Steven J. Kittner, M.D., M.P.H., Barney J. Stern, M.D., Barbara R. Feeser, M.P.H., J. Richard Hebel, Ph.D., David A. Nagey, M.D., David W. Buchholz, M.D., Christopher J. Earley, M.D., Ph.D., Constance J. Johnson, M.D., Richard F. Macko, M.D., Michael A. Sloan, M.D., Robert J. Wityk, M.D., and Marcella A. Wozniak, M.D., Ph.D.
Background It is widely believed that pregnancy increases therisk of stroke, but there are few data available to quantifythat risk.
Methods We identified all female patients 15 through 44 yearsof age in central Maryland and Washington, D.C., who were dischargedfrom any of 46 hospitals in the study area in 1988 or 1991.Two neurologists reviewed each case, using data from the women'smedical records. We determined whether the women had been pregnantat the time of the stroke or up to six weeks before it occurred.For purposes of this analysis, the six-week period after pregnancycould begin with an induced or spontaneous abortion or withthe delivery of a live or stillborn child.
Results Seventeen cerebral infarctions and 14 intracerebralhemorrhages occurred in women who were or had recently beenpregnant (pregnancy-related strokes), and there were 175 cerebralinfarctions and 48 intracerebral hemorrhages that were not relatedto pregnancy. For cerebral infarction, the relative risk duringpregnancy, adjusted for age and race, was 0.7 (95 percent confidenceinterval, 0.3 to 1.6), but it increased to 8.7 for the postpartumperiod (after a live birth or stillbirth) (95 percent confidenceinterval, 4.6 to 16.7). For intracerebral hemorrhage, the adjustedrelative risk was 2.5 during pregnancy (95 percent confidenceinterval, 1.0 to 6.4) but 28.3 for the postpartum period (95percent confidence interval, 13.0 to 61.4). Overall, for eithertype of stroke during or within six weeks after pregnancy, theadjusted relative risk was 2.4 (95 percent confidence interval,1.6 to 3.6), and the attributable, or excess, risk was 8.1 strokesper 100,000 pregnancies (95 percent confidence interval, 6.4to 9.7).
Conclusions The risks of both cerebral infarction and intracerebralhemorrhage are increased in the six weeks after delivery butnot during pregnancy itself.
Source Information
From the Departments of Neurology (S.J.K., B.R.F., R.F.M., M.A.S., M.A.W.), Epidemiology and Preventive Medicine (S.J.K., J.R.H., M.A.S.), and Obstetrics and Gynecology (D.A.N.), University of Maryland, Baltimore; the Department of Neurology, Johns Hopkins University, Baltimore (D.W.B., C.J.E., C.J.J., R.J.W.); the Division of Neurology, Sinai Hospital, Baltimore (R.J.W.); and the Department of Neurology, Emory University, Atlanta (B.J.S.). Other contributing authors were Thomas R. Price, M.D., and Roger Sherwin, M.B., B.Chir., University of Maryland, Baltimore.Investigators and institutions participating in the study are listed in the Appendix.
Address reprint requests to Dr. Kittner at Bressler Bldg., Rm. 12-013, University of Maryland, 655 W. Baltimore St., Baltimore, MD 21201.
MacClellan, L. R., Howard, T. D., Cole, J. W., Stine, O. C., Giles, W. H., O'Connell, J. R., Wozniak, M. A., Stern, B. J., Mitchell, B. D., Kittner, S. J.
(2009). Relation of Candidate Genes that Encode for Endothelial Function to Migraine and Stroke: The Stroke Prevention in Young Women Study. Stroke
40: e550-e557
[Abstract][Full Text]
Datta, S., Stern, J. S, Williams, B.
(2009). Stroke during induction of labour in a patient with carotid aneurysm and prior multiple venous thromboses. Obstet Med
2: 75-76
[Abstract][Full Text]
Helms, A. K., Drogan, O., Kittner, S. J.
(2009). First Trimester Stroke Prophylaxis in Pregnant Women With a History of Stroke. Stroke
40: 1158-1161
[Abstract][Full Text]
Tiel Groenestege, A. T., Rinkel, G. J.E., van der Bom, J. G., Algra, A., Klijn, C. J.M.
(2009). The Risk of Aneurysmal Subarachnoid Hemorrhage During Pregnancy, Delivery, and the Puerperium in the Utrecht Population: Case-Crossover Study and Standardized Incidence Ratio Estimation. Stroke
40: 1148-1151
[Abstract][Full Text]
Kurth, T., Bousser, M.-G.
(2009). Stroke in Women: An Evolving Topic. Stroke
40: 1027-1028
[Full Text]
Tang, C.-H., Wu, C.-S., Lee, T.-H., Hung, S.-T., Yang, C.-Y. C., Lee, C.-H., Chu, P.-H.
(2009). Preeclampsia-Eclampsia and the Risk of Stroke Among Peripartum in Taiwan. Stroke
40: 1162-1168
[Abstract][Full Text]
WRITING GROUP MEMBERS, , Lloyd-Jones, D., Adams, R., Carnethon, M., De Simone, G., Ferguson, T. B., Flegal, K., Ford, E., Furie, K., Go, A., Greenlund, K., Haase, N., Hailpern, S., Ho, M., Howard, V., Kissela, B., Kittner, S., Lackland, D., Lisabeth, L., Marelli, A., McDermott, M., Meigs, J., Mozaffarian, D., Nichol, G., O'Donnell, C., Roger, V., Rosamond, W., Sacco, R., Sorlie, P., Stafford, R., Steinberger, J., Thom, T., Wasserthiel-Smoller, S., Wong, N., Wylie-Rosett, J., Hong, Y., for the American Heart Association Statistics Comm,
(2009). Heart Disease and Stroke Statistics--2009 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation
119: e21-e181
[Full Text]
Treadwell, S D, Thanvi, B, Robinson, T G
(2008). Stroke in pregnancy and the puerperium. Postgrad. Med. J.
84: 238-245
[Abstract][Full Text]
Davie, C A, O'Brien, P
(2008). Stroke and pregnancy. J. Neurol. Neurosurg. Psychiatry
79: 240-245
[Abstract][Full Text]
Writing Group Members, , Rosamond, W., Flegal, K., Furie, K., Go, A., Greenlund, K., Haase, N., Hailpern, S. M., Ho, M., Howard, V., Kissela, B., Kittner, S., Lloyd-Jones, D., McDermott, M., Meigs, J., Moy, C., Nichol, G., O'Donnell, C., Roger, V., Sorlie, P., Steinberger, J., Thom, T., Wilson, M., Hong, Y., for the American Heart Association Statistics Comm,
(2008). Heart Disease and Stroke Statistics--2008 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation
117: e25-e146
[Full Text]
MacClellan, L. R., Giles, W., Cole, J., Wozniak, M., Stern, B., Mitchell, B. D., Kittner, S. J.
(2007). Probable Migraine With Visual Aura and Risk of Ischemic Stroke: The Stroke Prevention in Young Women Study. Stroke
38: 2438-2445
[Abstract][Full Text]
Rosamond, W., Flegal, K., Friday, G., Furie, K., Go, A., Greenlund, K., Haase, N., Ho, M., Howard, V., Kissela, B., Kittner, S., Lloyd-Jones, D., McDermott, M., Meigs, J., Moy, C., Nichol, G., O'Donnell, C. J., Roger, V., Rumsfeld, J., Sorlie, P., Steinberger, J., Thom, T., Wasserthiel-Smoller, S., Hong, Y., for the American Heart Association Statistics Comm,
(2007). Heart Disease and Stroke Statistics--2007 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation
115: e69-e171
[Full Text]
Bushnell, C. D., Hurn, P., Colton, C., Miller, V. M., del Zoppo, G., Elkind, M. S.V., Stern, B., Herrington, D., Ford-Lynch, G., Gorelick, P., James, A., Brown, C. M., Choi, E., Bray, P., Newby, L. K., Goldstein, L. B., Simpkins, J.
(2006). Advancing the Study of Stroke in Women: Summary and Recommendations for Future Research From an NINDS-Sponsored Multidisciplinary Working Group. Stroke
37: 2387-2399
[Abstract][Full Text]
Song, Q., Cole, J. W., O'Connell, J. R., Stine, O. C., Gallagher, M., Giles, W. H., Mitchell, B. D., Wozniak, M. A., Stern, B. J., Sorkin, J. D., McArdle, P. F., Naj, A. C., Xu, Q., Gibbons, G. H., Kittner, S. J.
(2006). Phosphodiesterase 4D polymorphisms and the risk of cerebral infarction in a biracial population: the Stroke Prevention in Young Women Study. Hum Mol Genet
15: 2468-2478
[Abstract][Full Text]
Bateman, B. T., Schumacher, H. C., Bushnell, C. D., Pile-Spellman, J., Simpson, L. L., Sacco, R. L., Berman, M. F.
(2006). Intracerebral hemorrhage in pregnancy: Frequency, risk factors, and outcome. Neurology
67: 424-429
[Abstract][Full Text]
Goldstein, L. B., Adams, R., Alberts, M. J., Appel, L. J., Brass, L. M., Bushnell, C. D., Culebras, A., DeGraba, T. J., Gorelick, P. B., Guyton, J. R., Hart, R. G., Howard, G., Kelly-Hayes, M., Nixon, J.V., Sacco, R. L.
(2006). Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline.. Circulation
113: e873-e923
[Abstract][Full Text]
Goldstein, L. B., Adams, R., Alberts, M. J., Appel, L. J., Brass, L. M., Bushnell, C. D., Culebras, A., DeGraba, T. J., Gorelick, P. B., Guyton, J. R., Hart, R. G., Howard, G., Kelly-Hayes, M., Nixon, J.V., Sacco, R. L.
(2006). Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline.. Stroke
37: 1583-1633
[Abstract][Full Text]
Brown, D. W., Dueker, N., Jamieson, D. J., Cole, J. W., Wozniak, M. A., Stern, B. J., Giles, W. H., Kittner, S. J.
(2006). Preeclampsia and the Risk of Ischemic Stroke Among Young Women: Results From the Stroke Prevention in Young Women Study. Stroke
37: 1055-1059
[Abstract][Full Text]
Murugappan, A., Coplin, W. M., Al-Sadat, A. N., McAllen, K. J., Schwamm, L. H., Wechsler, L. R., Kidwell, C. S., Saver, J. L., Starkman, S., Gobin, Y. P., Duckwiler, G., Krueger, M., Rordorf, G., Broderick, J. P., Tietjen, G. E., Levine, S. R.
(2006). Thrombolytic therapy of acute ischemic stroke during pregnancy. Neurology
66: 768-770
[Abstract][Full Text]
Sacco, R. L., Adams, R., Albers, G., Alberts, M. J., Benavente, O., Furie, K., Goldstein, L. B., Gorelick, P., Halperin, J., Harbaugh, R., Johnston, S. C., Katzan, I., Kelly-Hayes, M., Kenton, E. J., Marks, M., Schwamm, L. H., Tomsick, T.
(2006). Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and Intervention: The American Academy of Neurology affirms the value of this guideline.. Circulation
113: e409-e449
[Abstract][Full Text]
Thom, T., Haase, N., Rosamond, W., Howard, V. J., Rumsfeld, J., Manolio, T., Zheng, Z.-J., Flegal, K., O'Donnell, C., Kittner, S., Lloyd-Jones, D., Goff, D. C. Jr, Hong, Y., Members of the Statistics Committee and Stroke Sta, , Adams, R., Friday, G., Furie, K., Gorelick, P., Kissela, B., Marler, J., Meigs, J., Roger, V., Sidney, S., Sorlie, P., Steinberger, J., Wasserthiel-Smoller, S., Wilson, M., Wolf, P.
(2006). Heart Disease and Stroke Statistics--2006 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation
113: e85-e151
[Full Text]
Sacco, R. L., Adams, R., Albers, G., Alberts, M. J., Benavente, O., Furie, K., Goldstein, L. B., Gorelick, P., Halperin, J., Harbaugh, R., Johnston, S. C., Katzan, I., Kelly-Hayes, M., Kenton, E. J., Marks, M., Schwamm, L. H., Tomsick, T.
(2006). Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and Intervention: The American Academy of Neurology affirms the value of this guideline.. Stroke
37: 577-617
[Abstract][Full Text]
Zeidman, L. A., Videnovic, A., Bernstein, L. P., Pellar, C. A.
(2005). Lethal Pontine Hemorrhage in Postpartum Syndrome of Hemolysis, Elevated Liver Enzyme Levels, and Low Platelet Count. Arch Neurol
62: 1150-1153
[Abstract][Full Text]
Johnson, D. M., Kramer, D. C., Cohen, E., Rochon, M., Rosner, M., Weinberger, J.
(2005). Thrombolytic Therapy for Acute Stroke in Late Pregnancy With Intra-Arterial Recombinant Tissue Plasminogen Activator. Stroke
36: e53-e55
[Abstract][Full Text]
Roine, S., Poyhonen, M., Timonen, S., Tuisku, S., Marttila, R., Sulkava, R., Kalimo, H., Viitanen, M.
(2005). Neurologic symptoms are common during gestation and puerperium in CADASIL. Neurology
64: 1441-1443
[Abstract][Full Text]
Mercieri, M., Mercieri, A., Paolini, S., Arcioni, R., Lupoi, D., Passarelli, F., Pinto, G., Celleno, D.
(2003). Postpartum cerebral ischaemia after accidental dural puncture and epidural blood patch. Br J Anaesth
90: 98-100
[Abstract][Full Text]
Brey, R. L., Stallworth, C. L., McGlasson, D. L., Wozniak, M. A., Wityk, R. J., Stern, B. J., Sloan, M. A., Sherwin, R., Price, T. R., Macko, R. F., Johnson, C. J., Earley, C. J., Buchholz, D. W., Hebel, J. R., Kittner, S. J., Tuhrim, S., Levine, S. R.
(2002). Antiphospholipid Antibodies and Stroke in Young Women * Editorial Comment. Stroke
33: 2396-2401
[Abstract][Full Text]
Lanska, D. J., Jaigobin, C., Silver, F.
(2001). Re: Stroke and Pregnancy Response. Stroke
32: 1694-1695
[Full Text]
Goldstein, L. B., Adams, R., Becker, K., Furberg, C. D., Gorelick, P. B., Hademenos, G., Hill, M., Howard, G., Howard, V. J., Jacobs, B., Levine, S. R., Mosca, L., Sacco, R. L., Sherman, D. G., Wolf, P. A., del Zoppo, G. J., Members,
(2001). Primary Prevention of Ischemic Stroke : A Statement for Healthcare Professionals From the Stroke Council of the American Heart Association. Circulation
103: 163-182
[Full Text]
Malarcher, A. M., Giles, W. H., Croft, J. B., Wozniak, M. A., Wityk, R. J., Stolley, P. D., Stern, B. J., Sloan, M. A., Sherwin, R., Price, T. R., Macko, R. F., Johnson, C. J., Earley, C. J., Buchholz, D. W., Kittner, S. J.
(2001). Alcohol Intake, Type of Beverage, and the Risk of Cerebral Infarction in Young Women. Stroke
32: 77-83
[Abstract][Full Text]
DERKSEN, R H W M, DE GROOT, P. G, NIEUWENHUIS, H K, CHRISTIAENS, G C M L
(2001). How to treat women with antiphospholipid antibodies in pregnancy?. Ann Rheum Dis
60: 1-3
[Full Text]
Goldstein, L. B., Adams, R., Becker, K., Furberg, C. D., Gorelick, P. B., Hademenos, G., Hill, M., Howard, G., Howard, V. J., Jacobs, B., Levine, S. R., Mosca, L., Sacco, R. L., Sherman, D. G., Wolf, P. A., del Zoppo, G. J.
(2001). Primary Prevention of Ischemic Stroke : A Statement for Healthcare Professionals From the Stroke Council of the American Heart Association. Stroke
32: 280-299
[Full Text]
Jaigobin, C., Silver, F. L.
(2000). Stroke and Pregnancy. Stroke
31: 2948-2951
[Abstract][Full Text]
MacGregor, E A.
(2000). Migraine and female hormones - what factors increase the risk of ischemic stroke?. Vasc Med
5: 133-134
Lamy, C., Hamon, J. B., Coste, J., Mas, J. L.
(2000). Ischemic stroke in young women: Risk of recurrence during subsequent pregnancies. Neurology
55: 269-274
[Abstract][Full Text]
Gillum, L. A., Mamidipudi, S. K., Johnston, S. C.
(2000). Ischemic Stroke Risk With Oral Contraceptives: A Meta-analysis. JAMA
284: 72-78
[Abstract][Full Text]
Lanska, D. J., Kryscio, R. J.
(2000). Risk Factors for Peripartum and Postpartum Stroke and Intracranial Venous Thrombosis. Stroke
31: 1274-1282
[Abstract][Full Text]
Kittner, S. J., Giles, W. H., Macko, R. F., Hebel, J. R., Wozniak, M. A., Wityk, R. J., Stolley, P. D., Stern, B. J., Sloan, M. A., Sherwin, R., Price, T. R., McCarter, R. J., Johnson, C. J., Earley, C. J., Buchholz, D. W., Malinow, M. R.
(1999). Homocyst(e)ine and Risk of Cerebral Infarction in a Biracial Population : The Stroke Prevention in Young Women Study. Stroke
30: 1554-1560
[Abstract][Full Text]
Zuber, M, Gautschi, N, Oechslin, E, Widmer, V, Kiowski, W, Jenni, R
(1999). Outcome of pregnancy in women with congenital shunt lesions. Heart
81: 271-275
[Abstract][Full Text]
Ruiz-Sandoval, J. L., Cantu, C., Barinagarrementeria, F.
(1999). Intracerebral Hemorrhage in Young People : Analysis of Risk Factors, Location, Causes, and Prognosis. Stroke
30: 537-541
[Abstract][Full Text]
Bousser, M.-G.
(1999). Stroke in Women : The 1997 Paul Dudley White International Lecture. Circulation
99: 463-467
[Full Text]
Macko, R. F., Kittner, S. J., Epstein, A., Cox, D. K., Wozniak, M. A., Wityk, R. J., Stern, B. J., Sloan, M. A., Sherwin, R., Price, T. R., McCarter, R. J., Johnson, C. J., Earley, C. J., Buchholz, D. W., Stolley, P. D.
(1999). Elevated Tissue Plasminogen Activator Antigen and Stroke Risk : The Stroke Prevention in Young Women Study. Stroke
30: 7-11
[Abstract][Full Text]
Ursell, M. R., Marras, C. L., Farb, R., Rowed, D. W., Black, S. E., Perry, J. R.
(1998). Recurrent Intracranial Hemorrhage Due to Postpartum Cerebral Angiopathy : Implications for Management. Stroke
29: 1995-1998
[Abstract][Full Text]
Wagner, K. R., Giles, W. H., Johnson, C. J., Ou, C.-Y., Bray, P. F., Goldschmidt-Clermont, P. J., Croft, J. B., Brown, V. K., Stern, B. J., Feeser, B. R., Buchholz, D. W., Earley, C. J., Macko, R. F., McCarter, R. J., Sloan, M. A., Stolley, P. D., Wityk, R. J., Wozniak, M. A., Price, T. R., Kittner, S. J.
(1998). Platelet Glycoprotein Receptor IIIa Polymorphism P1A2 and Ischemic Stroke Risk : The Stroke Prevention in Young Women Study. Stroke
29: 581-585
[Abstract][Full Text]
Joynt, R. J., Kurlan, R. M.
(1997). Neurology. JAMA
277: 1873-1874
Marini, C., Carolei, A.
(1997). Traditional Risk Factors for Stroke in the Young. Arch Neurol
54: 351-352
[Abstract]
Forcier, G. L., Brown, A. J.C., Kittner, S. J.
(1997). Stroke and Pregnancy. NEJM
336: 665-665
[Full Text]
Previous
