For most women awaiting the arrival of their baby, pregnancy is filled with celebration — although it’s often coupled with fatigue and nausea. What most people don’t realize is that pregnancy places them at higher risk for stroke than they otherwise would be, not just during those nine months, but also in the weeks and months after giving birth.

This is also true for physicians who don’t regularly care for expectant women but nonetheless encounter them in daily practice. For neurologists, this often comes in the form of a patient presenting during pregnancy with focal neurologic deficits, which can be extremely daunting, says neurologist Constance Katsafanas, D.O., with Marcus Neuroscience Institute at Boca Raton Regional Hospital, part of Baptist Health. “Even though your patient is your patient, you still have someone else to consider — the unborn baby,” she says.

Stroke is three times more common in pregnant and postpartum women than it is in nonpregnant women of the same age, according to the American Heart Association. While it is important to note that maternal stroke isn’t common, it does occur approximately 30 of every 100,000 deliveries and one in 500 women who develop preeclampsia (which is a new onset of severe high blood pressure during pregnancy).

“Pregnancy increases the risk of thrombosis, or blood clots, three- to four-fold,” says Dr. Katsafanas, who was one of the experts who spoke recently at the Marcus Neuroscience Institute Brain & Spine Symposium, an educational meeting for physicians and other healthcare professionals highlighting the latest advances in the treatment of neurological conditions.

“During pregnancy, the blood gets more sticky, and there’s good reason for that,” she explains. “When women deliver, they bleed. Coagulation is the body’s protective mechanism, and the clotting is very important. But when this clotting gets out of control, we have problems.”

In addition, a lot changes during pregnancy and it’s not just hormones. Blood volume increases as well, which means the heart has to work harder. When this is coupled with the fact that many women become less active during pregnancy, for some this is enough to cause problems.

The likelihood of stroke is also raised in women who have medical conditions prior to pregnancy, such as high blood pressure, or with illnesses like diabetes, pre-existing cardiovascular conditions and structural heart conditions such as a patent foramen ovale (PFO). Black and Hispanic women are at higher risk for these underlying conditions than other groups.

Conditions such as infective endocarditis and acquired cardiac conditions, including peripartum cardiomyopathy (a form of heart failure that can occur toward the end of pregnancy or even in the months that follow childbirth), also increase the risk of stroke.

“Stroke can lead to significant long-term disability after pregnancy, and it can cause the death of mother and baby,” Dr. Katsafanas says.

She goes on to add that stroke prevention involves close monitoring of patients with known risk factors. If you’re a primary care or family physician, an OB/GYN, an emergency medicine doctor or any other specialist who may have a pregnant patient, be aware that some conditions are best evaluated by a neurologist or cardiologist who specializes in maternal health or high-risk pregnancies. Women may need to be placed on blood pressure medications or undergo other treatment to lessen their risk of stroke.

“In women who have had prior ischemic heart disease with or without revascularization therapy, the weakness of the heart muscle can become apparent with the increased cardiac output required by pregnancy,” she says. This means that if a woman had a heart attack, whether or not it was treated with stenting or bypass, the heart is weaker. While it may not show that weakness under normal conditions, the increased blood volume and work required in pregnancy can make it apparent.

If a woman has a stroke during or following pregnancy, the positive news is that treatment options are available, and outcomes can be quite good, particularly if the patient is cared for at a comprehensive stroke center.

“Unfortunately, 58 percent of pregnant or postpartum patients with acute ischemic stroke do not receive thrombolytic therapy (clot-busting drugs) because providers wrongly believe that pregnancy excludes them,” Dr. Katsafanas says. “This is a real problem. Pregnant women were not included in the drug trials for intravenous alteplase, so initially it was considered a contraindication. However, the American Heart Association/American Stroke Association said in their 2018 guidelines that ‘IV alteplase administration may be considered in pregnancy when the anticipated benefits of treating moderate or severe stroke outweigh the anticipated increased risks of uterine bleeding.’ These are decisions that take a trained neurologist to make.”

Some women with ischemic strokes, which account for about 87 percent of all strokes, are also candidates for endovascular thrombectomy. In a minimally invasive procedure, doctors thread a thin catheter through an artery to the point of the blockage and remove the clot, restoring blood flow to the brain. This, like the clot-busting medications, must be done quickly to save as much brain as possible.

One of the reasons that strokes are becoming more common in pregnant women is because more women are holding off pregnancy until they are older. Despite that, they are more likely to have a good outcome. “The one thing these women have going for them is that they are younger than the average stroke patient and younger brains typically do better. We have favorable outcomes for about 80 percent of these women,” Dr. Katsafanas says.

During pregnancy, all women should have their blood pressure regularly checked and if their BP readings equal or exceed 140/90 on two separate occasions they should be evaluated and treated. Also, expectant mothers should be aware of any signs of high blood pressure, including:

• Severe headaches
• Sudden weight gain or swelling of the face and/or extremities
• Upper stomach pain
• Vision changes, including temporary loss of vision, blurred eyesight or sensitivity to light
• Blood in the urine
• Shortness of breath

If you have a patient who is considering pregnancy and has a history of high blood pressure, an existing cardiac condition or another illness that puts her at high risk of stroke, talk to her about a referral to a specialist.