Prenatal and postpartum stroke risk should be proactively assessed, closely monitored, and aggressively managed through blood pressure control, early symptom recognition, and rapid treatment to improve outcomes for both mothers and infants, an expert panel advised in a new scientific statement from the American Heart Association (AHA).

The guidance highlights current evidence on stroke risk factors, prevention strategies, acute management, delivery considerations, and postpartum recovery in pregnant and postpartum patients, who have historically been excluded from clinical trials.

“Stroke remains a rare but life-threatening complication of pregnancy, with significant implications for both maternal and fetal health,” lead author Eliza Miller, MD, MS, associate professor of neurology and chief of women’s neurology at the University of Pittsburgh, Pittsburgh, and colleagues, wrote.

The statement, which was endorsed by the American College of Obstetricians and Gynecologists (ACOG), was published online on January 28 in Stroke.

Filling a Gap

Maternal stroke is uncommon, occurring in just 20-40 per 100,000 pregnancies. Yet it accounts for roughly 4%-6% of pregnancy-related deaths annually in the US.

Despite an increase in observational research on the topic, current stroke prevention and treatment guidelines offer limited guidance for managing stroke in pregnant and postpartum patients.

To address this gap, the AHA Women’s Health Science Committee of the Council on Clinical Cardiology and Stroke Council convened a panel of clinicians with expertise in vascular neurology, maternal-fetal medicine, emergency medicine, obstetric anesthesiology, cardio-obstetrics, vascular neurosurgery, and stroke nursing.

“This scientific statement represents a multidisciplinary effort to synthesize current knowledge and to offer consensus-driven suggestions for prevention, acute management, and postpartum recovery in maternal stroke,” the authors wrote.

“Given the complexity of evaluating and treating pregnancy-associated stroke, optimal care requires a multidisciplinary approach,” they added.

Identifying Maternal Stroke Risk

Physiologic, hemodynamic, and hormonal changes during pregnancy may increase the risk for stroke, the statement authors wrote. Established risk factors include chronic hypertension, hypertensive disorders of pregnancy such as gestational hypertension and preeclampsia or eclampsia, diabetes, obesity, infections, clotting disorders, migraine with aura, and underlying cardiac or cerebrovascular disease. Advanced maternal age, defined as 35 years or older, is also associated with an increased risk.

Stroke mechanisms in pregnant and postpartum patients differ from those seen in the general population, the statement authors wrote. Although ischemic stroke remains common, hemorrhagic stroke, including intracerebral hemorrhage and subarachnoid hemorrhage, account for a high percentage of pregnancy-associated stroke, particularly during the peripartum and early postpartum period, they noted.

The statement also sheds light on the persistent racial disparities in maternal stroke outcomes. A 2020 meta-analysis found that pregnant Black women face twice the likelihood of stroke compared with pregnant White women, even after accounting for socioeconomic differences.

Despite growing awareness, evidence to inform treatment decisions in pregnant and postpartum patients remains limited, the authors wrote.

Blood Pressure Control Is Key

Maternal stroke prevention starts before conception, with preconception planning and lifestyle management critical in reducing stroke risk during and after pregnancy, the authors advised.

Clinicians should encourage women considering pregnancy to follow established primary stroke prevention strategies and adopt healthy lifestyle behaviors consistent with the AHA’s Life’s Essential 8 cardiovascular health framework. These include smoking cessation, healthy eating, regular physical activity, and weight management.

Blood pressure control was a recurring theme in the statement, particularly as “nearly half of all US pregnancy-associated stroke hospitalizations occur in the setting of hypertensive disorders,” the authors noted.

The 2026 statement aligns with ACOG criteria defining hypertension in pregnancy as systolic blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg. The statement highlighted research that showed daily low-dose aspirin may significantly reduce the risk for preeclampsia in high-risk individuals compared with placebo.

The median time to stroke readmission occurs approximately 8 days after discharge, the statement noted, so close postpartum monitoring is important.

“Preeclampsia and eclampsia can occur before, during, or after delivery, and the early postpartum period is actually the highest risk time for stroke. Very close monitoring of blood pressure is essential,” Miller said in a news release.

Timely Diagnosis, Treatment Crucial

Timely diagnosis of acute stroke and treatment are essential to protect both the mother and the infant, the authors wrote.

The statement called for improved stroke awareness among clinicians who routinely care for pregnant patients, including obstetricians, primary care physicians, emergency clinicians, and nursing professionals.

Moreover, pregnancy alone should not preclude standard acute stroke evaluation or treatment.

“Computed tomography, computed tomography angiography, and magnetic resonance imaging without contrast are all safe neuroimaging modalities for rapid evaluation of pregnant patients with acute stroke symptoms,” the authors wrote.

During pregnancy, management of anticoagulation requires careful drug selection. Heparin-based therapies are preferred because they do not cross the placenta, which makes them the safest choice for a developing fetus, the authors advised.

In contrast, direct oral anticoagulants should be avoided due to a lack of safety data and concerns regarding potential fetal risks.

Multidisciplinary Approach Recommended

Multidisciplinary management, including vascular neurology, maternal-fetal medicine, cardiology, anesthesiology, and critical care teams, is recommended to ensure healthy delivery and recovery, the authors wrote.

If maternal and fetal conditions remain stable and gestation is preterm, stroke during pregnancy does not necessarily require immediate delivery, they noted. However, worsening of maternal neurologic or cardiovascular health could prompt early delivery.

When delivery is required, “vaginal delivery after stroke is preferred when feasible because it avoids the surgical risks and hemodynamic stress associated with cesarean delivery,” the authors advised.

The use of telemedicine for rapid consultation between stroke specialists and obstetric teams was also recommended, especially in hospitals that do not have a dedicated neurovascular department.

Poststroke recovery comes with its own set of challenges for postpartum patients as the management of mood and sleep disturbances after hormonal shifts may be worsened by postpartum hormonal shifts and breastfeeding.

The panel recommended a multidisciplinary rehabilitation team to address the long-term maternal disability that remains a significant concern. This would include counseling on future pregnancy risks, secondary stroke prevention strategies, and use of safe medication during lactation.

“Babies depend on their mothers’ well-being, and supporting recovery after stroke, both emotionally and practically, is essential so mothers can heal and families can thrive,” Miller said in a news release.

A Need for Better Research

Despite growing awareness of maternal stroke, the panel noted significant gaps in available research. To address the issue, pregnant and lactating individuals should be included in clinical trials to better inform evidence-based stroke prevention and treatment strategies, they wrote.

Future research should also include improving risk prediction models, optimizing blood management protocols, clarifying safety and efficacy of acute stroke therapies during pregnancy, and addressing ongoing healthcare disparities.

“Continued research, including inclusive clinical trials, is urgently needed to refine stroke risk assessment, to expand treatment options, and to improve maternal outcomes,” the panel wrote.

“Until then, coordinated care, early recognition, and patient-centered approaches remain critical to reducing the devastating impact of stroke in pregnancy and the postpartum period.”

Miller reported receiving research grants from the National Institute for Child Health and Development, the National Institute of Neurological Disorders and Stroke, and the National Institute on Aging.