INCIDENCE AND CAUSES OF STROKES ASSOCIATED WITH PREGNANCY AND PUERPERIUM - A STUDY IN PUBLIC HOSPITALS OF ILE-DE-FRANCE

Background and Purpose The incidence, causes, and prognosis of nonhemo rrhagic strokes and intraparenchymal hemorrhages occurring in associat ion with pregnancy or puerperium are poorly understood. Methods We car ried out a retrospective (1989 through 1991) and prospective (1992) st udy in 63 public maternities (348 295 deliveries) of the region of lie de France (10 660 554 inhabitants) and in the neurology, neurosurgery , and intensive care units of the same geographic area. Records of wom en who suffered a cerebrovascular event during pregnancy or the first 2 weeks postpartum were reviewed by two study neurologists. Stroke was defined according to the criteria of the World Health Organization. R esults Thirty-one cases of strokes were identified, including 15 nonhe morrhagic strokes (including strokelike deficits associated with eclam psia) and 16 intraparenchymal hemorrhages, assessed in all cases by CT scan and/or MRI. The incidence of nonhemorrhagic strokes in women who delivered in public maternities of Ile de France was 4.3 per 100 000 deliveries (95% confidence interval, 2.4 to 7.1) and that of intrapare nchymal hemorrhage was 4.6 per 100 000 deliveries (95% confidence inte rval, 2.6 to 7.5). Eclampsia accounted for 47% of cases of nonhemorrha gic strokes. The other causes were extracranial vertebral artery disse ction, postpartum cerebral angiopathy, inherited protein S deficiency, and disseminated intravascular coagulation associated with amniotic f luid embolism. The cause remained undetermined in four cases despite e xtensive investigations. Eclampsia accounted for 44% of intraparenchym al hemorrhages. Another 37% were due to rupture of a vascular malforma tion. The cause remained undetermined in three cases. There were four maternal deaths (all associated with intraparenchymal hemorrhage), thr ee of them in eclamptic women. Fetal mortality and prematurity were as sociated with eclampsia. Conclusions The incidence of nonhemorrhagic s troke does not seem to be much increased during pregnancy and early pu erperium. In contrast to that in the nonpregnant state, the frequency of intraparenchymal hemorrhage in pregnancy appears to be similar to t hat of nonhemorrhagic strokes, suggesting that pregnancy may increase the risk of cerebral hemorrhage. Eclampsia is the main cause of both n onhemorrhagic stroke and intraparenchymal hemorrhage. Intraparenchymal hemorrhage associated with eclampsia carries a poor prognosis.