Intracerebral hemorrhage risk remains elevated for months postpartum

  • Meeks JR & al.
  • JAMA Netw Open
  • 1 Apr 2020

  • curated by Susan London
  • Clinical Essentials
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Takeaway

  • Risk for primary intracerebral hemorrhage (ICH) remains elevated during pregnancy (especially the third trimester) and for 12 weeks afterward.

Why this matters

  • Vigilant monitoring, aggressive management of risk factors could reduce risk.
  • Editorial calls findings "informative," given the scarcity of data on ICH during these periods.

Study design

  • US cohort crossover study of 3,314,945 pregnant adolescents and adults without prior ICH.
  • Comparison: 64-week exposure period (40 weeks of pregnancy, 24 weeks postpartum) vs a 64-week nonexposure period starting a year later.
  • Main outcome: ICH.
  • Funding: None disclosed.

Key results

  • Compared with the nonexposure period, ICH risk was significantly elevated in the:
    • Third trimester:
      • 2.9 vs 0.7 cases per 100,000 pregnancies. 
      • Rate ratio (RR), 4.16 (95% CI, 2.52-6.86).
    • First 12 weeks postpartum:
      • 4.4 vs 0.5 cases per 100,000 pregnancies.
      • RR, 9.15 (95% CI, 5.16-16.23).
  • Independent predictors of ICH during pregnancy and postpartum period (aORs; 95% CIs):
    • Increasing maternal age: 1.08 (1.05-1.10).
    • Black race: 2.44 (1.73-3.44).
    • Asian ancestry: 2.12 (1.34-3.35).
    • Hispanic ethnicity: 1.59 (1.12-2.26).
    • Hypertension: 2.02 (1.19-3.42).
    • Gestational hypertension: 2.73 (1.91-3.91).
    • Coagulopathy: 14.17 (9.17-21.89).
    • Preeclampsia/eclampsia: 9.23 (6.99-12.19).
    • Tobacco use: 2.83 (1.53-5.23).
  • ICH during pregnancy/postpartum increased risks for:
    • Maternal death:
      • Relative risk difference: 792.6.
      • Absolute risk difference: 0.18.
    • Fetal death:
      • Relative risk difference: 5.3.
      • Absolute risk difference: 0.03.

Limitations

  • Possible selection, misclassification biases.
  • Potential residual/unmeasured confounding.