Incidence of First Stroke in Pregnant and Nonpregnant Women of Childbearing Age: A Population‐Based Cohort Study From England

Ban, Lu; Sprigg, Nikola; Sultan, Alyshah Abdul; Nelson‐Piercy, Catherine; Bath, Philip M.; Ludvigsson, Jonas F.; Stephansson, Olof; Tata, Laila J.

doi:10.1161/jaha.116.004601

Cited by 63 publications

(76 citation statements)

References 27 publications

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“…Similar evidence of elevated ICH risk in the early postpartum period also exists for non-US patient populations. 15 Although our findings broadly confirm these prior reports and other reviews, 13,16 there are differences in risk estimates. Temporal trends in risk profiles, differences in population characteristics, design effects (cross-sectional vs longitudinal), residual confounding in unmatched designs, and non-trimester-specific observing could potentially account for these differences.…”

Section: Maternal and Fetal Outcomessupporting

confidence: 88%

Association of Primary Intracerebral Hemorrhage With Pregnancy and the Postpartum Period

et al. 2020

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IMPORTANCE Intracerebral hemorrhage (ICH) during pregnancy and the postpartum period results in catastrophic maternal outcomes. There is a paucity of population-based estimates of pregnancyrelated ICH risk, including risk during the extended postpartum period. OBJECTIVE To evaluate ICH risk during pregnancy and an extended 24-week postpartum period in a population-level cohort and to determine fetal and maternal outcomes as well as demographic and comorbidity factors associated with ICH during pregnancy and post partum. DESIGN, SETTING, AND PARTICIPANTS This study used a cohort-crossover design in which patients serve as their own controls when no longer exposed (pregnant or post partum). Administrative data were obtained from all hospital admissions for New York, California, and Florida for a 7-to 10-year period. Participants included all women admitted for labor and delivery who were older than 12 years and did not have a prior diagnosis of ICH. Conditional Poisson regression models were used to evaluate ICH risk, and data were reported as rate ratios and 95% CIs. Data analysis was performed from August 2018 to February 2020. EXPOSURES Women were tracked using hospitalization records for the duration of pregnancy (40 weeks), for 24 weeks post partum, and for an additional 64 weeks when no longer exposed. MAIN OUTCOMES AND MEASURES Diagnosis of ICH during both 64-week observation periods was determined using validated International Classification of Diseases, Ninth Revision codes. RESULTS A total of 3 314 945 pregnant women were included (mean [SD] age, 28.17 [6.47] years; 1 451 780 white [43.79%], 474 808 black [14.32%], 246 789 Asian [7.44%], and 835 917 Hispanic [25.22%]). The risk of ICH was significantly higher during the third trimester (2.9 vs 0.7 cases per 100 000 pregnancies; rate ratio, 4.16; 95% CI, 2.52-6.86) and remained elevated during the first 12 weeks post partum (4.4 vs 0.5 cases per 100 000 pregnancies; rate ratio, 9.15; 95% CI, 5.16-16.23).

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Section: Maternal and Fetal Outcomessupporting

confidence: 88%

Association of Primary Intracerebral Hemorrhage With Pregnancy and the Postpartum Period

et al. 2020

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“…After completing our systematic review and meta-analysis, on 27 April 2017, an additional population-level analysis was published online. 12 This study, from the United Kingdom, reported a stroke event rate of 24.7/100,000 pregnancies. It should be noted that the population study of Leffert et al 17 from the United States included here showed a rate of 38.6.…”

Section: Stroke Subtypes and Stroke Timingmentioning

confidence: 94%

“…While an association between stroke and pregnancy has been long identified, 7,8 estimates of incidence vary widely, from 1.5 per 100,000 deliveries 9 to 98 per 100,000 deliveries. 10 There are many sources of this variability, including differences in populations (pregnant women found in stroke registries 11 versus strokes found in pregnancy registries 12 ), setting (case series, 13,14 single institution experiences, 15,16 population-level data abstraction 12 ), and geography, 10,[15][16][17][18][19] which include variations in genetics, diet, risk factor prevalence, and health care systems. Estimates may also be affected by changes over time (e.g.…”

Section: Introductionmentioning

confidence: 99%

The incidence of pregnancy-related stroke: A systematic review and meta-analysis

Swartz

Cayley

Foley

et al. 2017

International Journal of Stroke

229

163

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Background Stroke risk is increased during pregnancy, but estimates of pregnancy-related stroke incidence vary widely. Aims A systematic review and meta-analysis was conducted to assess the incidence of stroke during pregnancy and the puerperium. Ovid Medline, EMBASE, and ISI Web of Science were searched for studies published between 1990 and January 2017 reporting stroke incidence during pregnancy and postpartum, from defined pregnancy populations. Pooled analyses were conducted using a random effects approach and expressed as an incidence rate per 100,000 pregnancies, with 95% confidence intervals. Subgroup analyses of stroke type and timing were conducted. Summary of review Eleven studies met inclusion criteria. Variation in estimated rates was noted based on geography and study methodology. The pooled crude rate of pregnancy-related stroke was 30.0 per 100,000 pregnancies (95% confidence interval 18.8-47.9). The pooled crude rates from nonhemorrhagic stroke (arterial and cerebral venous sinus thrombosis) were 19.9 (95% confidence interval 10.7-36.9) and from hemorrhage 12.2 (95% confidence interval 6.4-23.2) per 100,000 pregnancies. For studies separately reporting cerebral venous sinus thrombosis, the rates were roughly equal between ischemic stroke (12.2, 95% confidence interval 6.7-22.2), cerebral venous sinus thrombosis (9.1, 95% confidence interval 4.3-18.9), and hemorrhage (12.2, 95% confidence interval 6.4-23.2). The crude stroke rate for antenatal/perinatal stroke was 18.3 (95% confidence interval 11.9-28.2), and for postpartum stroke was 14.7 (95% confidence interval 8.3-26.1). Conclusions Stroke affects 30.0 per 100,000 pregnancies, with ischemia, cerebral venous sinus thrombosis, and hemorrhage causing roughly equal numbers and with highest risk peripartum and postpartum. Organized approaches to the management of this high-risk population, informed by existing evidence from stroke and obstetrical care are needed.

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“…Maternity data contained in HES includes extensive information on pregnancy, labour and delivery; it is the main data source for monitoring maternity statistics in England and is used to for perinatal epidemiology research . Our previous studies using the CPRD‐HES linked population show maternities are representative of those across the English population . Patients were not involved in the development of the research.…”

Section: Methodsmentioning

confidence: 99%

“…23,24 Our previous studies using the CPRD-HES linked population show maternities are representative of those across the English population. 25,26 Patients were not involved in the development of the research.…”

Section: Data Sourcementioning

confidence: 99%

Clinical management of nausea and vomiting in pregnancy and hyperemesis gravidarum across primary and secondary care: a population‐based study

Fiaschi

Nelson‐Piercy

Deb

et al. 2019

BJOG

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Objectives To assess how nausea and vomiting in pregnancy (NVP) and hyperemesis gravidarum (HG) are managed and treated across primary and secondary care. Design Population‐based pregnancy cohort. Setting Medical records (CPRD‐GOLD) from England. Population 417 028 pregnancies during 1998–2014. Methods Proportions of pregnancies with recorded NVP/HG diagnoses, primary care treatment, and hospital admissions were calculated. Multinomial logistic regression was employed to estimate adjusted relative risk ratios (aRRRs) with 99% confidence intervals (CIs) for the association between NVP/HG management paths and maternal characteristics. Main outcome measures NVP/HG diagnoses, treatments, and hospital admissions. Results Overall prevalence of clinically recorded NVP/HG was 9.1%: 2.1% had hospital admissions, 3.4% were treated with antiemetics in primary care only, and 3.6% had only recorded diagnoses. Hospital admissions and antiemetic prescribing increased continuously during 1998–2013 (trend P < 0.001). Younger age, deprivation, Black/Asian/mixed ethnicity, and multiple pregnancy were associated with NVP/HG generally across all levels, but associations were strongest for hospital admissions. Most comorbidities had patterns of association with NVP/HG levels. Among women with NVP/HG who had no hospital admissions, 49% were prescribed antiemetics, mainly from first‐line treatment (21% prochlorperazine, 15% promethazine, 13% cyclizine) and metoclopramide (10%). Of those admitted, 38% had prior antiemetic prescriptions (34% first‐line, 9% second‐line, 1% third‐line treatment). Conclusion Previous focus on hospital admissions has greatly underestimated the NVP/HG burden. Although primary care prescribing has increased, most women admitted to hospital have no antiemetics prescribed before this. An urgent call is made to assess whether admissions could be prevented with better primary care recognition and timely treatment. Tweetable abstract The NVP/HG burden is increasing over time and management optimisation should be high priority to help reduce hospital admissions.

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Incidence of First Stroke in Pregnant and Nonpregnant Women of Childbearing Age: A Population‐Based Cohort Study From England

Cited by 63 publications

References 27 publications

Association of Primary Intracerebral Hemorrhage With Pregnancy and the Postpartum Period

Association of Primary Intracerebral Hemorrhage With Pregnancy and the Postpartum Period

The incidence of pregnancy-related stroke: A systematic review and meta-analysis

Clinical management of nausea and vomiting in pregnancy and hyperemesis gravidarum across primary and secondary care: a population‐based study

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