Stroke is a rare but serious complication of pregnancy, affecting approximately 20-40 per 100,000 pregnancies. The risks are higher in women with preeclampsia. Stroke can cause severe harm to both the mother and the fetus. It accounts for 4-6% of maternal deaths in the U.S., although stroke-related deaths may be underreported. Recovery can be good, but mortality remains significant. Risk factors include blood disorders, migraine, hypertensive disorder, heart disease, and infection, with Black patients disproportionately affected. Pregnancy-related strokes vary in type and commonly occur around delivery or in the postpartum period. Care requires a multidisciplinary approach. A scientific statement from the American Heart Association (AHA) summarizes the causes and risk factors of pregnancy-related stroke, highlights hypertensive disorders as major contributors, and provides consensus guidance on postpartum recovery, prevention, and acute care.
Primary prevention of pregnancy-related stroke follows the 2024 AHA/American Stroke Association (ASA) Life’s Essential 8 framework with additional targeted strategies for high-risk patients. Severe hypertension (≥ 160/110 mmHg) is a medical emergency, as most fatal maternal strokes from intracerebral hemorrhage are preventable with timely blood pressure control. Treatment aims to maintain blood pressure of <140/90 mmHg during pregnancy, while optimal postpartum targets remain under investigation. Low-dose aspirin reduces the risk of preeclampsia in high-risk individuals with a risk ratio of 0.85 (95% confidence interval [CI]: 0.75-0.95). Peripartum cardiomyopathy, cardiac conditions, and hematologic disorders markedly increase the risk of stroke. Close postpartum monitoring, multidisciplinary care, and individualized antithrombotic therapy are essential to reduce maternal mortality and morbidity.
Secondary prevention focuses on reducing recurrent stroke in women with prior cerebrovascular events. Recurrence during pregnancy is rare, with cohort studies demonstrating a very low risk. Management primarily involves close monitoring of blood pressure, use of low-dose aspirin or anticoagulation, preconception counseling and lifestyle modification, as well as careful medication review.
Acute stroke in pregnancy and the postpartum period requires rapid diagnosis and care to reduce the morbidity of fetal and maternal complications. New-onset neurological deficits or severe headache, particularly with hypertension, warrant immediate evaluation as hypertensive disorders of pregnancy markedly increase the risk of stroke. Assessment includes neurological examination, history, and measurement of blood pressure. Pregnant and postpartum patients may represent outpatient settings, emergencies, or obstetric settings. All clinicians caring for pregnant individuals should be trained to activate a stroke alert and mobilize a multidisciplinary maternal stroke team, such as emergency medicine, neonatology, anesthesiology, pharmacy, nursing, vascular neurology, and maternal-fetal medicine or obstetrics when needed. Telestroke consultation is recommended when in-person neurology is unavailable.
Both magnetic resonance imaging (MRI) and computed tomography (CT) without contrast are considered safe during pregnancy, and fetal radiation exposure from a maternal head CT is extremely low, at less than 0.1 mGy. Contrast-enhanced imaging may be performed when the expected diagnostic benefit to the mother outweighs potential risks to the fetus. Registry data show in-hospital deaths among pregnant or postpartum patients treated with thrombectomy or thrombolysis with outcomes comparable to non-pregnant patients. Alteplase does not cross the placenta and may be used when the benefits outweigh bleeding risks. Mechanical thrombectomy is recommended for eligible large-vessel occlusions, preferably using a transradial approach.
Hemorrhagic stroke management requires individualized, multidisciplinary planning, including neurosurgical intervention when indicated. Postpartum monitoring for 24-72 hours with strict blood pressure control is essential. Recovery is supported by multidisciplinary rehabilitation, mental health screening, and individualized counseling on contraception and lactation.
Overall, this multidisciplinary approach synthesizes current evidence and provides consensus guidance for postpartum recovery, acute treatment, and prevention in maternal stroke. Until further research is available, early recognition, coordinated management, and patient-centered care remain critical to improve maternal outcomes and reduce the burden of pregnancy-related stroke.
Reference: Miller EC, Bello NA, Chen PR, et al. Prevention and Treatment of Maternal Stroke in Pregnancy and Postpartum: A Scientific Statement from the American Heart Association. Stroke. 2026. doi:10.1161/STR.0000000000000514
