Twelve days after giving birth, at the age of 36, Marguerita Hill suffered a stroke.
Her symptoms began with the worst headache she’d ever had. “It was so severe that I couldn’t sit down, I couldn’t lay down, I couldn’t do anything,” she recalls. Her fiancé suggested she take two Tylenol and try to rest, and she said no way. “I told him, ‘This is a headache where I need to go to the emergency room.’ ”
It took the ER staff a while to discover the horrible truth: A blood vessel had burst and was bleeding in her brain. Two surgeries saved her life, but the road back has been rocky. Six years later, Hill still suffers seizures, left-side weakness and other health problems.
Although stroke in conjunction with pregnancy is not common, it does occur – often with devastating results. “Everybody thinks it can’t happen [in this age group], so it often gets mismanaged because the symptoms can have a large overlap with more common problems like migraine,” says Dr. Ann Helms, a Medical College of Wisconsin neurologist practicing at Froedtert Hospital. In fact, some of the physical changes that accompany pregnancy, and especially the postpartum period, can raise a woman’s risk for stroke. Certain pregnancy complications may also have long-term effects, increasing a woman’s stroke risk later in life.
While some factors are beyond your control, understanding the risks and seeking good prenatal care can help prevent stroke. What’s more, making sure you’re in good physical condition before you conceive goes a long way toward ensuring the health of you and your baby for years to come.
Understanding Stroke
Stroke is the third-biggest killer of Americans after heart disease and cancer. Because the rate of stroke increases with age and women live longer than men, more women have strokes than men. However, younger women have strokes, too. In 2006, the National Health Interview Survey found that some 253,000 women between the ages of 18 and 44 had been told by a health professional that they’d had a stroke.
Numbers identifying the rate of stroke in pregnancy vary – sometimes widely – although studies suggest that pregnant women have a higher risk. A 2005 study published in Obstetrics & Gynecology put the rate at 34.2 per 100,000 deliveries and estimated pregnant women had three times the stroke risk of nonpregnant women. A previous study suggested pregnant women had a thirteenfold higher risk. Even with an elevated risk, it’s important to note that the overall chance of experiencing a stroke during pregnancy is low.
But that doesn’t mean it can’t happen, notes Marguerita Hill’s physician, Dr. Matthew Lee, obstetrician/gynecologist with Wheaton Franciscan Medical Group. “Whenever I’m teaching residents or medical students, I say that by definition, ‘rare’ things happen. We have to watch out for them and respond.”
Most pregnancy-related strokes occur during the third trimester or in the period immediately following delivery and up to several weeks afterward. Some experts believe the postpartum period is the time of greatest risk. Bodily changes that accompany pregnancy, such as hormonal fluctuations and an increase in blood volume, can make a woman more vulnerable. In the first six weeks postpartum, Helms explains, a woman’s blood clots more than it does at other times to stop the bleeding from delivery. This puts her at higher risk of blood clots in her legs, pulmonary embolisms and certain kinds of strokes.
Other issues separate from pregnancy itself may also contribute to stroke. For example, the risk of stroke climbs with age, and more and more women are having children later in life. Maternal obesity (like obesity in general) is common in the United States – occurring at a rate between 10 and 36 percent, according to the American College of Obstetricians and Gynecologists – and obesity is another risk factor for stroke. Diseases such as lupus, diabetes or thrombophilia (a clotting disorder) also put women at higher risk, as does smoking, alcohol or substance abuse. African-American women have an elevated risk.
Finally, some common complications of pregnancy, such as preeclampsia, can increase a woman’s risk of stroke not just during the pregnancy, but later in life. “Pregnancy is a stress for a woman’s health. It can unmask or almost forecast the complications you will have years later,” explains Dr. Suneet P. Chauhan, who practices maternal-fetal medicine at Aurora Women’s Pavilion. The symptoms of preeclampsia (characterized by high blood pressure) and gestational diabetes – another common pregnancy complication – usually go away after delivery. Yet a 2005 study by doctors at Duke University Medical Center revealed that women who developed preeclampsia and gestational diabetes during pregnancy were twice as likely or more to have a stroke, on average, 13.5 years after pregnancy. Another study, published in 2006 in the American Heart Association journal Stroke, showed that women with preeclampsia were 60 percent more likely to have a stroke in the months and years following pregnancy.
Healthy Pregnancy
Seeking prenatal counseling and making sure you’re in good health before you conceive are the best ways to prevent stroke and a slew of other negative outcomes. Chauhan likens preparing for pregnancy to getting ready for an extended trip. “Fine-tune the car before you get on the road, because it is a long journey. It’s much better to check the oil and the tires and the pressure before you get on than in the middle of it.” If you’re obese, he says, you should consider weight loss. If you already have high blood pressure, get it under control before you get pregnant. Diabetics should have their blood sugar under control for at least two months before conception. Women should also keep an eye on their cholesterol and diets and avoid smoking, notes Helms. “Once you develop these problems, it’s very hard to deal with them. If you prevent them in the first place, it’s a lot easier,” she says.
Women who have disorders that may predispose them to stroke or who have strong family histories of aneurysm should talk with their doctors, adds Lee. Maintaining regular prenatal care throughout your pregnancy will ensure that if problems develop, they’re caught early and managed appropriately.
The optimum age to get pregnant can be a delicate issue, but “if given an option,” Chauhan says, it’s better to do so before the age of 35. “It’s easier to conceive and you’re less likely to have complications,” he notes, emphasizing that the recommendation is to deliver, not just conceive, the child before the age of 35.
While all women considering pregnancy would benefit from prenatal counseling and improving their health, women with a history of stroke have a unique set of concerns. Unfortunately, they may have the hardest time determining how to manage the risks associated with pregnancy. A recent survey conducted by Helms and her colleagues at the Medical College found there is little consensus about how to treat pregnant women with a stroke history, especially during the early stages of pregnancy, when the risk of medication causing birth defects is highest. While most physicians would prescribe anti-clotting medication, especially for women who’d had pregnancy-related strokes, there is disagreement about which drug to use. “In the past, [these] women were told, ‘Just don’t get pregnant,’ ” says Helms. “Now, women are more likely to say, ‘That doesn’t work for me.’ ” The study calls for a national registry of outcomes to help physicians guide such women through pregnancy safely.
Finally, it’s important to be aware of stroke symptoms that come on suddenly, including: weakness on one side of the body, confusion, vision changes, difficulty with speaking or balance, and severe headaches. According to the National Stroke Association, women may also experience unique stroke symptoms, including sudden hiccups, sudden shortness of breath and sudden face or limb pain. The most effective stroke treatments are only available within the first three hours of the onset of symptoms, so it’s crucial to act quickly. If something doesn’t seem right, says Helms, “Don’t blow it off and say, ‘Oh, it’s just from the pregnancy.’ Take it seriously.”
Caroline Goyette is Milwaukee Magazine’s monthly health columnist.
Health Tips by Scott R. Weinberger
More heartbreak from psoriasis. If you are among the 7.5 million Americans suffering from psoriasis, a chronic autoimmune disease that shows up on the skin, you should be regularly screened for vascular disease. A recent study in the Archives of Dermatologynotes that psoriasis is not only a risk factor for heart disease, but also for stroke and hardening of the arteries in the legs.
Traveling? Watch out for blood clots. If you are at risk for blood clots, particularly in the legs and pelvis, traveling can significantly increase your chances of getting a clot. An analysis in the Annals of Internal Medicinefound that for both flying and surface travel, the longer the journey, the greater the risk. People who are especially susceptible may include those who recently had major surgery, who have vascular disease, or who use certain medications, such as birth control. Precautions include drinking fluids and keeping your legs moving as much as possible.
Fatty diet causes fatty liver. A study in Hepatology suggests that diet may affect the progression of cirrhosis, “fatty liver” disease and liver cancer. Patients with diets rich in cholesterol and protein were more likely to be hospitalized or die from cirrhosis or liver cancer than those with a high-carbohydrate diet. However, the study did not find a link between liver diseases and total fat consumed, total calories consumed or blood cholesterol levels.
Trouble conceiving? Could be the Paxil. In a Fertility & Sterility study, the popular antidepressant Paxil (also sold as Seroxat) had a subtle impact on sperm DNA. The drug caused sperm DNA “fragmentation” in more than 40 percent of participants, but didn’t affect typical measures of sperm quality, such as volume or concentration. Paxil is in the same class of drugs as Prozac and Zoloft – selective serotonin reuptake inhibitors (SSRIs). Men trying to have children may wish to discuss other depression treatments with their physicians.
Heavy menstrual blood flow solved? Using less-invasive microwave heat therapy to treat heavy menstrual bleeding may be better than surgically removing the lining of the uterus, reports a study in BJOG: An International Journal of Obstetrics and Gynaecology.Patients were followed for 10 years or more. Microwave ablation was shown to be just as effective, more acceptable to patients, and led to a lower incidence of hysterectomy in later years. It also is cheaper and results in fewer surgical complications.
