Possible misdiagnosis of pregnancy-associated stroke in the emergency department

Objectives

Pregnancy and the postpartum period are associated with an increased risk of ischemic and hemorrhagic stroke. The incidence of missed or delayed diagnosis of pregnancy-associated stroke (PAS) in the emergency setting is unknown.

Materials and methods

We conducted a retrospective cohort study of women hospitalized for labor and delivery identified through administrative claims data from all nonfederal EDs and hospitals in 11 states (New York 2006-2017, Florida 2005-2019, 3 states from 2016-2020, 6 states from 2016-2019). We then identified women hospitalized for stroke (ischemic or hemorrhagic) using validated ICD-9-CM or ICD-10-CM codes during a 270-day period extending from 6 months before through 3 months after delivery. The primary study outcome was possible ED misdiagnosis of PAS, defined as an ED treat-and-release visit for a neurological complaint within the 30 days preceding PAS hospitalization. Standard tests of comparison were used to compare differences in characteristics between PAS patients with a possible ED stroke misdiagnosis versus those without.

Results

Among 5,308,962 women hospitalized for labor and delivery, 1,656 (0.03%) were hospitalized for a stroke during the study period. Of the pregnant or postpartum women hospitalized for stroke, 79 (4.8%; median age, 30 years) had at least one preceding ED visit for a neurological symptom (possible misdiagnosis). Demographics and vascular comorbidities were similar between those with versus without possible misdiagnosis. There were also no differences in the average length of stay (7.5 versus 9.6 days, p=0.43) or discharge to home (63.3% versus 56.6%, p=0.24) after stroke.

Conclusions

Possible ED misdiagnosis occurred in nearly 1 of 20 cases of pregnancy-associated strokes in this multistate cohort though there were few of these strokes overall.