ISC 2026 | Risk factors and prevention strategies for maternal stroke in pregnancy and postpartum

Almost all maternal strokes, I shouldn’t say all, but half of them at least are associated with hypertensive disorders of pregnancy. And we consider this category of patient to be patients with underlying chronic hypertension or those with gestational hypertension or preeclampsia. So that is the category or the bucket of conditions that is most highly associated and also is the bucket that we have the most prevention or ability to treat and prevent stroke. Other conditions, though, can be things like underlying thrombophilias, sickle cell disease, antiphospholipid antibody syndrome, underlying cardiac disease, things like congenital heart disease. Sometimes we find that we have unrecognized patent foramen ovale or arterioseptal defects that result in paradoxical cardioembolism. And then the other category to bring up in the postpartum period would be patients who develop cardiomyopathy. They have about a five-fold risk for developing stroke as well. So a large amount of prevention centers around aggressively treating blood pressures, especially in the hypertensive emergency situation. So we know through multi-center randomized trial that we now treat mild-range blood pressures in pregnancy. We used to not do that before because we were concerned about its effect, the anti-hypertensive effect on utero-placental perfusion resulting in fetal growth restriction or small for gestational age infants. But we did this multi-center trial that actually looked at more aggressive treatment of patients with mild ranges, chronic hypertension, trying to aim blood pressure goals to less than 140 over 90 during the course of pregnancy. And we actually found a decrease in adverse outcomes such as preeclampsia, preterm birth, without increasing the risk for growth restriction or small for gestational age. So it’s become standard of care now in our country to treat mild range blood pressures in pregnancy with common medications like labetalol or nifedipine. So that is one group that we really target to try to reduce the risk of maternal stroke. The other group would be patients who are developing severe range blood pressures. So systolic blood pressure is greater than 160 or diastolic blood pressure is greater than 110 in the course of pregnancy increase the risk for maternal stroke. So if you have persistence of those pressures, let’s say over 10 to 15 minutes, we have protocols to aggressively treat those blood pressures to get them below the 140 over 90 range immediately so that we prevent the stroke risk for that patient.

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