title: Treatment patterns and short-term outcomes in ischemic stroke in pregnancy or postpartum period.
abstract: Stroke, which is a rare but devastating event during pregnancy, occurs in 34 of every 100,000 deliveries; obstetricians are often the first providers to be contacted by symptomatic patients. At least one-half of pregnancy-related strokes are likely to be of the ischemic stroke subtype. Most pregnant or newly postpartum women with ischemic stroke do not receive acute stroke reperfusion therapy, although this is the recommended treatment for adults. Little is known about these therapies in pregnant or postpartum women because pregnancy has been an exclusion criterion for all reperfusion trials. Until recently, pregnancy and obstetric delivery were specifically identified as warnings to intravenous alteplase tissue plasminogen activator in Federal Drug Administration labeling.
  
  
  
  The primary study objective was to compare the characteristics and outcomes of pregnant or postpartum vs nonpregnant women with ischemic stroke who received acute reperfusion therapy.
  
  
  
  Pregnant or postpartum (<6 weeks; n = 338) and nonpregnant (n = 24,303) women 18-44 years old with ischemic stroke from 1991 hospitals that participated in the American Heart Association's Get With the Guidelines-Stroke Registry from 2008-2013 were identified by medical history or International Classification of Diseases, Ninth Revision, codes. Acute stroke reperfusion therapy was defined as intravenous tissue plasminogen activator, catheter-based thrombolysis, or thrombectomy or any combination thereof. A sensitivity analysis was done on patients who received intravenous tissue plasminogen activator monotherapy only. Chi-square tests were used for categoric variables, and Wilcoxon Rank-Sum was used for continuous variables. Conditional logistic regression was used to assess the association of pregnancy with short-term outcomes.
  
  
  
  Baseline characteristics of the pregnant or postpartum vs nonpregnant women with ischemic stroke revealed a younger group who, despite greater stroke severity, were less likely to have a history of hypertension or to arrive via emergency medical services. There were similar rates of acute stroke reperfusion therapy in the pregnant or postpartum vs nonpregnant women (11.8% vs 10.5%; P = .42). Pregnant or postpartum women were less likely to receive intravenous tissue plasminogen activator monotherapy (4.4% vs 7.9%; P = .03), primarily because of pregnancy and recent surgery. There was a trend toward increased symptomatic intracranial hemorrhage in the pregnant or postpartum patients who were treated with tissue plasminogen activator, yet no cases of major systemic bleeding or in-hospital death occurred, and there were similar rates of discharge to home. Data on the timing of pregnancy, which were available in 145 of 338 cases, showed that 44.8% of pregnancy-related strokes were antepartum, that 2.8% occurred during delivery, and that 52.4% were during the postpartum period.
  
  
  
  Using data from the Get With the Guidelines-Stroke Registry to assemble the largest cohort of pregnant or postpartum ischemic stroke patients who had been treated with reperfusion therapy, we observed that pregnant or postpartum women had similarly favorable short-term outcomes and equal rates of total reperfusion therapy to nonpregnant women, despite lower rates of intravenous tissue plasminogen activator use. Future studies should identify the characteristics of pregnant and postpartum ischemic stroke patients who are most likely to safely benefit from reperfusion therapy.
authors.affiliation: Obstetric Anesthesia Division, the Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Boston, MA. Electronic address: lleffert@partners.org.
authors.forename: Lisa R
authors.initials: LR
authors.lastname: Leffert
authors.affiliation: Obstetric Anesthesia Division, the Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Boston, MA.
authors.forename: Caitlin R
authors.initials: CR
authors.lastname: Clancy
authors.affiliation: Obstetric Anesthesia Division, the Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Boston, MA.
authors.forename: Brian T
authors.initials: BT
authors.lastname: Bateman
authors.affiliation: Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, NC.
authors.forename: Margueritte
authors.initials: M
authors.lastname: Cox
authors.affiliation: Clinical Trials Statistics Group, Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, NC.
authors.forename: Phillip J
authors.initials: PJ
authors.lastname: Schulte
authors.affiliation: Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Smith
authors.affiliation: Department of Medicine, Ahmanson-University of California- Los Angeles Cardiomyopathy Center, Ronald Reagan- University of California- Los Angeles Medical Center, Los Angeles, CA.
authors.forename: Gregg C
authors.initials: GC
authors.lastname: Fonarow
authors.affiliation: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Elena V
authors.initials: EV
authors.lastname: Kuklina
authors.affiliation: Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Mary G
authors.initials: MG
authors.lastname: George
authors.affiliation: Department of Neurology, Massachusetts General Hospital, Boston, MA.
authors.forename: Lee H
authors.initials: LH
authors.lastname: Schwamm
mesh_terms: D000293:Adolescent; D000328:Adult; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D020300:Intracranial Hemorrhages / Q000139:chemically induced / Q000453:epidemiology; D061185:Mechanical Thrombolysis / Q000706:statistics & numerical data; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology / Q000628:therapy*; D011644:Puerperal Disorders / Q000453:epidemiology / Q000628:therapy*; D012042:Registries; D020521:Stroke / Q000453:epidemiology / Q000628:therapy*; D017131:Thrombectomy / Q000706:statistics & numerical data; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D014481:United States / Q000453:epidemiology; D055815:Young Adult
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: ischemic; pregnancy; stroke