Cerebrovascular Disease in Preeclampsia

Chronic hypertension as well as pregnancy-induced hypertension with the increased risk of preeclampsia (PE) and eclampsia put a high morbidity and mortality risk upon pregnant women. PE is one of the main contributors to maternal, foetal, and newborn morbidity and mortality worldwide, affecting up to 2–5% of pregnancies globally. It is a progressive, unpredictable, and serious condition characterized by placental malperfusion and subsequent multi-organ injury. Maternal biologic and social risk factors are involved, with abnormal blood pressure being the hallmark of this multisystem disorder. Most symptoms of PE arise at term and are mild and transient. However, 5–20% of women, especially those in whom PE arises preterm, have higher per-pregnancy risk of complications compared with term disease. Early-onset PE shares many features with atherosclerosis, whereas late-onset PE seems to result from a metabolic crisis. PE also increases long-term cardio- and cerebrovascular risk in women and promotes alterations in developmental cognition in infants. Stroke in pregnancy is a neurological emergency and a key cause of severe maternal morbidity and mortality. In women with PE, the incidence of stroke of any type is up to six-fold higher than in pregnant women without the disorder, and over 50% of pregnancy-related strokes are hemorrhagic. The combination of hypertension and endothelial activation in PE can also lead to the development of posterior reversible encephalopathy syndrome (PRES). PRES is a nonspecific but characteristic disorder often associated with pregnancy, marked by rapidly progressive neurological symptoms and a distinctive pattern of vasogenic oedema observed on neuroimaging. Malignant PRES may be accompanied by ischaemic stroke, intracranial haemorrhage, and/or intracranial hypertension. Symptoms of stroke and PRES overlap significantly and may include headache, visual symptoms, nausea, dizziness, speech arrest, behavioural changes, motor weakness, and seizure among others. A grand-mal seizure or unexplained coma in preeclamptic women converts the diagnosis to eclampsia. Early identification of stroke is critical, and women with pregnancy-related stroke require complex interdisciplinary care. The immediate influence of PE on cerebrovascular complications as well as its long-term consequences require a coordinated care not only in the peripartum period, but also long term, with the goal to minimize complications and disability, both in mother and in neonatal.