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Pregnancy in paraplegia: A case report
ht. J. Gynaecol. Obstet., 1982,20: 79-83 International Federation of Gynaecology & Obstetrics
PREGNANCY IN PARAPLEGIA: A CASE REPORT
GEORGE C. TSOUTSOPLIDES Department of Obstetricsand Gynecology, Berwick Hospital,Berwick, PA, USA (Received January 27th, 1981) (Accepted February 3Oth, 1981)
Abstract Tsoutsoplides GC (Dept of Obstetrics and Gynecology, Berwick Hospital, Berwick, Pennsylvania). Pregnancy in paraplegia: a case report. Int J Gynaecol Obstet 20: 79-83, 1982 Two uneventful pregnancies are reported in a young paraplegic patient with spontaneous births. The common problems of concern to the obstetrician are emphasized. Pregnancy in paraplegic patients is discussed with emphasis on obstetric management and the urgent need for more Regional Model Cord Injury Systems.
Key words: Paraplegic patients; Obstetric management; Regional model cord injury systems ; Spinal cord injuries; Autonomic stress syndrome ; Urinary tract infections and anemia; Ultrasound investigations.
the services of the Regional Model Spinal Cord Injury Systems of each state. At present there are 14 federally funded model systems in the United States, however, this number is inadequate; the state of Pennsylvania alone should have 3-5 spinal cord injury programs [ 31. The pregnant paraplegic patient may have unusual problems such as the autonomic stress syndrome, urinary tract infections and anemia, which should be of special concern to the obstetrician. A review of the literature revealed that only a few cases have been reported during the last 25 years and that textbooks devote little space to this uncommon clinical entity [ 21. The following case describes two uneventful pregnancies in a young paraplegic patient, they point up some of the problems and confirm that these patients can be very successful and good mothers. Case report
Introduction
First pregnancy
In the United States, automobile accidents are responsible for approximately 50,000 deaths and for an estimated 11,000 spinal cord injuries annually. Eighty percent of these spinal cord injuries involve adolescents and young adults aged 15-30 years. The possibility of marriage and motherhood for paraplegics, or quadriplegics, had gained importance as the number of survivors increases, with the majority wishing to live full lives. This goal is best achieved through
KM, age 19 had been a paraplegic for the last 2.5 years and was referred to the author for antenatal care and delivery when she was about 22 weeks pregnant. She was in an automobile accident on July 4th, 1976, and sustained a compression fracture of the Tiz, with impingement on the cauda equina and distal segment of the spinal cord. Decompressive laminectomy was done at T, 1, Tlz and L1. The patient was discharged on August 25th, 1976 with a Foley catheter in situ and a final diagnosis of fracture of the thoracic
002-7292/82/0000-0000/$02.75 0 1982 International Federation of Gynaecology & Obstetrics
In t J Gynaecol Obstet 20
80
Tsoutsoplides
spine (T,,) with spinal cord contusion, paraparesis, multiple lacerations, contusions and abrasions and cerebral concussion. She was readmitted to the Hazleton State General Hospital for reevaluation on October 12th, 1976, when removal of the catheter was first tried. Myelography revealed no blockage. Culture of the urine showed Pseudomonas, and the patient was given two tablets of Geocillin (carbenicillin indanyl sodium, Roerig, New York, NY, USA) every 6 h for 10 days. Following reevaluation, the patient was transferred to the Allentown rehabilitation center on October lSth, 1976, where she remained for 3 months with satisfactory improvement on discharge. She was given one Ornade Spansule capsule (8 mg of chlorpheniramine maleate and 50 mg of phenylpropanolamine hydrochloride, Smith Kline & French Laboratories, Philadelphia, PA, USA) twice a day to improve bladder control. This medication was never discontinued, even during both described pregnancies. The patient was admitted to the Berwick Hospital on February 26, 1979, with a history of amenorrhea since August 20th, 1978, that corresponded with an intrauterine pregnancy of 27 weeks, which was confirmed by ultrasound (biparietal diameter, 68 mm). Physical examination revealed a welldeveloped, young white woman. Neurologic evaluation showed some trophic skin changes in the feet and lower legs due to sensory denervation. The patient also had noticeably slow healing with lacerations and trauma. There was a marked degree of plantar flexion contracture and moderate inversion of both feet. There was no motility around the ankle joints and only reflex motility of the toes. There was a strong Babinski reflex on the left and a moderate one on the right foot. A patellar reflex was absent in the right knee. The left knee jerk was l+. The patient could extend the left thigh and exert the quadriceps muscle of the left leg against the force of gravity, but could not do so with the right. There was some motility and mild strength in adduction In t J Gynaecol Obstet 20
of the thighs, but not of external rotation. Abdominal musculature appeared to be good. Normal sensation was present down to about T,,. There was a hyperesthetic segment from T,, to L3 and essentially an anesthesia below that level. There was no sensitivity present in the sacral dermatome. Complete blood count showed hemoglobin of 11.4 g/100 ml, hematocrit 35 of vol.%, serum iron of 80 pg/lOO ml and total ironbinding capacity of 360 pg/lOO ml; 12-parameter sequential multiple analysis and electrolytes were normal. Creatinine clearance was within normal limits. A urinalysis from a catheter specimen showed a heavy presence of bacteria and 12-l 5 pus cells, but no casts, albumin, sugar or acetone. Culture of the urine showed growth of more than 100,000 Escherichia coZi/ml, which were sensitive to ampicillin. The patient was treated with 500 mg of ampicillin given orally every 6 h for 10 days. She was discharged within a few days with her supply of oral ampicillin. Urinalysis and culture repeated in 3 weeks both showed negative results. The patient was readmitted in false labor 1 week before her due date, when an enema was given because of impacted feces. Urinalysis showed the presence of many bacteria and pus cells, and the patient was given Duricef (cefadroxil monohydrate, Mead Johnson Pharmaceutical Division, Evansville, IN, USA) and discharged. Three days later the patient was readmitted in labor. She was able to palpate uterine contractions for the last 2 h before she was admitted to the hospital. On admission the cervix was dilated 4 cm with the fetal vertex at the -1 station. After 4 h of labor in the first stage, and 45 min in the second stage, the patient was delivered (Figs. 1 and 2) of a male infant weighing 2800 g with l- and 5-minute Apgar scores of 9 and 10, respectively. The delivery was spontaneous over a mediolateral without right episiotomy, anesthesia. Labor and delivery were painless except for a mild backache and a poorly localized sensa-
Pregnancy in paraplegia
Fig. 1. Delivery of infant’s head, by the modified maneuver in a young paraplegic woman.
Ritgen
tion of visceral pressure at the time of delivery of the head. The placenta was partially adherent to the fundal area, and was removed manually, without anesthesia. Maternal blood loss was less than average. The patient’s blood pressure during the antenatal period, labor, delivery and puerperium was normal. Breast-feeding was successful. The episiotomy was sutured with vicryl No. 0 and No. 00, and healed well. Normal menses resumed within 2 months after weaning. Second pregnancy
The patient conceived for the second time 10 months after the delivery of the first child. She made her first antenatal visit at
Fig. 2. Spontaneous
delivery
in a young
paraplegic
woman.
81
20 weeks’ gestation. Results of physical examination were normal with no changes in neurologic findings. Complete blood count revealed mild iron-deficiency anemia, and urinalysis showed many pus cells; urine reaction for protein was l+. She was treated with a 10 day course of Geocillin. The patient was admitted in labor at term, 5 h after she palpated the first uterine contractions. On admission, the cervix was 8-cm dilated with the fetal vertex at the - 1 station. After a labor of 6.5 h in the first stage and 1.5 h in the second stage, the patient was delivered of a male infant weighing 3 108 g with I-min and 5-min Apgar scores of 8 and 9, respectively. The delivery was spontaneous over a small, right mediolateral episiotomy, without anesthesia. Labor and delivery were, as on the first occasion, essentially painless. The placenta was removed manually within a few minutes after the delivery of the baby because of moderate postpartum hemorrhage. The bleeding was controlled by bimanual massage and 10 units of Pitocin (oxytocin, Parke, Davis & Co, Detroit, MI, USA) (bolus) intravenously. The estimated blood loss was close to 800 cc. The episiotomy was sutured with vicryl No. 000 with satisfactory results. Two hours after delivery, the patient was administered general endotracheal anesthesia, and sterilization was performed by Pomeroy operation through a 3.5-cm midline incision starting 4 cm below the umbilicus. Two days after delivery, the patient’s hemoglobin dropped to 9 g/ 100 ml and hematocrit to 28 vol.%. Results of a urinalysis were negative, and culture of the urine showed no growth. Blood pressure was normal during pregnancy, labor, delivery and puerperium. The patient was discharged 3 days postpartum with a prescription for iron and Ornade Spansules. At 6 weeks postpartum, the patient’s hemoglobin rose to 11 g/l00 ml and her hematocrit to 34 vol.%. Urinalysis results were negative. The uterus was well involuted and the episiotomy and abdominal incision were well healed. Breast-feeding was successful, and she had good bladder control. Int J Gynaecol Obstet 20
82
Tsoutsoplides
Discussion Performance of sexual intercourse is not a problem for a paraplegic woman and is psychologically rewarding despite sensory anesthesia. Orgasm is absent if both spinothalamic tracts are severed. Breast manipulation remains sexually stimulating, and breastfeeding is possible. Fertility is unaffected, but short amenorrhea after an injury is not unusual. Pregnant patients with spinal cord injuries should be classified into theree groups: (a) those with lesions below Tll, T12 or L1 (the uterine sensory afferents); (b) those with midthoracic lesions (T5+ to T&; and (c) those with cervical and high thoracic lesions (above T5_& Sacral anesthesia is not necessary during labor. Patients with cauda equina lesions have relaxed perineal muscles, and those with lesions above Tll have painless labor. When the cord lesion is above the T5+, that is, above the level of the sympathetic nerve supply to the uterus, autonomic stress syndrome, or autonomic dysreflexia, which may cause panic and great concern to the obstetrician, may be initiated by bladder distention, rectal digital examination, uterine contractions, genital stimulation or immersion of a foot into ice water. The autonomic stress syndrome consists of throbbing headache, facial flushing, dilated pupils (sometimes unilateral), nasal congestion, marked sweating, bradycardia, irregular heart rhythm and severe paroxysmal hypertention. Premature ventricular bigeminy, atrioventricular nodal block and prominent U waves have been observed during uterine contractions, and electrocardiographic monitoring during labor and [ 1I. The delivery is strictly indicated symptoms of this syndrome are caused by a sudden release of catecholamines. This syndrome can be misdiagnosed as severe preeclampsia, but the blood pressure usually returns to low-normal levels immediately after delivery. Paroxysms associated with hypertension In t J Gynaecol Obstet 20
are correlated with serum dopamine-bhydroxylase and urinary normetanephrine excretion. Hexamethonium chloride, an autonomic ganglionic blocking agent, can be used several weeks before the patient’s delivery date to prevent occurrence of the symptoms. Propranolol hydrochloride, a P-receptor blocking agent, also prevents symptoms and has fewer side effects. In women with paraplegia, pregnancy is likely to be complicated by urinary tract infections and pressure necrosis of the skin. Frequent examinations to rule out urinary tract infections should be done during the pregnancy. If they are detected, the infection should be treated immediately to avoid chronic kidney disease and anemia that does not respond to iron or folic acid. Anemia must be avoided because it lowers tissue resistance to pressure sores. Constipation will be aggravated. Premature labor is more common when lesions are above the level of Tll. Frequent examinations near term, especially in multigravidas, should be done to detect cervical dilation and effacement. The second stage of labor may be prolonged by an inability to increase intraabdominal pressure (i.e., an inability to bear down), but this only occurs when the abdominal muscles (T,,, Tll and T12 innervated) are affected by the lesion. In our case, the second stage of labor was not prolonged with the first pregnancy, and was slightly prolonged with the second. Spontaneous delivery was accomplished on both occasions. Vaginal delivery is preferred if no obstetric indication for cesarean section is present. Episiotomies should be repaired with nonabsorbable sutures (silk or nylon), or delayed absorbable sutures (vicryl or dexon), which have the advantage of good tensile strength and do not cause a foreign-body reaction. Catgut sutures are poorly absorbed by paraplegics and often cause sterile abscesses. In our case, on both occasions, delayed absorbable sutures (vicryl No. 0, No. 00 and No. 000) were used with satisfactory results. Both pregnancies were uneventful, except
Pregnancy in paraplegia
for recurrent urinary tract infections, which were successfully treated. Both babies were healthy and had high Apgar scores. This confirms again that paraplegics who become pregnant do not have an increased risk of fetal abnormality, stillbirth or abortion. In already-pregnant women who become paraplegics, this risk could be increased because of direct trauma and diagnostic radiation, as shielding is not possible with roentgenography of the spine or with myelography.
References
Acknowledgements
Address for reprints:
I should like to express my thanks to Dr. Joseph Bittenbender for the neurological evaluation of the patient.
George C. Tsoutsopkh, RD No. 1, Box 567 Berwick, PA 18603 USA
83
Donaldson JO: Neurology of Pregnancy (Major problems in Neurology; vol. 7). W.B. Saunders Co., Philadelphia, 1978. Oppenhimer WM: Pregnancy in paraplegic patients: Two case reports. Am J Obstet Gynecol 110: 784, 1971. Schwentker EP, Keegan EM, Skinner SR: Coordinated management of spinal cord injuries. Pennsyhrania Medicine, pp 39-41, September 1980.
M.D.
Int J Gynaecol Obstet 20
PREGNANCY IN PARAPLEGIA: A CASE REPORT
GEORGE C. TSOUTSOPLIDES Department of Obstetricsand Gynecology, Berwick Hospital,Berwick, PA, USA (Received January 27th, 1981) (Accepted February 3Oth, 1981)
Abstract Tsoutsoplides GC (Dept of Obstetrics and Gynecology, Berwick Hospital, Berwick, Pennsylvania). Pregnancy in paraplegia: a case report. Int J Gynaecol Obstet 20: 79-83, 1982 Two uneventful pregnancies are reported in a young paraplegic patient with spontaneous births. The common problems of concern to the obstetrician are emphasized. Pregnancy in paraplegic patients is discussed with emphasis on obstetric management and the urgent need for more Regional Model Cord Injury Systems.
Key words: Paraplegic patients; Obstetric management; Regional model cord injury systems ; Spinal cord injuries; Autonomic stress syndrome ; Urinary tract infections and anemia; Ultrasound investigations.
the services of the Regional Model Spinal Cord Injury Systems of each state. At present there are 14 federally funded model systems in the United States, however, this number is inadequate; the state of Pennsylvania alone should have 3-5 spinal cord injury programs [ 31. The pregnant paraplegic patient may have unusual problems such as the autonomic stress syndrome, urinary tract infections and anemia, which should be of special concern to the obstetrician. A review of the literature revealed that only a few cases have been reported during the last 25 years and that textbooks devote little space to this uncommon clinical entity [ 21. The following case describes two uneventful pregnancies in a young paraplegic patient, they point up some of the problems and confirm that these patients can be very successful and good mothers. Case report
Introduction
First pregnancy
In the United States, automobile accidents are responsible for approximately 50,000 deaths and for an estimated 11,000 spinal cord injuries annually. Eighty percent of these spinal cord injuries involve adolescents and young adults aged 15-30 years. The possibility of marriage and motherhood for paraplegics, or quadriplegics, had gained importance as the number of survivors increases, with the majority wishing to live full lives. This goal is best achieved through
KM, age 19 had been a paraplegic for the last 2.5 years and was referred to the author for antenatal care and delivery when she was about 22 weeks pregnant. She was in an automobile accident on July 4th, 1976, and sustained a compression fracture of the Tiz, with impingement on the cauda equina and distal segment of the spinal cord. Decompressive laminectomy was done at T, 1, Tlz and L1. The patient was discharged on August 25th, 1976 with a Foley catheter in situ and a final diagnosis of fracture of the thoracic
002-7292/82/0000-0000/$02.75 0 1982 International Federation of Gynaecology & Obstetrics
In t J Gynaecol Obstet 20
80
Tsoutsoplides
spine (T,,) with spinal cord contusion, paraparesis, multiple lacerations, contusions and abrasions and cerebral concussion. She was readmitted to the Hazleton State General Hospital for reevaluation on October 12th, 1976, when removal of the catheter was first tried. Myelography revealed no blockage. Culture of the urine showed Pseudomonas, and the patient was given two tablets of Geocillin (carbenicillin indanyl sodium, Roerig, New York, NY, USA) every 6 h for 10 days. Following reevaluation, the patient was transferred to the Allentown rehabilitation center on October lSth, 1976, where she remained for 3 months with satisfactory improvement on discharge. She was given one Ornade Spansule capsule (8 mg of chlorpheniramine maleate and 50 mg of phenylpropanolamine hydrochloride, Smith Kline & French Laboratories, Philadelphia, PA, USA) twice a day to improve bladder control. This medication was never discontinued, even during both described pregnancies. The patient was admitted to the Berwick Hospital on February 26, 1979, with a history of amenorrhea since August 20th, 1978, that corresponded with an intrauterine pregnancy of 27 weeks, which was confirmed by ultrasound (biparietal diameter, 68 mm). Physical examination revealed a welldeveloped, young white woman. Neurologic evaluation showed some trophic skin changes in the feet and lower legs due to sensory denervation. The patient also had noticeably slow healing with lacerations and trauma. There was a marked degree of plantar flexion contracture and moderate inversion of both feet. There was no motility around the ankle joints and only reflex motility of the toes. There was a strong Babinski reflex on the left and a moderate one on the right foot. A patellar reflex was absent in the right knee. The left knee jerk was l+. The patient could extend the left thigh and exert the quadriceps muscle of the left leg against the force of gravity, but could not do so with the right. There was some motility and mild strength in adduction In t J Gynaecol Obstet 20
of the thighs, but not of external rotation. Abdominal musculature appeared to be good. Normal sensation was present down to about T,,. There was a hyperesthetic segment from T,, to L3 and essentially an anesthesia below that level. There was no sensitivity present in the sacral dermatome. Complete blood count showed hemoglobin of 11.4 g/100 ml, hematocrit 35 of vol.%, serum iron of 80 pg/lOO ml and total ironbinding capacity of 360 pg/lOO ml; 12-parameter sequential multiple analysis and electrolytes were normal. Creatinine clearance was within normal limits. A urinalysis from a catheter specimen showed a heavy presence of bacteria and 12-l 5 pus cells, but no casts, albumin, sugar or acetone. Culture of the urine showed growth of more than 100,000 Escherichia coZi/ml, which were sensitive to ampicillin. The patient was treated with 500 mg of ampicillin given orally every 6 h for 10 days. She was discharged within a few days with her supply of oral ampicillin. Urinalysis and culture repeated in 3 weeks both showed negative results. The patient was readmitted in false labor 1 week before her due date, when an enema was given because of impacted feces. Urinalysis showed the presence of many bacteria and pus cells, and the patient was given Duricef (cefadroxil monohydrate, Mead Johnson Pharmaceutical Division, Evansville, IN, USA) and discharged. Three days later the patient was readmitted in labor. She was able to palpate uterine contractions for the last 2 h before she was admitted to the hospital. On admission the cervix was dilated 4 cm with the fetal vertex at the -1 station. After 4 h of labor in the first stage, and 45 min in the second stage, the patient was delivered (Figs. 1 and 2) of a male infant weighing 2800 g with l- and 5-minute Apgar scores of 9 and 10, respectively. The delivery was spontaneous over a mediolateral without right episiotomy, anesthesia. Labor and delivery were painless except for a mild backache and a poorly localized sensa-
Pregnancy in paraplegia
Fig. 1. Delivery of infant’s head, by the modified maneuver in a young paraplegic woman.
Ritgen
tion of visceral pressure at the time of delivery of the head. The placenta was partially adherent to the fundal area, and was removed manually, without anesthesia. Maternal blood loss was less than average. The patient’s blood pressure during the antenatal period, labor, delivery and puerperium was normal. Breast-feeding was successful. The episiotomy was sutured with vicryl No. 0 and No. 00, and healed well. Normal menses resumed within 2 months after weaning. Second pregnancy
The patient conceived for the second time 10 months after the delivery of the first child. She made her first antenatal visit at
Fig. 2. Spontaneous
delivery
in a young
paraplegic
woman.
81
20 weeks’ gestation. Results of physical examination were normal with no changes in neurologic findings. Complete blood count revealed mild iron-deficiency anemia, and urinalysis showed many pus cells; urine reaction for protein was l+. She was treated with a 10 day course of Geocillin. The patient was admitted in labor at term, 5 h after she palpated the first uterine contractions. On admission, the cervix was 8-cm dilated with the fetal vertex at the - 1 station. After a labor of 6.5 h in the first stage and 1.5 h in the second stage, the patient was delivered of a male infant weighing 3 108 g with I-min and 5-min Apgar scores of 8 and 9, respectively. The delivery was spontaneous over a small, right mediolateral episiotomy, without anesthesia. Labor and delivery were, as on the first occasion, essentially painless. The placenta was removed manually within a few minutes after the delivery of the baby because of moderate postpartum hemorrhage. The bleeding was controlled by bimanual massage and 10 units of Pitocin (oxytocin, Parke, Davis & Co, Detroit, MI, USA) (bolus) intravenously. The estimated blood loss was close to 800 cc. The episiotomy was sutured with vicryl No. 000 with satisfactory results. Two hours after delivery, the patient was administered general endotracheal anesthesia, and sterilization was performed by Pomeroy operation through a 3.5-cm midline incision starting 4 cm below the umbilicus. Two days after delivery, the patient’s hemoglobin dropped to 9 g/ 100 ml and hematocrit to 28 vol.%. Results of a urinalysis were negative, and culture of the urine showed no growth. Blood pressure was normal during pregnancy, labor, delivery and puerperium. The patient was discharged 3 days postpartum with a prescription for iron and Ornade Spansules. At 6 weeks postpartum, the patient’s hemoglobin rose to 11 g/l00 ml and her hematocrit to 34 vol.%. Urinalysis results were negative. The uterus was well involuted and the episiotomy and abdominal incision were well healed. Breast-feeding was successful, and she had good bladder control. Int J Gynaecol Obstet 20
82
Tsoutsoplides
Discussion Performance of sexual intercourse is not a problem for a paraplegic woman and is psychologically rewarding despite sensory anesthesia. Orgasm is absent if both spinothalamic tracts are severed. Breast manipulation remains sexually stimulating, and breastfeeding is possible. Fertility is unaffected, but short amenorrhea after an injury is not unusual. Pregnant patients with spinal cord injuries should be classified into theree groups: (a) those with lesions below Tll, T12 or L1 (the uterine sensory afferents); (b) those with midthoracic lesions (T5+ to T&; and (c) those with cervical and high thoracic lesions (above T5_& Sacral anesthesia is not necessary during labor. Patients with cauda equina lesions have relaxed perineal muscles, and those with lesions above Tll have painless labor. When the cord lesion is above the T5+, that is, above the level of the sympathetic nerve supply to the uterus, autonomic stress syndrome, or autonomic dysreflexia, which may cause panic and great concern to the obstetrician, may be initiated by bladder distention, rectal digital examination, uterine contractions, genital stimulation or immersion of a foot into ice water. The autonomic stress syndrome consists of throbbing headache, facial flushing, dilated pupils (sometimes unilateral), nasal congestion, marked sweating, bradycardia, irregular heart rhythm and severe paroxysmal hypertention. Premature ventricular bigeminy, atrioventricular nodal block and prominent U waves have been observed during uterine contractions, and electrocardiographic monitoring during labor and [ 1I. The delivery is strictly indicated symptoms of this syndrome are caused by a sudden release of catecholamines. This syndrome can be misdiagnosed as severe preeclampsia, but the blood pressure usually returns to low-normal levels immediately after delivery. Paroxysms associated with hypertension In t J Gynaecol Obstet 20
are correlated with serum dopamine-bhydroxylase and urinary normetanephrine excretion. Hexamethonium chloride, an autonomic ganglionic blocking agent, can be used several weeks before the patient’s delivery date to prevent occurrence of the symptoms. Propranolol hydrochloride, a P-receptor blocking agent, also prevents symptoms and has fewer side effects. In women with paraplegia, pregnancy is likely to be complicated by urinary tract infections and pressure necrosis of the skin. Frequent examinations to rule out urinary tract infections should be done during the pregnancy. If they are detected, the infection should be treated immediately to avoid chronic kidney disease and anemia that does not respond to iron or folic acid. Anemia must be avoided because it lowers tissue resistance to pressure sores. Constipation will be aggravated. Premature labor is more common when lesions are above the level of Tll. Frequent examinations near term, especially in multigravidas, should be done to detect cervical dilation and effacement. The second stage of labor may be prolonged by an inability to increase intraabdominal pressure (i.e., an inability to bear down), but this only occurs when the abdominal muscles (T,,, Tll and T12 innervated) are affected by the lesion. In our case, the second stage of labor was not prolonged with the first pregnancy, and was slightly prolonged with the second. Spontaneous delivery was accomplished on both occasions. Vaginal delivery is preferred if no obstetric indication for cesarean section is present. Episiotomies should be repaired with nonabsorbable sutures (silk or nylon), or delayed absorbable sutures (vicryl or dexon), which have the advantage of good tensile strength and do not cause a foreign-body reaction. Catgut sutures are poorly absorbed by paraplegics and often cause sterile abscesses. In our case, on both occasions, delayed absorbable sutures (vicryl No. 0, No. 00 and No. 000) were used with satisfactory results. Both pregnancies were uneventful, except
Pregnancy in paraplegia
for recurrent urinary tract infections, which were successfully treated. Both babies were healthy and had high Apgar scores. This confirms again that paraplegics who become pregnant do not have an increased risk of fetal abnormality, stillbirth or abortion. In already-pregnant women who become paraplegics, this risk could be increased because of direct trauma and diagnostic radiation, as shielding is not possible with roentgenography of the spine or with myelography.
References
Acknowledgements
Address for reprints:
I should like to express my thanks to Dr. Joseph Bittenbender for the neurological evaluation of the patient.
George C. Tsoutsopkh, RD No. 1, Box 567 Berwick, PA 18603 USA
83
Donaldson JO: Neurology of Pregnancy (Major problems in Neurology; vol. 7). W.B. Saunders Co., Philadelphia, 1978. Oppenhimer WM: Pregnancy in paraplegic patients: Two case reports. Am J Obstet Gynecol 110: 784, 1971. Schwentker EP, Keegan EM, Skinner SR: Coordinated management of spinal cord injuries. Pennsyhrania Medicine, pp 39-41, September 1980.
M.D.
Int J Gynaecol Obstet 20