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Intracerebral hemorrhage in pregnancy

Frequency, risk factors, and outcome

From the Department of Anesthesiology (M.F.B.), College for Physicians & Surgeons (B.T.B.), Columbia University, New York; Doris and Stanley Tananbaum Stroke Center, Neurological Institute (H.C.S., R.L.S.), and Interventional Neuroradiology, Departments of Radiology, Neurology, and Neurosurgery (J.P.-S.), New York-Presbyterian Hospital, College of Physicians & Surgeons, Columbia University, New York; Duke Center for Cerebrovascular Disease (C.D.B.), Department of Medicine (Neurology), Duke University Medical Center, Durham, NC; Department of Obstetrics and Gynecology (L.L.S.), Division of Maternal Fetal Medicine, New York Presbyterian Medical Center, College of Physicians and Surgeons, Columbia University, New York; and Department of Epidemiology (R.L.S.), Mailman School of Public Health, Columbia University, New York, NY.

Address correspondence and reprint requests to Dr. H. Christian Schumacher, Doris & Stanley Tananbaum Stroke Center, Neurological Institute, New York Presbyterian Hospital, College of Physicians & Surgeons, Columbia University, 710 West 168th Street, Box 163, New York, NY 10032; e-mail: hs775{at}columbia.edu

Objective: To describe the frequency, risk factors, and outcome of intracerebral hemorrhage (ICH) in pregnancy and the postpartum period using a large database of US inpatient hospitalizations.

Methods: The authors obtained data from an administrative dataset, the Nationwide Inpatient Sample, which includes approximately 20% of all discharges from non-Federal hospitals, for the years 1993 through 2002. Women aged 15 to 44 years with a diagnosis of ICH were selected from the database for analysis, and within this group patients coded as pregnant or postpartum were identified. Using US Census data, estimates were made of the rates of ICH in pregnant/postpartum and non-pregnant women. Rates of various comorbidities in patients with pregnancy-related ICH were compared to the rates found in the general population of delivering patients using multivariate logistic regression to identify independent risk factors for pregnancy-related ICH.

Results: The authors identified 423 patients with pregnancy-related ICH, which corresponded to 6.1 pregnancy-related ICH per 100,000 deliveries and 7.1 pregnancy-related ICH per 100,000 at-risk person-years (compared to 5.0 per 100,000 person-years for non-pregnant women in the age range considered). The increased risk of ICH associated with pregnancy was largely attributable to ICH occurring in the postpartum period. The in-hospital mortality rate for pregnancy-related ICH was 20.3%. ICH accounted for 7.1% of all pregnancy-related mortality recorded in this database. Significant independent risk factors for pregnancy-related ICH included advanced maternal age (OR 2.11, 95% CI 1.69 to 2.64), African American race (OR 1.83, 95% CI 1.39 to 2.41), preexisting hypertension (OR 2.61, 95% CI 1.34 to 5.07), gestational hypertension (OR 2.41, 95% CI 1.62 to 3.59), preeclampsia/eclampsia (OR 10.39, 95% CI 8.32 to 12.98), preexisting hypertension with superimposed preeclampsia/eclampsia (OR 9.23, 95% CI 5.26 to 16.19), coagulopathy (OR 20.66, 95% CI 13.67 to 31.23), and tobacco abuse (OR 1.95, 95% CI 1.11 to 3.42).

Conclusion: Intracerebral hemorrhage (ICH) accounts for a substantial portion of pregnancy-related mortality. The risk of ICH associated with pregnancy is greatest in the postpartum period. Advanced maternal age, African American race, hypertensive diseases, coagulopathy, and tobacco abuse were all independent risk factors for pregnancy-related ICH.

B.T.B. was supported by the Doris Duke Charitable Foundation. J.P.S. was supported in part by a grant from NYSTAR. C.D.B. receives research support from the NIH and from Bristol Myers Squibb/Sanofi Partnership. R.L.S. is supported by grants from NINDS (Specialized Program on Translational Research in Acute Stroke, P50 049060).

Disclosure: The authors report no conflicts of interest.

Received December 20, 2005. Accepted in final form April 4, 2006.

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