New Guidelines and Research Highlight Maternal Stroke Risks and Care

The American Heart Association (AHA), endorsed by the American College of Obstetricians & Gynecologists (ACOG), has released a new scientific statement summarizing research and offering suggestions for the prevention, management, and recovery of stroke during pregnancy and the postpartum period. Concurrently, a preliminary study presented at the American Stroke Association's International Stroke Conference 2026 indicates that women with a history of stroke face a more than two-fold increased risk of experiencing another ischemic stroke during pregnancy or within six weeks postpartum.

New Scientific Statement on Maternal Stroke Care

The AHA's scientific statement, titled "Prevention and Treatment of Maternal Stroke in Pregnancy and Postpartum," consolidates current research on risk factors and causes while providing recommendations for care. Stroke, though rare, is a potentially life-threatening complication, occurring in approximately 20 to 40 out of every 100,000 pregnancies and contributing to an estimated 4-6% of annual pregnancy-related deaths in the U.S.

Strokes are categorized as ischemic (caused by a blood vessel blockage) or hemorrhagic (caused by a blood vessel rupture). Historically, pregnant and postpartum women have often been excluded from clinical trials, but observational research over the past decade has contributed to informing optimal care strategies.

Dr. Eliza Miller, chair of the writing group for the statement, emphasized the significance of blood pressure control, risk management, and timely recognition of stroke symptoms.

Identified Risk Factors

Physiological changes inherent to pregnancy, including vascular and hormonal shifts, are recognized contributors to stroke risk. Additional identified risk factors include:

• Chronic hypertension (high blood pressure present before or early in pregnancy)
• Hypertensive disorders of pregnancy (e.g., gestational hypertension, preeclampsia/eclampsia)
• Advanced maternal age (35 years or older)
• Diabetes
• Obesity
• Migraine, particularly with aura
• Infections
• Existing heart or cerebrovascular disease
• Clotting disorders

Data indicates that Black pregnant women experience stroke at twice the rate of white pregnant women, even after adjusting for socioeconomic factors.

Prevention Strategies

Prevention efforts are recommended to begin before conception, encouraging women to adopt primary stroke prevention strategies such as smoking cessation, healthy eating, regular physical activity, and weight management. The statement identifies early and consistent blood pressure control as a critical factor in preventing most maternal strokes.

The AHA's 2025 High Blood Pressure Guideline references ACOG's diagnostic criteria for hypertension in pregnancy, defined as a systolic blood pressure of ≥140 mm Hg or a diastolic blood pressure of ≥90 mm Hg. Close monitoring of blood pressure, particularly in the early postpartum period, is considered essential due to elevated risk during this time. Treating high blood pressure with medication during pregnancy and postpartum can mitigate complications from severe hypertension and preeclampsia. Low-dose aspirin has been noted to reduce preeclampsia risk in high-risk individuals.

Diagnosis and Treatment

Healthcare professionals involved in the care of pregnant and postpartum patients are advised to be trained in recognizing stroke symptoms to facilitate prompt treatment. Rapid evaluation for possible stroke is crucial for women who are pregnant or have recently given birth and present with new neurological deficits or severe headaches, especially when accompanied by elevated blood pressure.

Diagnostic imaging techniques, including computed tomography (CT), CT angiography, and magnetic resonance imaging (MRI) without contrast, are considered safe for rapid evaluation in pregnant patients exhibiting acute stroke symptoms. The statement asserts that pregnancy should not delay recommended acute stroke treatments. Various anti-clotting medications are deemed safe for pregnant and lactating women, and mechanical thrombectomy may be necessary for patients with large-vessel blockages.

Delivery and Recovery Considerations

A stroke occurring during pregnancy does not automatically necessitate immediate delivery if the mother's condition is stable and the fetus is preterm. However, if the mother's neurological or cardiovascular status deteriorates, preterm delivery may become necessary. Cesarean delivery is preferably avoided when feasible to minimize surgical risks and blood pressure changes.

Survivors of pregnancy-associated stroke often face unique challenges, including infant care, and benefit from support provided by a multidisciplinary rehabilitation team. Post-stroke mood and sleep disorders, fatigue, anxiety, and depression are common occurrences, which may be intensified by postpartum factors. These conditions can be managed with behavioral therapy, counseling, and medication, with the involvement of family members and caregivers in rehabilitation planning considered beneficial for recovery.

Preliminary Study Highlights Increased Stroke Risk for Prior Stroke Survivors

A separate preliminary study, presented at the American Stroke Association's International Stroke Conference 2026, utilized a national database of electronic health records from 2015 to 2025, encompassing 220,479 pregnant women aged 15 to 50. The research found that women with a history of prior ischemic stroke were over two times more likely to experience a recurrent ischemic stroke during pregnancy or within six weeks postpartum, even after adjusting for demographic and health factors.

Specific Risks Identified:

• Women with a history of prior ischemic stroke had a 34.82% stroke rate (415 new ischemic strokes among 1,192 pregnant women) compared to 0.34% (737 new strokes among 219,287 pregnant women) for those without a prior stroke.
• The risk of ischemic stroke during pregnancy and early postpartum was 82% higher for pregnant women with a previous heart attack.
• The risk was 25% higher for pregnant women with obesity.

Dr. Adnan I. Qureshi, the study's lead author, stated that the increased risk for women with a prior stroke during pregnancy and early postpartum does not appear to be influenced by other risk factors. He emphasized the need for increased attention and a higher level of care for pregnant women who have previously experienced a stroke.

Dr. Jennifer Lewey highlighted the importance of pre-conception counseling for women with a history of ischemic stroke to discuss and mitigate risks during pregnancy. She also suggested that an interdisciplinary team of neurologists and obstetricians could develop comprehensive surveillance and treatment plans.

Recommendations from the study include intensifying preventive efforts for women with a history of ischemic stroke, which may involve identifying the cause of the initial stroke, reviewing medications during pregnancy, managing blood pressure, maintaining a healthy diet, and engaging in regular physical activity. Dr. Qureshi proposed that these high-risk pregnancies should be managed at specialized healthcare centers, noting the current absence of specific clinical guidelines for this demographic.

Study Limitations:

The study is an observational analysis relying on data from a large database of electronic health records. The findings are considered preliminary as abstracts presented at American Heart Association/American Stroke Association scientific meetings are not peer-reviewed and await publication as full manuscripts in a peer-reviewed scientific journal.