Wednesday, December 16, 2015

Investigation: Maternal Stroke

This is part of a series of posts aimed at attempting to uncover possible causes behind maternal and neonatal mortality. Often, these deaths are said to be "unpreventable" or have "unknown causes". The "Investigation" series of posts will delve into some of these cases and see what possible causes might be applicable so that greater awareness and education can hopefully lead to lower death rates for mothers and babies.
Case: 20 year old previously healthy pregnant mother admitted to the hospital for placenta tear at seven months gestation. All vitals appear normal, but the mother complains of a migraine. She is given a narcotic for the pain of the headache and over the next hour starts to go numb. She then turns blue and suffers a fatal stroke. The baby is delivered via emergency c-section and survives. Doctors say the cause of the stroke is unknown. News article here.
Analysis: Pregnant women are at a higher risk of stroke, and in fact it is the leading cause of death in pregnant women in the United States and Canada. Most of these strokes are caused by preeclampsia/eclampsia (a disorder of pregnancy characterized by high protein in the urine and high blood pressure). The migraine and the placenta tear are telling here, since migraine-like headaches are one of the telltale signs of preeclampsia and preeclampsia can lead to placenta abruption or a lack of blood flow to the placenta.
The doctors state that the mother's vital signs, including blood pressure were normal, but this may not have been the case. Typically, doctors won't consider preeclampsia unless the mother's blood pressure is greater than 140/90 on two separate readings more than six hours apart. The problem is that blood pressure rates can vary greatly from person to person (just like average basal body temperature). A woman whose blood pressure tends to be on the lower-than-average side may be technically within the guidelines of normal blood pressure numbers while her body is getting dangerously close to disaster.
A rise of 15 degrees or more in the lower number  (diastolic) or of 30 degrees or more in the higher number  (systolic) during pregnancy can also be a signal that preeclampsia is underway. But this sort of data requires multiple readings on separate occasions. A mother who shows up at the emergency room and gets a single reading may not get the help she needs because the number is taken out of context. For an account of a mother who experienced the nearly fatal situation of having a variation of preeclampsia called HELLP syndrome but was repeatedly told that her blood pressure was normal read here.
Preeclampsia is called the silent killer because often mothers don't feel poorly until the condition has progressed to a serious stage and it often goes undetected by doctors because of variations in blood pressure readings and dismissal of the symptoms as "normal pregnancy complaints". Preeclampsia can also progress to a dangerous point very quickly, another reason it sometimes escapes notice, even in women receiving full prenatal care. A urine test at the time of admission may have revealed dangerously high levels of protein in the urine and could have alerted doctors to possibility of preeclampsia, but it doesn't sound as if a urine test was performed. These tests are typically very quick and easy to do.
Conclusion: While it is impossible to know for sure what happened without a complete set of data from blood pressure readings or tests for protein in the urine, there are many indications pointing to advanced preeclampsia as the cause of the stroke. It is very possible that this mother had developed preeclampsia that quickly progressed to a dangerous stage.

Prevention: Because it is so easy for preeclampsia to be overlooked, it's important for mothers to know the signs and symptoms and also to know their blood pressure and even keep a log throughout their prenatal care visits. If you're feeling sicker than usual, yet being told that nothing is wrong, you may have to become very assertive in getting the care you need. If preeclampsia progresses to a point where the mother's and baby's lives are in danger, a c-section will probably be necessary, even if the baby has not reached full-term gestation. For information on signs of preeclampsia and it variations, go to the Preeclampsia Foundation's website here.

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