Interventions at the Community,Patient,and Provider Level to Improve Timely Diagnosis and Treatment of Neurovascular Emergencies in the Peripartum Period

Abstract

Neurovascular emergencies in the peripartum period, though rare, represent a significant cause of maternal morbidity and mortality worldwide. These conditions include ischemic and hemorrhagic strokes, cerebral venous sinus thrombosis, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, and cervical artery dissection. Clinical presentation can be subtle or nonfocal, delaying diagnosis. Early recognition through high clinical suspicion, prompt neuroimaging, and involvement of a neurological team is critical. This review highlights the most common neurovascular emergencies in the peripartum period and proposed interventions to better prevent, diagnose, and treat them.

Introduction

Neurovascular emergencies are a leading cause of maternal morbidity and mortality and require timely recognition and management. During this period, individuals are at higher risk of neurological complications such as cerebral venous sinus thrombosis, reversible cerebral vasoconstriction syndrome, intracranial hemorrhage, cervical artery dissection, posterior reversible encephalopathy syndrome, and ischemic stroke. Though acute stroke treatment has advanced, delays persist in detection, management, and treatment of stroke in the peripartum period. Providers that frequently encounter these patients, like obstetricians and midwives, often lack neurological training. Furthermore, symptoms of neurological emergencies in the peripartum period may overlap with symptoms related to pregnancy or preeclampsia such as headache, nausea, or anxiety, obscuring the diagnosis. Table 1 shows the most common neurovascular emergencies associated with pregnancy and the postpartum period.

Table 1.

Neurovascular Emergencies Related to Pregnancy, Their Clinical Presentations, and Epidemiology

Neurovascular emergency	Description	Clinical presentation	Epidemiology/health disparities
Cerebral Venous Sinus Thrombosis (CVST)	Clot forms in the venous sinuses around the brain leading to pressure buildup, which can cause infarction or intraparenchymal hemorrhage	Insidious headache, blurry vision, focal neurological symptoms, and sometimes seizure	Of all pregnancy-associated strokes, the crude rate of CVST is about 9.1% 1
Posterior Reversible Vasoconstriction Syndrome (PRES)	Neurotoxic state characterized by increased vasogenic edema, often predominantly in the parieto-occipital lobes	Headache, seizure, altered mental status, visual disturbances, hypertension	High overlap with eclampsia and severe preeclampsia, reported up to 51.4% occurrence in eclampsia and 19.8% in severe preeclampsia 2
Ischemic Stroke	Decreased blood flow to the brain tissue leads to lasting brain damage and neurological deficits	Acute focal neurological symptoms, headache	Minority groups have a higher risk for stroke compared to non-Hispanic whites, even after adjusting for SDOH.3,4 Among women with chronic HTN, black, Hispanic, and Asian/Pacific Islander women had higher risk of stroke 4
Hemorrhagic Stroke	Blood in the brain or around the brain. May be from underlying arterio-venous malformation or aneurysm. Other causes include HDP, CVST, hemorrhagic conversion of ischemic strokes, and RCVS	Headache, altered mental status, focal neurological symptoms	Individuals without HTN: all minority groups were at increased risk of hemorrhagic stroke compared with white women; highest risk seen in black women. 3 HDP are the largest risk factor for hemorrhagic stroke in pregnancy and postpartum. For patients with chronic hypertension, the risk is over 6 times higher among Black and Hispanic women compared to non-Hispanic white women 3
Cervical Artery Dissection (CAD)	A tear in the internal carotid arteries or vertebral arteries that can lead to ischemic stroke	Neck pain, headache, focal neurological symptoms, nausea, vomiting	Risk of dissection is doubled during pregnancy and post-partum compared to nonpregnant individuals. The risk is felt to be about 8 per 100,000 pregnant individuals 5
Reversible Vasoconstriction Syndrome (RCVS)	Vasoconstriction of the intracranial arteries with varying clinical course form self-limited to fulminant. Can be complicated by ischemic and hemorrhagic stroke	Thunderclap headache, typically associated with a trigger (vasoactive substance, Valsalva, postpartum state)	Meta-analysis of pregnancy-related RCVS found that the prevalence in the postpartum period was 11.9% 6 Disproportionate number of Hispanic patients who experience RCVS related to pregnancy 7

HTN, hypertension; SDOH, social drivers of health; HDP, hypertensive disorders of pregnancy.

Pregnancy-related neurological complications are also influenced by health-related social needs (e.g., access to healthy food, stable housing, financial stability, and transportation). ⁸ Social drivers of health (SDOH) are conditions in the environments where people are born and live that affect health. ⁸ Limited access to health care, lack of provider education, racism, and provider bias can all lead to diagnostic delays in patients presenting with acute neurological emergencies in pregnancy and postpartum. Here, we draw on our clinical expertise and limited available data to offer suggestions for improving neurovascular outcomes in peripartum and postpartum individuals.

Interventions

Identification of signs and symptoms of neurological emergencies is critical in the peripartum period. Often, patients first present to urgent care, community members, family, labor triage, or the emergency department, and not to a neurologist, who may be better equipped to recognize red flag symptoms. We propose the following interventions to address and reduce neurovascular complications related to pregnancy (Fig. 1). The levels of intervention are influenced by social-ecological models, like the one proposed by Mcleroy et al. 1988. ⁹

FIG. 1.

Levels of intervention to improve timely diagnosis and management of neurovascular emergencies related to pregnancy. FMLA, family and medical leave act; OBLS, obstetric life support.

Patient level

Early identification starts with the patient. In prenatal visits, patients should be educated on all warning signs and symptoms that are common in the postpartum period, including those specific to neurology, so that they can advocate for themselves in the peripartum period. For patients who are considered at high risk for complications (history of preeclampsia, chronic hypertension, etc.), counseling could include advising blood pressure (BP) monitoring from 20 weeks through 6 weeks postpartum. We recommend patients be given a BP monitor to keep at home.

Provider level

Providers have an opportunity to prevent neurovascular complications during prenatal visits. Since we already know that members of minority groups have a higher risk for stroke, especially those with chronic hypertension, their BP should be diligently monitored during and after pregnancy. ³ Those with chronic hypertension and superimposed preeclampsia, and those with sustained BP over 140/90 mmHg, have an increased risk for stroke related to pregnancy.^10,11 A retrospective study of 44 million US deliveries found that stroke occurred in 1 in 370 deliveries among people with superimposed preeclampsia, compared with 1 in 5000 deliveries in those without hypertension. ¹⁰ Additionally, a meta-analysis that pooled 12 studies of BP after 20 weeks gestation found that systolic BP >140 mmHg or diastolic BP >90 mm Hg was associated with more than double the risk for stroke, compared with normal BP. ¹²

The recent Chronic Hypertension and Pregnancy trial showed that treating chronic hypertension to a target BP of <140/90 mmHg resulted in a 20% reduction in the primary composite outcome, which included preeclampsia with severe features, medically indicated preterm birth, placental abruption, and fetal or neonatal death, prompting the ACOG to adjust their recommended BP threshold for chronic hypertension in pregnancy to treat if >140/90 mmHg.^13,14 Due to the rarity of neurovascular emergencies related to pregnancy and postpartum, there are limited data regarding the effects of antihypertensive treatment on stroke risk in pregnancy; however, observational data suggest that tighter control of BP in pregnancy is associated with reduced stroke risk.^15,16

Headache is a common symptom of pregnancy, but it can also be a sign of a neurological emergency. ACOG does recommend that patients are screened for history of migraine during prepregnancy and initial prenatal visits. ¹⁷

If a patient or community member identifies a high-risk situation and makes a referral to the emergency department or urgent care, it is then vital that health care providers recognize red flag signs and symptoms of neurovascular emergencies and order appropriate workup. Educational interventions are important for the emergency room, primary care, OBGYN, and neurology trainees. We recommend the required education for all neurology residents in neurological issues specific to women, including obstetric neurological emergencies, unique neurological risks of pregnancy and in the postpartum period, as well as how neurological conditions can be affected during pregnancy.

Lastly, obstetric units should have maternal stroke protocols in place with a triage system and easy way of emergent communication with neurology.

Community level

Community-based solutions can offer culturally aligned care that builds trust and improves outcomes. For example, doulas provide nonclinical emotional, physical, and informational support before, during, and after birth. It is therefore imperative that neurovascular emergencies are added to the discussion of other pregnancy and postpartum complications as part of doula training.

Centering Pregnancy is a group prenatal care model that combines health assessment, education, and support into an unified program led by health care providers. This has been associated with improved birth outcomes, increased prenatal attendance, and reduced racial disparities. ¹⁸

Black-led birth centers may also help reduce adverse pregnancy outcomes. Birth Center Equity, born during the COVID-19 pandemic, is an organization that invests in local birth centers nationwide led by Black, Indigenous, and people of color. These birth centers offer culturally sensitive care and work to address maternal disparities.

Policy level

Legislation at the local, state, and federal levels can improve health care during and after pregnancy. Many patients lose health care coverage from Medicaid just weeks after delivery. The American Rescue Plan Act, signed by President Biden, included a provision allowing states to extend Medicaid and Children’s Health Insurance Program (CHIP) coverage for pregnant individuals from 60 days to 12 months postpartum. This increased access to providers but is only a temporary measure, with some parts of the funding expiring in December 2025 and some in December 2026. Fortunately, the Consolidated Appropriations Act 2023 was passed, which gave the permanent option for states to extend Medicaid postpartum coverage to 12 months. Wisconsin and Arkansas are the only two states that did not extend coverage and offer up to 60 days of coverage postpartum. ¹⁹

The Momnibus Act proposes 13 bills to congress to address health and disparities from expanding WIC to increasing maternal vaccinations. There is a website through the Black Maternal Health Caucus that is currently tracking the act and bill progress.

The Family and Medical Leave Act (FMLA) provides certain employees with unpaid protected leave for up to 12 weeks, which can be used after giving birth or to care for a newborn. During that time, benefits are continued. This policy includes public agencies, public and private primary and secondary institutions, companies with 50 or more employees. ¹⁴ Though this benefit provides comfort in job security and benefits, it is often difficult or not an option for families to go 12 weeks without pay. ²⁰ Lack of salary or paycheck support during parental leave may limit the ability of parents to utilize their benefits, especially for those with higher costs of living or increased rates of SDOH. Paid parental leave varies by state: California, Colorado, Connecticut, Delaware, Maryland, Massachusetts, New Jersey, New York, Oregon, Rhode Island, Washington, and the District of Columbia offer paid leave.

Lastly, while telemedicine has increased access to specialized care for many Americans, insurance coverage for telemedicine has been changing since the COVID-19 pandemic, and it is unknown if this will continue to remain a sustainable option. Access for patients and other providers to reach specialists is crucial and allows for more rural hospitals to quickly access neurological expertise, including stroke subspecialty care. For neurovascular emergencies, local clinicians often use “doctor to doctor” telemedicine to consult a neurologist in emergency situations. Most patients in this category will be covered under private insurance or Medicaid. As of now, telehealth is covered under Medicaid, but may vary by state.

System/Structural level

Currently, standard postpartum visits occur 6 weeks postpartum. The American College of Obstetricians and Gynecologists (ACOG) recommends that this timeline shift and be individualized with either an in-person or phone visit in the first 3 weeks postpartum. ²¹ The highest risk for neurovascular complications comes within the first 2 weeks postpartum. Adding a nurse or provider check-in with vitals and symptom screening around the 1-week mark could help capture undiagnosed issues between these visits, allowing early triage to a neurologist or emergency department if needed. ACOG recommends a paradigm shift to include a BP check in the 7–10 days postpartum and, if the pregnancy has been high risk, to have follow-up in 1–3 weeks. ²² For individuals in whom gestational hypertension, preeclampsia, or superimposed preeclampsia is diagnosed, ACOG recommends BP be monitored at 72 h and again 7–10 days outpatient. ²² This includes those with chronic hypertension or a history of preeclampsia in previous pregnancies. Home BP monitoring with close provider follow-up could be beneficial, but more work needs to be done to address billing for this care. Right now OBGYN payment is bundled in a global payment that includes prenatal, delivery and at least one first visit postpartum. Depending on the state, this could include up to 6 or 12 weeks postpartum. These bundled payments do not account for more complex or higher-risk cases. Starting in 2027, there will be new CPT codes and unbundling of care, aimed at better compensating OBGYNs.

A future intervention could include digital and AI tools to identify individuals at higher risk for neurovascular complications before and during pregnancy, and the peripartum period. Early identification would allow monitoring and management of risk factors to help prevent neurovascular events. Expanded access to virtual blood pressure monitoring and home cuffs—ideally covered by insurance—could support daily monitoring for patients at higher risk.

Obstetric life support (OBLS) training represents a system-level intervention aimed at strengthening obstetric emergency preparedness and care delivery within health care organizations, with downstream benefits for maternal and perinatal outcomes at the population level. ²³ Ideally, OBLS would be more broadly recognized and integrated in communities similar to ACLS training. Maternal stroke and acute cerebrovascular disease are included in the OBLS Manual, with information on how to recognize and manage neurological emergencies. ²⁴ Broader OBLS training among health care providers and community members may enhance early recognition of obstetric neurological emergencies.

Lastly, creation of a national registry for peripartum neurovascular emergencies would strengthen our knowledge on the risk factors, management and outcomes of these diseases and aid in guidance for future pregnancies, if desired.

Conclusion

Neurovascular emergencies in the peripartum period represent a significant cause of maternal morbidity and mortality worldwide. Early recognition through high clinical suspicion, prompt neuroimaging, and involvement of a neurological team is critical to improve clinical outcomes. We believe multilevel interventions targeting patients, providers, institutions, and systemic policies can decrease poor outcomes from neurovascular emergencies.

Authors’ Contributions

E.C.M.: Conceptualization and writing—review and editing. J.M.B.: Conceptualization and writing—original draft. All authors approved the final version of the article.