Maternal Stroke Stories

Mothers-to-be and newly delivered mothers who have increased blood pressure, have certain headaches with associated auras, who are overweight or are diabetic, and those who smoke, face a higher risk of suffering from a maternal stroke.  Maternal stroke has been described as a heart attack in your brain.  There are two ways that you may have a stroke.  One way is when the blood flow to the brain is blocked by blood clots and the other way is from bleeding in the brain, which may be caused by increased blood pressure. Obstetric or maternal stroke is a medical emergency.

Fortunately for the general population of pregnant women and those who have already given birth, the occurrence of a maternal stroke is low (30 per 100,000 deliveries).  Some researchers say that maternal stroke rarely occurs.  However, there is more to the maternal stroke story other than how often it occurs.  Statistics support that 7.7% of the 30 women who have a stroke related to pregnancy will die.  If medical help does not come immediately for the pregnant woman having a stroke, her unborn baby may also die.  Mothers who have already delivered, either vaginally or by Cesarean section, may also suffer from stroke and die or be permanently brain damaged.  Their newborns may also suffer from brain damage.

Saving the Mother’s Life is the Priority

When reviewing maternal stroke stories, it is important to remember that the pregnant woman’s health and well-being come first.  Fetal heart rates may drop and become very slow while lifesaving efforts are directed toward the mother. Sometimes, hospital medical teams stop monitoring the fetal heart rate during an acute stroke event.  While this may sound uncaring, saving the mother’s life has proven to be the best way to save the unborn baby’s life and to minimize bad outcomes.

Death and Disability

Even when medical help does come quickly, there may be bad outcomes.  Mothers and their babies may survive the stroke event, but may have brain damage related to inadequate or delayed medical decision making. Sometimes, the mother’s brain damage may not be severe, but other times it is severe.  Some pregnancy related stroke survivors are dependent on others for all of their daily activities as their brain damage was very bad.  Sometimes, these mothers cannot even care for their newborns.   These newly delivered mothers may not be able to speak simple words to their babies or bundle them and cuddle together because the stroke cut off the flow of blood oxygen to their brain for too long.  Even when mothers and babies survive a stroke, the prolonged lack of normal blood flow and oxygen robs mothers and their babies of the simple pleasures in their lives.

Paying Attention to Risk Factors

Maternal stroke stories usually begin with the occurrence of a risk factor.  Some risk factors cannot be altered or changed.  Some examples are women of minorities, women of younger age, women of older age, women who are obese, and women who are economically insecure.  Other risk factors occur during the physical changes that accompany pregnancy, such as an increase in the amount of circulating blood, leaky blood vessel lining, increased pregnancy hormones, and blood pressure changes. Some health conditions, like migraines, preeclampsia, heart disease, and lupus increase the risks of maternal stroke. Even a low-risk pregnancy can become at-risk for the onset of a stroke.  Low-risk does not mean no-risk.

Stroke Assessments

Not all mothers-to-be who complain of a headache, blurry vision, who have an elevated BMI, or who have smoked will have a stroke.  However, their risk of experiencing a stroke will increase.  Because of the rising rates of death for pregnant patients, with the leading cause of pregnancy-related deaths being cardiovascular in nature, it is critical that health care teams pay close attention to patient concerns and complaints when they involve the brain, blood vessels, and the heart.  Below are some examples of assessment questions to assess maternal health history, that when answered affirmatively, may require very fast medical action:

• Does she describe her headache as a 20 out of a 10 on the pain scale or the worst pain ever?
• Did her vision change suddenly from clear to cloudy?
• Is she able to walk without stumbling?
• Has she been vomiting?
• Has she had a seizure?
• Is she an insulin dependent diabetic or a newly diagnosed preeclamptic or both?
• Is she unable to hold a cup of water in her hand due to weakness in her arm or numbness in her fingers?
• Does she complain of stiffness in her neck?
• Does she have difficulty forming words when she says her name?
• Does she act confused about the date, time, or where she is currently?
• Did she recently deliver vaginally?
• Did she deliver recently by Cesarean with spinal anesthesia?
• Was she treated for an infection after her recent Cesarean delivery?
• Did she receive a blood transfusion during or after her recent Cesarean delivery?

Rapid Response Required

The key to saving lives when this obstetrical medical emergency occurs in a hospital includes the implementation of a hospital safety plan that emphasizes maintaining obstetrical stroke readiness, early recognition of obstetrical stroke signs, rapid obstetrical stroke response, and a reporting system as a quality control process.

When the pregnant woman or a newly delivered woman shows signs of a stroke and is not in a clinic or hospital, the best plan is to get help quickly by calling 911.  Be ready to give the dispatcher the woman’s name (if you know it) and describe what you witnessed.  Stay with the woman until paramedics arrive.  Your actions may be the first lifeline for the pregnant woman and her unborn baby to get the lifesaving care that she needs.

Using an acronym such as BE FAST* can be helpful in recognizing signs and symptoms of stroke, getting rapid treatment for women having strokes, and may also be helpful in changing the outcomes of some stroke stories for mothers and babies.

BE FAST

• Balance (a sudden loss of balance or coordination)
• Eyes (a sudden loss or blurred vision)
• Face (smile, does one side droop?)
• Arms (raise both arms, does one drift down?)
• Speech (difficulty speaking or understanding)
• Time (Call 911 if outside of a medical facility, or if inside a medical facility, use the emergency call light at the bedside or go to the nurses’ station and get help)

*Adapted from:

Sushanth  Aroor, MBBS, Rajpreet Singh, MD, and Larry B. Goldstein, Stroke.2017 Feb;48(2):479-481. DOI:  10.1161/STROKEAHA.116.015169

Treating Maternal Stroke

The treatment plans for maternal stroke vary based on the type of stroke, but should begin with rapid medical assessments including a neurologic examination.  Additional medical specialties should be contacted and be involved in the stroke treatment team.  Laboratory testing will be ordered and monitored.  The maternal heart vital signs will be monitored.  Magnetic Resonance Imaging and Computed Tomography will be used to differentiate the type of maternal stroke by the treatment team.  It is best for the mother if all of these are accomplished in the first 24 hours with a transfer to a specialty hospital equipped with the technology and teams to best serve her and her unborn baby, or when the mother has already delivered.

2 Types of Maternal Stroke and 2 Paths for Treatment

Ischemic stroke is the more common type of maternal stroke.  For pregnant women with ischemic stroke, the flow of blood is blocked by a blood clot and does not reach the brain tissue, and the brain tissue dies.  In some cases, the blood does not flow regularly to the brain.  It no longer flows smoothly but becomes still or motionless.  When this happens, clots may form.  When ischemic stroke has been diagnosed, the plan of care will focus on dissolving the clot immediately with medications.  Some of the medications have to be given within a small time frame to be effective.  The clot may have to be removed surgically to help the oxygenated blood flow at a normal rate and volume again to the brain tissue for the pregnant woman.

For pregnant women with hemorrhagic stroke, one or more blood vessels break and spill the good contents (oxygen and nutrients) and the bad contents (unwanted by-products) onto brain tissue. Then, brain tissue injury or irritation, such as swelling occurs.  The bleeding, irritation, and swelling can cause increased pressure in the brain, resulting in brain damage and injury.  When a hemorrhagic stroke has been diagnosed, the plan of care will focus on decreasing the pressure in the brain.  Surgical intervention may be required for the pregnant woman.

Conclusion

This is a summary of some information on maternal stroke. While maternal stroke may not happen often, the consequences for women and their babies are tragic, real, and often devastating. The number of stroke stories for pregnant women and for newly delivered mothers continues to rise.  Ongoing research may help clinical caregivers and family members with a path forward toward decreasing the occurrence of maternal strokes and improving outcomes.

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