pregnancy allows us to explore many issues that are applicable to decisionally incapacitated but physiologically functioning pregnant women.We outline a document, the purpose of which is to obtain advance directives from pregnant women regarding end-of-life decisions and to appoint a surrogate decision maker.We believe that evaluation and treatment of the arteriovenous malformation may be undertaken without regard for the pregnancy and that the pregnancy should progress without concern for the arteriovenous malformation.

Objective: To examine associations of gravidity and parity with all-cause, cardiovascular disease (CVD), and coronary heart disease (CHD) mortality in postmenopausal women. Design: Prospective cohort study. Setting: Rancho Bernardo, a southern California community. Patient(s): One thousand two hundred ninety-four postmenopausal women ages 50–96 who attended a 1984–87 research clinic visit at which reproductive and medical histories were obtained and who were followed through 2007. Intervention(s): None. Main Outcome Measure(s): All-cause, CVD, CHD, and non-CHD CVD mortality, determined by nosologist-coded death certificates. Result(s): Average baseline age was 70.6
9.2. Numbers of pregnancies ranged from 0 to 13 (median ¼ 2); births ranged from 0 to 11 (median ¼ 2). During a median of 19.3 years of follow-up, 707 women (54.6%) died, with 46.5% attributed to CVD, 20.5% to CHD, and 26.0% to non-CHD CVD. Trend analyses showed inverse associations of gravidity with CVD mortality and non-CHD CVD mortality. Women with four or more pregnancies were less likely than nulligravidas to have fatal CVD (hazard ratio [HR] ¼ 0.63, 95% confidence interval [CI] ¼ 0.40–0.99) and non-CHD CVD (HR ¼ 0.48, 95% CI ¼ 0.26–0.91) independent of age, years postmenopause, obesity, and HDL. Associations increased after the first decade of follow-up. Parity and gravidity were not associated with overall or CHD mortality. Conclusion(s): High gravidity was associated with reduced CVD and non-CHD CVD mortality in postmenopausal women. Protective associations could reflect biological mechanisms that occur with repeated pregnancy or greater social support related to family size among multiparous women.

Background It is widely believed that pregnancy increases the risk of stroke, but there are few data available to quantify that risk. Methods We identified all female patients 15 through 44 years of age in central Maryland and Washington, D.C., who were discharged from any of 46 hospitals in the study area in 1988 or 1991. Two neurologists reviewed each case, using data from the women’s medical records. We determined whether the women had been pregnant at the time of the stroke or up to six weeks before it occurred. For purposes of this analysis, the six-week period after pregnancy could begin with an induced or spontaneous abortion or with the delivery of a live or stillborn child. Results Seventeen cerebral infarctions and 14 intracerebral hemorrhages occurred in women who were or had recently been pregnant (pregnancy-related strokes), and there were 175 cerebral infarctions and 48 intracerebral hemorrhages that were not related to pregnancy. For cerebral infarction, the relative risk during pregnancy, adjusted for age and race, was 0.7 (95 percent confidence interval, 0.3 to 1.6), but it increased to 8.7 for the postpartum period (after a live birth or stillbirth) (95 percent confidence interval, 4.6 to 16.7). For intracerebral hemorrhage, the adjusted relative risk was 2.5 during pregnancy (95 percent confidence interval, 1.0 to 6.4) but 28.3 for the postpartum period (95 percent confidence interval, 13.0 to 61.4). Overall, for either type of stroke during or within six weeks after pregnancy, the adjusted relative risk was 2.4 (95 percent confidence interval, 1.6 to 3.6), and the attributable, or excess, risk was 8.1 strokes per 100,000 pregnancies (95 percent confidence interval, 6.4 to 9.7). Conclusions The risks of both cerebral infarction and intracerebral hemorrhage are increased in the six weeks after delivery but not during pregnancy itself.

Abstract Recent studies suggest that the risk of cerebral infarction is increased during the puerperium but not during pregnancy itself. Most of the known causes of ischaemic stroke in the young have been reported during pregnancy. In most of these conditions, it is uncertain whether pregnancy is coincidental or plays a role in the occurrence of stroke. Eclampsia is the main pregnancy-specific cause, which may be associated with focal neurological deficits of sudden onset, consistent with a clinical diagnosis of stroke. However, the precise pathogenesis of these stroke-like focal deficits remains poorly understood. The two other pregnancy-specific conditions (choriocarcinoma and amniotic fluid embolism) are rarely responsible for focal cerebral ischaemia. In a significant number of patients, the cause of the stroke remains undetermined, despite an extensive aetiological investigation. Whether a hypercoagulable state and vessel wall changes associated with pregnancy may play a role in the occurrence of these otherwise unexplained ischaemic strokes remains unknown. The occurrence of cerebral venous thrombosis is clearly linked to the puerperal state, suggesting a direct role of the latter. However, cerebral venous thrombosis during pregnancy or the puerperium has been related to various aetiologies, stressing the need for an aetiological study, particularly when the thrombosis occurs during pregnancy. Pregnancy may increase the risk of subarachnoid haemorrhage, The most common cause is rupture of an arterial aneurysm. Although this is a controversial issue, the increased tendency of an aneurysm to bleed with advancing gestational age suggests that haemodynamic, hormonal or other physiological changes of pregnancy may play a role in aneurysmal rupture. The classic notion that rupture of an arterial aneurysm occurs more frequently during labour has not been confirmed. Most authors agree that surgical management after subarachnoid haemorrhage in pregnancy should be the same as that in the non-pregnant state. Data specifically devoted to intraparenchymal haemorrhage in pregnancy are scarce. Pregnancy and in particular the puerperium seem to be associated with an increased risk of intracerebral haemorrhage. The most common causes are eclampsia and ruptured vascular malformations. Whether pregnancy increases the risk of rupture of an arteriovenous malformation is controversial.

Cerebral aneurysmal complications rarely occur during pregnancy. Telling the difference between eclampsia and cerebral hemorrhage due to aneurysmal rupture can prove to be difficult. Aneurysmal management should be performed in an emergency but fetal prognosis should be considered. We report a series of eight pregnant women presenting aneurysmal complications and we have assessed their management and outcome. Both maternal and perinatal mortality rates were correlated with the maternal clinical score. We stress the role of combined care by both neurosurgeons and obstetricians. An emergency cesarean section followed by aneurysmal treatment appears to be a widely accepted strategy in pregnant women with cerebral aneurysmal complications.

Between January 1975 and June 1989, 240 patients with cerebral vascular malformations were treated at Henry Ford Hospital . In 16 of the patients, the treatment was influenced by pregnancy. Eleven of the patients presented with hemorrhage, four with seizures, and one with hydrocephalus. There were no maternal or fetal deaths in thepatients presenting with seizure or hydrocephalus. There were two maternal deaths and one fetal death among the cases presenting with hemorrhage . In the patients with seizure or hydrocephalus, the pregnancy was brought to term and obstetric indications used to determine the time and method of delivery . Hydrocephalus was treated by shunting, and seizures with medication . Antiepileptic drug levels fluctuate in pregnancy and hence were closely monitored to ensure therapeutic levels . Vascular malformations are the most common cause of subarachnoid hemorrhage in pregnancy . The risk of rebleed in the same pregnancy is about 27% . If an arteriovenous malformation ruptures during pregnancy and the patient's condition deteriorates, appropriate emergency surgery should be done. In stable patients, our policy has been to bring the pregnancy to term and then electively perform a craniotomy to excise the arteriovenous malformation.

Background and Purpose: The incidence, causes, and prognosis of nonhemorrhagic strokes and intraparenchymal hemorrhages occurring in association with pregnancy or puerperium are poorly understood. Methods: We carried out a retrospective (1989 through 1991) and prospective (1992) study in 63 public maternities (348 295 deliveries) of the region of Ile de France (10 660 554 inhabitants) and in the neurology, neurosurgery, and intensive care units of the same geographic area. Records of women who suffered a cerebrovascular event during pregnancy or the first 2 weeks postpartum were reviewed by two study neurologists. Stroke was defined according to the criteria of the World Health Organization. Results: Thirty-one cases of strokes were identified, including 15 nonhemorrhagic strokes (including strokelike deficits associated with eclampsia) and 16 intraparenchymal hemorrhages, assessed in all cases by CT scan and/or MRI. The incidence of nonhemorrhagic strokes in women who delivered in public maternities of Ile de France was 4.3 per 100 000 deliveries (95% confidence interval, 2.4 to 7.1) and that of intraparenchymal hemorrhage was 4.6 per 100 000 deliveries (95% confidence interval, 2.6 to 7.5). Eclampsia accounted for 47% of cases of nonhemorrhagic strokes. The other causes were extracranial vertebral artery dissection, postpartum cerebral angiopathy, inherited protein S deficiency, and disseminated intravascular coagulation associated with amniotic fluid embolism. The cause remained undetermined in four cases despite extensive investigations. Eclampsia accounted for 44% of intraparenchymal hemorrhages. Another 37% were due to rupture of a vascular malformation. The cause remained undetermined in three cases. There were four maternal deaths (all associated with intraparenchymal hemorrhage), three of them in eclamptic women. Fetal mortality and prematurity were associated with eclampsia. Conclusions: The incidence of nonhemorrhagic stroke does not seem to be much increased during pregnancy and early puerperium. In contrast to that in the nonpregnant state, the frequency of intraparenchymal hemorrhage in pregnancy appears to be similar to that of nonhemorrhagic strokes, suggesting that pregnancy may increase the risk of cerebral hemorrhage. Eclampsia is the main cause of both nonhemorrhagic stroke and intraparenchymal hemorrhage. Intraparenchymal hemorrhage associated with eclampsia carries a poor prognosis.

Aneurysmal subarachnoid hemorrhage during pregnancy is rare but is an important cause of maternal mortality. Physiologic changes in pregnancy may predispose to aneurysm formation and rupture. In general, neurosurgical considerations take precedence over obstetric considerations. Ruptured aneurysms should be treated as they would be in patients who are not pregnant. Unruptured aneurysms should be treated if they are symptomatic or enlarging. Other aneurysms should be treated on an individual basis.