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Chapter 75 - Eclampsia and Strokes During Pregnancy and Postpartum

from Section 9 - Vasospastic Conditions and Other Miscellaneous Vasculopathies

Published online by Cambridge University Press:  15 June 2018

By
Jennifer J. Majersik ,
Michael W. Varner  and
Kathleen B. Digre
Edited by
Louis Caplan  and
José Biller
Louis Caplan
Affiliation:
Beth Israel-Deaconess Medical Center, Boston
José Biller
Affiliation:
Loyola University Stritch School of Medicine, Chicago
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Uncommon Causes of Stroke , pp. 606 - 620
Publisher: Cambridge University Press
Print publication year: 2018

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References

Kuklina, EV, Tong, X, Bansil, P, George, MG, Callaghan, WM. Trends in pregnancy hospitalizations that included a stroke in the United States from 1994 to 2007: Reasons for concern? Stroke. 2011;42:2564–70.Google Scholar
Lidegaard, O, Lokkegaard, E, Jensen, A, Skovlund, CW, Keiding, N. Thrombotic stroke and myocardial infarction with hormonal contraception. N Engl J Med. 2012;366:2257–66.Google Scholar
Kittner, SJ, Stern, BJ, Feeser, BR, et al. Pregnancy and the risk of stroke. N Engl J Med. 1996;335:768–74.Google Scholar
Bateman, BT, Schumacher, HC, Bushnell, CD, et al. Intracerebral hemorrhage in pregnancy: Frequency, risk factors, and outcome. Neurology. 2006;67:424–9.Google Scholar
Scott, CA, Bewley, S, Rudd, A, et al. Incidence, risk factors, management, and outcomes of stroke in pregnancy. Obstet Gynecol. 2012;120: 318–24.Google Scholar
Kamel, H, Navi, BB, Sriram, N, et al. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med. 2014;370:1307–15.Google Scholar
O’Donnell, MJ, Xavier, D, Liu, L, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): A case–control study. Lancet. 2010;376:112–23.Google ScholarPubMed
Liang, CC, Chang, SD, Lai, SL, et al. Stroke complicating pregnancy and the puerperium. Eur J Neurol. 2006;13:1256–60.Google Scholar
Tang, CH, Wu, CS, Lee, TH, et al. Preeclampsia–eclampsia and the risk of stroke among peripartum in Taiwan. Stroke. 2009;40:1162–8.CrossRefGoogle ScholarPubMed
Sharshar, T, Lamy, C, Mas, JL. Incidence and causes of strokes associated with pregnancy and puerperium. A study in public hospitals of Ile de France. Stroke in Pregnancy Study Group. Stroke. 1995;26:930–6.CrossRefGoogle Scholar
Bateman, BT, Olbrecht, VA, Berman, MF, et al. Peripartum subarachnoid hemorrhage: Nationwide data and institutional experience. Anesthesiology. 2012;116:324–33.CrossRefGoogle ScholarPubMed
Kim, YW, Neal, D, Hoh, BL. Cerebral aneurysms in pregnancy and delivery: Pregnancy and delivery do not increase the risk of aneurysm rupture. Neurosurgery. 2013;72:143–9.CrossRefGoogle Scholar
Leffert, LR, Clancy, CR, Bateman, BT, et al. Treatment patterns and short-term outcomes in ischemic stroke in pregnancy or postpartum period. Am J Obstet Gynecol. 2016;214:723.Google Scholar
Leffert, LR, Clancy, CR, Bateman, BT, et al. Patient characteristics and outcomes after hemorrhagic stroke in pregnancy. Circ Cardiovasc Qual Outcomes. 2015;8:S170–178.Google Scholar
Cruz-Herranz, A, Illan-Gala, I, Martinez-Sanchez, P, Fuentes, B, Diez-Tejedor, E. Recurrence of stroke amongst women of reproductive age: Impact of and on subsequent pregnancies. Eur J Neurol. 2015;22:681-e642.CrossRefGoogle ScholarPubMed
American College of Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122:1122–31.Google Scholar
Sibai, BM. Eclampsia. In Goldstein, PJ, Stern, BJ, eds. Neurological Disorders of Pregnancy. Mount Kisco, NY: Futura Publishing; 1992, pp. 1–24.Google Scholar
Douglas, KA, Redman, CW. Eclampsia in the United Kingdom. BMJ. 1994;309:1395–400.CrossRefGoogle ScholarPubMed
Hirshfeld-Cytron, J, Lam, C, Karumanchi, SA, Lindheimer, M. Late postpartum eclampsia: Examples and review. Obstet Gynecol Surv. 2006;61:471–80.Google Scholar
Andersgaard, AB, Herbst, A, Johansen, M, et al. Eclampsia in Scandinavia: Incidence, substandard care, and potentially preventable cases. Acta Obstet Gynecol Scand. 2006;85:929–36.Google ScholarPubMed
Lopez-Jaramillo, P, Garcia, RG, Lopez, M. Preventing pregnancy-induced hypertension: Are there regional differences for this global problem? J Hypertens. 2005;23:1121–9.Google Scholar
Creanga, AA, Berg, CJ, Syverson, C, Seed, K, Bruce, FC, Callaghan, WM. Pregnancy-related mortality in the United States, 2006–2010. Obstet Gynecol. 2015;125:5–12.Google Scholar
Duckitt, K, Harrington, D. Risk factors for pre-eclampsia at antenatal booking: Systematic review of controlled studies. BMJ. 2005;330:565.Google Scholar
Foo, L, Bewley, S, Rudd, A. Maternal death from stroke: A thirty year national retrospective review. Eur J Obstet Gynecol Reprod Biol. 2013;171:266–70.CrossRefGoogle ScholarPubMed
MacKay, AP, Berg, CJ, Atrash, HK. Pregnancy-related mortality from preeclampsia and eclampsia. Obstet Gynecol. 2001;97:533–8.Google ScholarPubMed
Lucas, MJ, Leveno, KJ, Cunningham, FG. A comparison of magnesium sulfate with phenytoin for the prevention of eclampsia. N Engl J Med. 1995;333:201–5.Google Scholar
Anon. Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet. 1995;345:1455–63.Google Scholar
Belfort, MA, Anthony, J, Saade, GR, Allen, JC Jr., Nimodipine Study, Group. A comparison of magnesium sulfate and nimodipine for the prevention of eclampsia. N Engl J Med. 2003;348:304–11.Google Scholar
Altman, D, Carroli, G, Duley, L, et al. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: A randomised placebo-controlled trial. Lancet. 2002;359:1877–90.Google Scholar
Duley, L, Henderson-Smart, DJ, Meher, S. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database Syst Rev. 2006:CD001449.CrossRefGoogle Scholar
Granger, JP, Alexander, BT, Llinas, MT, Bennett, WA, Khalil, RA. Pathophysiology of hypertension during preeclampsia linking placental ischemia with endothelial dysfunction. Hypertension. 2001; 38: 718–22.Google Scholar
Khong, TY, De Wolf, F, Robertson, WB, Brosens, I. Inadequate maternal vascular response to placentation in pregnancies complicated by pre-eclampsia and by small-for-gestational age infants. Br J Obstet Gynaecol. 1986;93:1049–59.Google Scholar
Johnson, AC, Cipolla, MJ. The cerebral circulation during pregnancy: Adapting to preserve normalcy. Physiology (Bethesda). 2015;30:139–47.Google ScholarPubMed
Wilson, ML, Goodwin, TM, Pan, VL, Ingles, SA. Molecular epidemiology of preeclampsia. Obstet Gynecol Surv. 2003;58:39–66.Google Scholar
Esplin, MS, Fausett, MB, Fraser, A, et al. Paternal and maternal components of the predisposition to preeclampsia. N Engl J Med. 2001;344:867–72.Google Scholar
Easton, JD. Severe preeclampsia/eclampsia: Hypertensive encephalopathy of pregnancy? Cerebrovasc Dis. 1998;8:53–8.Google Scholar
Schobel, HP, Fischer, T, Heuszer, K, Geiger, H, Schmieder, RE. Preeclampsia: A state of sympathetic overactivity. N Engl J Med. 1996;335:1480–5.Google Scholar
Witlin, AG, Friedman, SA, Egerman, RS, Frangieh, AY, Sibai, BM. Cerebrovascular disorders complicating pregnancy: Beyond eclampsia. Am J Obstet Gynecol. 1997;176:1139–1145.Google Scholar
Singhal, AB, Hajj-Ali, RA, Topcuoglu, MA, et al. Reversible cerebral vasoconstriction syndromes: Analysis of 139 cases. Arch Neurol. 2011;68:1005–12.CrossRefGoogle ScholarPubMed
Singhal, AB. Postpartum angiopathy with reversible posterior leukoencephalopathy. Arch Neurol. 2004;61:411–16.Google Scholar
Tanaka, K, Matsushima, M, Matsuzawa, Y, et al. Antepartum reversible cerebral vasoconstriction syndrome with pre-eclampsia and reversible posterior leukoencephalopathy. J Obstet Gynaecol Res. 2015;41:1843–7.Google Scholar
Hinchey, J, Chaves, C, Appignani, B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996;334:494–500.Google Scholar
Manfredi, M, Beltramello, A, Bongiovanni, LG, Polo, A, Pistoia, L, Rizzuto, N. Eclamptic encephalopathy: Imaging and pathogenetic considerations. Acta Neurol Scand. 1997;96:277–82.Google Scholar
Demirtas, O, Gelal, F, Vidinli, BD, Demirtas, LO, Uluc, E, Baloglu, A. Cranial MR imaging with clinical correlation in preeclampsia and eclampsia. Diagn Interv Radiol. 2005;11:189–94.Google Scholar
Bartynski, WS. Posterior reversible encephalopathy syndrome, part 1: Fundamental imaging and clinical features. AJNR Am J Neuroradiol. 2008;29(6):1036–42.Google Scholar
Hefzy, HM, Bartynski, WS, Boardman, JF, Lacomis, D. Hemorrhage in posterior reversible encephalopathy syndrome: Imaging and clinical features. AJNR Am J Neuroradiol. 2009;30:1371–9.CrossRefGoogle ScholarPubMed
Pande, AR, Ando, K, Ishikura, R, et al. Clinicoradiological factors influencing the reversibility of posterior reversible encephalopathy syndrome: A multicenter study. Radiat Med. 2006;24:659–68.CrossRefGoogle ScholarPubMed
Akins, PT, Axelrod, Y, Silverthorn, JW, et al. Management and outcomes of malignant posterior reversible encephalopathy syndrome. Clin Neurol Neurosurg. 2014;125:52–7.Google Scholar
Bartynski, WS. Posterior reversible encephalopathy syndrome, part 2: Controversies surrounding pathophysiology of vasogenic edema. AJNR Am J Neuroradiol. 2008;29:1043–9.Google Scholar
Demir, BC, Ozerkan, K, Ozbek, SE, Yildirim Eryilmaz, N, Ocakoglu, G. Comparison of magnesium sulfate and mannitol in treatment of eclamptic women with posterior reversible encephalopathy syndrome. Arch Gynecol Obstet. 2012;286:287–93.Google Scholar
Lanska, DJ, Kryscio, RJ. Risk factors for peripartum and postpartum stroke and intracranial venous thrombosis. Stroke. 2000;31:1274–82.CrossRefGoogle ScholarPubMed
Coutinho, JM, Ferro, JM, Canhao, P, et al. Cerebral venous and sinus thrombosis in women. Stroke. 2009;40:2356–61.CrossRefGoogle ScholarPubMed
Nasr, DM, Brinjikji, W, Cloft, HJ, Saposnik, G, Rabinstein, AA. Mortality in cerebral venous thrombosis: Results from the national inpatient sample database. Cerebrovasc Dis. 2013;35:40–4.Google Scholar
Cantu, C, Barinagarrementeria, F. Cerebral venous thrombosis associated with pregnancy and puerperium. Review of 67 cases. Stroke. 1993;24:1880–4.CrossRefGoogle ScholarPubMed
Saposnik, G, Barinagarrementeria, F, Brown, RD Jr., et al. Diagnosis and management of cerebral venous thrombosis: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:1158–92.CrossRefGoogle ScholarPubMed
Aguiar de Sousa, D, Canhao, P, Ferro, JM. Safety of pregnancy after cerebral venous thrombosis: A systematic review. Stroke. 2016;47:713–18.Google Scholar
Lewey, J, Haythe, J. Cardiomyopathy in pregnancy. Semin Perinatol. 2014;38:309–17.Google Scholar
Sliwa, K, Hilfiker-Kleiner, D, Petrie, MC, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: A position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail. 2010;12:767–78.Google Scholar
Elkayam, U. Clinical characteristics of peripartum cardiomyopathy in the United States: Diagnosis, prognosis, and management. J Am Coll Cardiol. 2011;58:659–70.CrossRefGoogle ScholarPubMed
Goland, S, Modi, K, Bitar, F, et al. Clinical profile and predictors of complications in peripartum cardiomyopathy. J Card Fail. 2009;15:645–50.Google Scholar
Sliwa, K, Blauwet, L, Tibazarwa, K, et al. Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy: A proof-of-concept pilot study. Circulation. 2010;121:1465–73.Google Scholar
Ishii, A, Miyamoto, S. Endovascular treatment in pregnancy. Neurol Med Chir (Tokyo). 2013;53:541–8.Google Scholar
Protection ICoR. Pregnancy and medical radiation. ICRP Publication 84. 2000;30.Google Scholar
Patel, SJ, Reede, DL, Katz, DS, Subramaniam, R, Amorosa, JK. Imaging the pregnant patient for nonobstetric conditions: Algorithms and radiation dose considerations. Radiographics. 2007;27:1705–22.Google Scholar
American College of Radiology and American Society of Neuroradiology Statement on CT Protocols and Radiation Dose. 2009; http://www.acr.org/about-us/media-center/position-statements/position-statements-folder/the-acr-and-american-society-of-neuroradiology-statement-on-ct-protocols-and-radiation-dose. Accessed 1/7/16.Google Scholar
Kozan, A, Yildirmak, ST, Mihmanli, V, et al. Serum oxidized low density lipoprotein levels in preeclamptic and normotensive pregnants. Clin Exp Obstet Gynecol. 2015;42:746–8.Google Scholar
Abbassi-Ghanavati, M, Greer, LG, Cunningham, FG. Pregnancy and laboratory studies: A reference table for clinicians. Obstet Gynecol. 2009;114:1326–31.Google Scholar
Jauch, EC, Saver, JL, Adams, HP Jr., et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870–947.CrossRefGoogle ScholarPubMed
Selim, MH, Molina, CA. The use of tissue plasminogen-activator in pregnancy: A taboo treatment or a time to think out of the box. Stroke. 2013;44:868–9.CrossRefGoogle ScholarPubMed
Ahearn, GS, Hadjiliadis, D, Govert, JA, Tapson, VF. Massive pulmonary embolism during pregnancy successfully treated with recombinant tissue plasminogen activator: A case report and review of treatment options. Arch Intern Med. 2002;162:1221–7.Google Scholar
Turrentine, MA, Braems, G, Ramirez, MM. Use of thrombolytics for the treatment of thromboembolic disease during pregnancy. Obstet Gynecol Surv. 1995;50:534–41.Google Scholar
Dapprich, M, Boessenecker, W. Fibrinolysis with alteplase in a pregnant woman with stroke. Cerebrovasc Dis. 2002;13:290.Google Scholar
Del Zotto, E, Giossi, A, Volonghi, I, Costa, P, Padovani, A, Pezzini, A. Ischemic stroke during pregnancy and puerperium. Stroke Res Treat. 2011;2011:606780.Google ScholarPubMed
Li, Y, Margraf, J, Kluck, B, Jenny, D, Castaldo, J. Thrombolytic therapy for ischemic stroke secondary to paradoxical embolism in pregnancy: A case report and literature review. Neurologist. 2012;18:44–8.Google Scholar
Ritchie, J, Lokman, M, Panikkar, J. Thrombolysis for stroke in pregnancy at 39 weeks gestation with a subsequent normal delivery. BMJ Case Rep. 2015 ;2015:bcr2015209563.Google Scholar
Demchuk, AM. Yes, intravenous thrombolysis should be administered in pregnancy when other clinical and imaging factors are favorable. Stroke. 2013;44:864–5.Google Scholar
Broderick, JP. Should intravenous thrombolysis be considered the first option in pregnant women? Stroke. 2013;44:866–7.CrossRefGoogle ScholarPubMed
Demaerschalk, BM, Kleindorfer, DO, Adeoye, OM, et al. Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016;47:581–641.CrossRefGoogle ScholarPubMed
Powers, WJ, Derdeyn, CP, Biller, J, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:3020–35.Google Scholar
Abou-Chebl, A, Lin, R, Hussain, MS, et al. Conscious sedation versus general anesthesia during endovascular therapy for acute anterior circulation stroke: Preliminary results from a retrospective, multicenter study. Stroke. 2010;41:1175–9.Google Scholar
Bushnell, C, McCullough, LD, Awad, IA, et al. Guidelines for the prevention of stroke in women: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:1545–88.Google Scholar
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 125: Chronic hypertension in pregnancy. Obstet Gynecol. 2012; 119:396–407.Google Scholar
Abalos, E, Duley, L, Steyn, DW, Henderson-Smart, DJ. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2007:CD002252.Google Scholar
von Dadelszen, P, Magee, LA. Fall in mean arterial pressure and fetal growth restriction in pregnancy hypertension: An updated metaregression analysis. J Obstet Gynaecol Can. 2002;24:941–5.Google Scholar
Brown, DW, Dueker, N, Jamieson, DJ, et al. Preeclampsia and the risk of ischemic stroke among young women: Results from the Stroke Prevention in Young Women study. Stroke. 2006;37:1055–9.Google Scholar
Irgens, HU, Reisaeter, L, Irgens, LM, Lie, RT. Long term mortality of mothers and fathers after pre-eclampsia: Population based cohort study. BMJ. 2001;323:1213–17.Google Scholar
Sattar, N, Greer, IA. Pregnancy complications and maternal cardiovascular risk: Opportunities for intervention and screening? BMJ. 2002;325:157–60.Google Scholar
Wilson, BJ, Watson, MS, Prescott, GJ, et al. Hypertensive diseases of pregnancy and risk of hypertension and stroke in later life: Results from cohort study. BMJ. 2003;326:845.Google Scholar
Lee, G, Tubby, J. Preeclampsia and the risk of cardiovascular disease later in life: A review of the evidence. Midwifery. 2015;31:1127–34.Google Scholar
Seely, EW, Tsigas, E, Rich-Edwards, JW. Preeclampsia and future cardiovascular disease in women: How good are the data and how can we manage our patients? Semin Perinatol. 2015;39:276–83.Google Scholar
Rich-Edwards, JW, Klungsoyr, K, Wilcox, AJ, Skjaerven, R. Duration of pregnancy, even at term, predicts long-term risk of coronary heart disease and stroke mortality in women: A population-based study. Am J Obstet Gynecol. 2015;213:518e511–18.Google Scholar
Smith, GN, Pudwell, J, Walker, M, Wen, SW. Ten-year, thirty-year, and lifetime cardiovascular disease risk estimates following a pregnancy complicated by preeclampsia. J Obstet Gynaecol Can. 2012;34:830–5.Google Scholar
Bellamy, L, Casas, JP, Hingorani, AD, Williams, DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: Systematic review and meta-analysis. BMJ. 2007;335:974.Google Scholar
McDonald, SD, Malinowski, A, Zhou, Q, Yusuf, S, Devereaux, PJ. Cardiovascular sequelae of preeclampsia/eclampsia: a systematic review and meta-analyses. Am Heart J. 2008;156:918–30.Google Scholar
Aukes, AM, De Groot, JC, Wiegman, MJ, et al. Long-term cerebral imaging after pre-eclampsia. BJOG. 2012;119:1117–22.Google Scholar
Williams, D. Pregnancy: A stress test for life. Curr Opin Obstet Gynecol. 2003;15:465–71.Google Scholar
Romundstad, PR, Magnussen, EB, Smith, GD, Vatten, LJ. Hypertension in pregnancy and later cardiovascular risk: Common antecedents? Circulation. 2010;122:579–84.Google Scholar
Berks, D, Hoedjes, M, Raat, H, et al. Risk of cardiovascular disease after pre-eclampsia and the effect of lifestyle interventions: A literature-based study. BJOG. 2013;120:924–31.Google Scholar
Berks, D, Steegers, EA, Molas, M, Visser, W. Resolution of hypertension and proteinuria after preeclampsia. Obstet Gynecol. 2009;114:1307–14.Google Scholar
Amaral, LM, Cunningham, MW Jr., Cornelius, DC, LaMarca, B. Preeclampsia: Long-term consequences for vascular health. Vasc Health Risk Manag. 2015;11:403–15.Google Scholar
Mosca, L, Benjamin, EJ, Berra, K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women – 2011 update: A guideline from the American Heart Association. J Am Coll Cardiol. 2011;57:1404–23.Google Scholar
Heidema, WM, Scholten, RR, Lotgering, FK, Spaanderman, ME. History of preeclampsia is more predictive of cardiometabolic and cardiovascular risk factors than obesity. Eur J Obstet Gynecol Reprod Biol. 2015;194:189–93.Google Scholar
Skurnik, G, Roche, AT, Stuart, JJ, et al. Improving the postpartum care of women with a recent history of preeclampsia: A focus group study. Hypertens Pregnancy. 2016;35:371–81.CrossRefGoogle Scholar

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