Pregnancy and Stroke: Insight From the Cosmos Database

BACKGROUND: Maternal stroke is an uncommon but serious complication of pregnancy. This study assessed the incidence, temporal trends, and outcomes of maternal stroke in the United States using the Cosmos Epic database. METHODS: We conducted a retrospective analysis of pregnancies resulting in births between January 1, 2016, and January 1, 2024, using the Cosmos Epic database, which includes deidentified electronic health records from >1800 US hospitals and 41 500 clinics. Maternal stroke was defined as any inpatient admission with a stroke diagnosis during pregnancy or within 6 weeks postpartum. The primary outcome was maternal stroke incidence; secondary outcomes included maternal mortality, delivery complications, and neonatal outcomes. Propensity score matching (1:1) was applied to adjust for confounding. RESULTS: Among 5 404 933 pregnancies, 2637 were complicated by stroke, yielding an incidence of 48.8 per 100 000 pregnancies. Ischemic stroke was most common (52.6%), followed by hemorrhagic stroke (40.7%). The overall rate remained stable though ischemic stroke showed an upward trend. Women with stroke were older and more likely to be Black, and had higher rates of hypertension, dyslipidemia, congenital heart disease, and eclampsia. In the matched cohort (n=1200 pairs), the stroke group had higher mortality (1.7% versus 0%), more delivery complications, lower birth weight, and longer neonatal hospital stays. Among 409 subsequent pregnancies, recurrent stroke occurred in 14.7% but with no maternal mortality and favorable neonatal outcomes. CONCLUSIONS: Maternal stroke, though rare, carries substantial risks. The increasing ischemic stroke trend warrants targeted prevention and multidisciplinary perinatal management.