- Email: [email protected]
Pregnancy in the Spinal Cord Injured Patient
, , , , , , ,
OBSTETR
C 5
, , , , , , ,
PREGNANCY IN THE SPINAL CORD INJURED PATIENT William G. Kingston, MB, DRCOG,l Ian R. Lange, MD, FRCSC,2 1Resident,
2Associate
Professor, University of Calgary, Chief, Division of Obstetrics, 1,2Department of Obstetrics and Gynaecology, Foothills Hospital, Calgary, Alberta
ABSTRACT
With improved trauma and rehabilitation services, more spinal cord injured women are entering the reproductive age group. These women continue to have a normal potential for reproduction and their fecundity rates are unchanged. They are, however, predisposed to a number of complications during pregnancy induJing decubitus ulcers, anaemia, urinary tract infections, sepsis, precipitous unattended delivery, and autonomic hyper-reflexia. The attending obstetncian should be aware of the clinical manifestations of autonomic hyper-reflexia and be able to provide optimal management to prevent the development of this potentiaUy fatal condition. This requires a team approach involving obstetrical, anaesthetic, neurologic, and nursing services. RESUME
Grace it /' amelioration des services de traitement des traumatismes et de readaptation, un nombre croissant de femmes souffrant d'un traumatisme de la moelle epimere envisagent de devenir enceintes. Ces femmes presentent un potentiel de reproduction et un taux de [econdite normaux. Toutefois, elles sont exposers it un certain nombre de complications pendant leur grossesse, y compris les u/.ceres de decubitus, l'anemie, les infections des voies urinaires, la septicemie, l'accouchement precipice et l'hyper;reactivite du systeme nerwux vegetatif. L' obstetricien devrait etre conscient des manifestations diniques de l' hyper-reactivice du sysceme nerveux vegetatif et capable de proposer un traitement optimal pour la prevention de ce probleme qui peut avoir des consequences fatales. Il convient it cette fin de favoriser la cooperation des services d' obscetrique, d' anesmesie, de neurologie et de soins infirmiers.
J SOGe KEY WORDS Paraplegia, pregnancy, autonomic, hyperreflexia. Received on April 3rd, 1996. Revised and accepted on May 15th, 1996.
JOURNAL SOGe
881
SEPTEMBER 1996
1996;18:881-88
No two women have the same story. Why should they have the same estrogen patch?
Emma McCulloch, age 50, Vivelle 100
Anna \Vanless, age 60, Viuelle 75
Introducing Vivelle. The widest range of dosage strengths available in an estrogen patch. Cross section of Vivelle matrix system. Backing membrane
r
:; ;~ ::;.·:.,,, :-,. ).:.;. :;.:-•.-.-: :.:o,-:., ...:t,.• >t:-;-:.'.•.:,..;.. :.~: ) ~~ i!·:
/>dhesive matrix containing estradiol
• Vivelle comes in strengths of 37.5, 50, 75, 100 pg/day for increased dosing flexibility.' • New midrange doses for additional titration options 1
Estradiol is uniformly distributed within the adhesive matrix on a thin single membrane
• Vivelle offers:
-start with Vivelle 50 twice-weekly -adjust dose to achieve effective control with a minimum dose.
- high level of cosmetic appeal -thin, almost invisible patch - reliable skin adhesiod - good skin tolerability.3 • Convenient twice-weekly dosage regimen.1 For more information call: 1-800-387-8396
ivelleM (estrad ioi-17B)
37.5
50
75
100
Estrogen therapy designed to meet a woman's needs.
CIBA Mississauga, Ontario l5N2W5 or Dorval, Quebec H9S 181
Emma McCulloch. Nad•a Hale, Anna Wanless and jocelyn Laporte are fictitious characters used to show the benefits of ViveUe. Vivelle should be used in conjunction with progeuins in women with an intact uterus. Adverse reactions generally reponed with ERT
include breast tenderness. bloating, and weight changes. Vivelle, like other estrogens, should be prescribed only after consulting the ProduC-t Monograph for warnings, precautions, and contra indications.
C96021 E
mill 8
, , , INTRODUCTION
may return home following treatment in a rehabilitation unit. Many are anxious to re-establish a sense of normality in their lives which could extend to recommencing sexual relationships. In the presence of amenorrhoea, many patients may be unaware of the need for effective contraception. Contraceptive counselling is, therefore, an essential part of the care of women with recent cord injury who are in the reproductive age group.
Trauma, infection, tumours, and vascular lesions are the most common causes of spinal cord injury.! Paraplegia describes paralysis of the lower limbs, and quadriplegia (tetraplegia) is paralysis of all four limbs. As these conditions have diverse aetiologies, it has proved difficult for the authors to obtain accurate prevalence or incidence statistics about such Canadian women within the reproductive age group. Prior to 1945, little was known of the measures required to rehabilitate spinal cord injured women who were often permanently bedridden. Not surprisingly, during the decade of 1940 to 1950 there were only two cases of pregnancy in paralysed women reported in the world literature. Subsequently, the treatment offered to these people has transformed their lives, marriage is not discouraged, and pregnancy is not banned merely because they are paralysed. 2 The goals of this review are to present and discuss the acute and chronic pathophysiological changes associated with spinal cord injury and also to discuss the obstetrical management of these patients. The clinical presentation and management of autonomic hyper-reflexia will be emphasized. A knowledge of issues related to sexuality in the spinal cord injured patient (both male and female) is considered important for the obstetrician/gynaecologist, however it is an area, which alone, is deserving of a full review, and therefore beyond the scope of this article. The interested reader may wish to consult references. 'A.I
EFFECT ON ABORTION RATE
The spontaneous abortion rate in the paraplegic patient may be influenced by the timing of the spinal cord injury in relation to gestational age. When cord injury occurs prior to conception, the pregnancy rate and risk of spontaneous abortion remain as they were before the injury.6.1 When spinal cord injury occurs during the course of an established pregnancy, it may be followed by spontaneous abortion or stillbirth. If the pregnancy continues, the detailed radiological investigations that are often required to determine the nature and extent of the spinal injury may be hazardous to the developing fetus. In such circumstances, however, the interests of the mother are of paramount importance." Magnetic resonance imaging (MRI) may assist in determining the extent of spinal cord injury without radiation exposure. Whilst the safety of MRI in pregnancy has not been proven, to date there has been no indication that it has produced deleterious effects in the fetus. This diagnostic method may be used more frequently in the future, with concomitant reduction in the exposure of fetuses to ionizing radiation."!!
PATHOPHYSIOLOGY
ANTEPARTUM CARE
Acute transection of the spinal cord produces a flaccid paralysis and loss of sensation below the lesion. The initial phase is characterized by hypotension, bradycardia, ECG abnormalities suggestive of myocardial damage, loss of tendon reflexes, atonicity of the bladder, and faecal retention. This phase lasts for days or weeks. The cord below the level of transection then recovers reflex function, the paralysis becomes spastic, the patient is prone to muscle spasms, the plantar responses become extensor, and the bladder and bowel begin to empty reflexly.!
Urinary infections are common and often recurrent in spinal cord injured women, especially those patients with in-dwelling urinary catheters. Cystitis may be ineradicable. Urinary stasis and bacteruria lead frequently to pyelonephritis as well as the formation of renal and bladder calculae. For these reasons, frequent urine cultures, antibiotic prophylaxis, and serial renal ultrasound to detect calculae are recommended. Long term antibiotic prophylaxis may be necessary. Examples of suitable drugs for this purpose are nitrofurtantoin and ampicillin.!2 Decubitus ulcers may be exacerbated by pregnancy due to increased maternal weight, reduced mobility, stasis, and tissue oedema.12 If these lesions are neglected,
CONTRACEPTION
Women in the reproductive age group often experience amenorrhoea for two to three months following injury. It is often towards the end of this time that they
JOURNAL SOGC
884
SEPTEMBER 1996
, , , The onset of labour may be silent or may result in autonomic hyper-reflexia. The sensory (pain) innervation of the uterus is derived from TlO, 11, 12, and Ll. Therefore, if the spinal cord lesion is at or above the tenth thoracic vertebra, uterine contractions may not be appreciated by the patient. Any patient with complaints of spotting, leakage of fluid, or increased discharge per vagina, with or without pelvic, back or abdominal pressure, requires an urgent obstetrical assessment. It is important that the patient be familiar with the subtle signs and symptoms of impending labour, and should be educated to seek rapid assessment in the presence of these symptoms. Robertson described a hospitalized patient at 34 weeks gestation who gave birth unaware that labour had started. She rang the bell at 0400 hours to tell the nurse that she could hear a baby crying. When the nurse pulled back the bed clothes there was no doubt about which baby was crying. Z
they may be a source of cellulitis, necrotising infection, and sepsis. It is the author's experience that referral to and regular follow up by a health care professional who specialises in skin care may be of great benefit. For example, an ostomy nurse may help to prevent the occurrence of decubitus ulcers and provide optimal therapy should they occur. In addition, limiting the time spent sitting in a wheel chair during the day, especially in the third trimester, is often beneficial. For those patients who find such limitations intrusive, the provision of a timing device with an auditory alarm can be of assistance. The device is set to activate every ten to fifteen minutes, and can provide the necessary cue to remind the patient to elevate the dependent parts from the seat cushion and allow re-establishment of blood flow to the area. Anaemia due to chronic low grade infection is common before pregnancy and is often exacerbated by pregnancy. Anaemia predisposes to slow healing, decubitus ulcer formation, and decreased resistance to infection. 1z Oral iron therapy is recommended and should be supplemented with stool softeners and bulk forming agents. In addition to the routine antepartum surveillance of the fetus, consultation with an anaesthetist at 34 to 36 weeks gestation is advised. The aim of this meeting is to facilitate discussion of the possible use of epidural anaesthesia during labour. Previous series and case reports have suggested that the spinal cord injured patient has an increased risk of preterm labour and deliveryYl1 This has been disputed by Baker et al. who felt, following critical review of these data, that the rate of preterm delivery was similar to that of the general population. 16 These authors argued against the widespread use of prolonged hospitalization and home tocodynamometry to detect preterm delivery. As an alternative, they suggested weekly cervical examination as surveillance of premature cervical ripening. Assessment of the cervix should be started after the 24th to 26th week of gestation. 8 The authors noted, however, that this method failed to prevent unsupervised term delivery in one of their eleven patients.
AUTONOMIC HYPER-REFLEXIA
Autonomic hyper-reflexia (also known as autonomic dysreflexia) was first described by Head and Riddoch in 1917Y It is a condition that has the potential for maternal and perinatal mortality and morbidity. The obstetrician supervising the labour of any spinal cord injured parturient should have a good understanding of the pathophysiology of this condition and knowledge of its optimal management. Autonomic hyper-reflexia (whether during or remote from labour) presents with pilomotor erection, excessive sweating, facial flushing, dilated pupils, severe headache, bradycardia, and severe paroxysmal hypertension. If the stimulus is not removed, the increase in blood pressure can result in loss of consciousness and convulsions. Retinal haemorrhages and fatal cerebral and subarachnoid haemorrhages have been reported. The syndrome does not occur if the spinal lesion is below the T7 level but does occur in over 85 percent of patients with a cord injury above this level. If there is any doubt concerning the level of the spinal insult, the obstetrician is advised to seek a neurological opinion. It must be remembered that the cord may be traumatized at different levels and at different parts of the cord. The aetiology of autonomic hyper-reflexia is described in Figure l. In essence, it is the result of afferent impulses reaching an isolated spinal cord uninhibited and unmodulated by higher centres.
LABOUR
In 1872, Sir James Young Simpson showed that an intact spinal cord was not necessary for the initiation and progress of labour. He demonstrated normal parturition in pigs following removal of the thoracic and lumbar cord. 2
JOURNAL SOGe
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SEPTEMBER 1996
, , , catastrophic rise in blood pressure. An epidural anaesthetic, using a locally acting agent, blocks the afferent nerves during the first and second stages of labour. Supplementation of the epidural anaesthetic may be required for a vaginal or abdominal instrumental delivery. Epidural fentanyl alone has not been shown to be effective in preventing the development of autonomic hyper-reflexia. 20 Epidural meperidine, probably because of its local anaesthetic effect, can prevent its development.2l If autonomic hyper-reflexia is not controlled adequately by regional anaesthesia, or access to the epidural space is impeded by previous vertebral trauma, short acting antihypertensive agents should be given under careful control. 18 Safe vaginal delivery is the desired goal. Instrumental delivery (either vaginally or abdominally) is reserved for the usual obstetrical indications. Whenever possible, epidural anaesthesia should also be used for Caesarian section. If this is not possible and if general anaesthesia is required, it is important to note that severe hyperkalaemia may result from the use of succinylcholineY A denervated or degenerating muscle may leak potassium, and is especially sensitive to the chemical stimulation of acetylcholine or succinylcholine. The serum potassium levels may rise to a point which is sufficient to produce fatal cardiac arrhythmiae. This may occur up to a year following acute spinal cord injury. In cases where paralysis is progressive, hyperkalaemia remains a risk. 22,23 If autonomic hyper-reflexia is not controlled adequately, the fetus may exhibit tachycardia and variable decelerations during paroxysms of hyper-reflexia. 24 Despite the maternal catecholamine surge and resultant maternal hypertension, the fetal pH is usually normal and the stress is tolerated by the fetus. '5
FIGUREl AETIOLOGY AN D CLINICAL SIGNS OF AN EPISODE OF AUTONOMIC HYPER·REFLEXIA
Afferent impulses arising from stimulation of the skin below the level of the cord lesion or distention and contraction of a hollow viscus such as the urinary bladder, uterus or bowel. J.Massive stimulation of the sympathetic nervous system. J.Efferent impulses travel from spinal cord segments T5 to T9 to the adrenal medulla causing discharge of catecholamines.
+ Efferent impulses from the sympathetic centres from T1 to L1 travel directly to the vasculature . J.SEVERE HYPERTENSION
J.Hypertension detected at the carotid sinus and aortic arch which send afferent impulses to the cardiac centres in the medulla oblongata. Efferent impulses then travel via the vagus nerve to the heart. J.BRADYCARDIA
Acute hypertension is mediated by splanchnic vasoconstriction and commonly reaches levels of 200/150 mm Hg.181t is important to note that autonomic hyperreflexia has been reported to be mistaken for preeclampsia, with lethal consequences. Abouleish reported a maternal death from intracranial haemorrhage due to autonomic hyper-reflexia which was misdiagnosed as pre-eclampsia. 19 Overall, there is no increase in the incidence of pre-eclampsia in these patients. Obstetrical procedures that are commonly employed in the conduct of labour and delivery can precipitate autonomic hyper-reflexia. These manoeuvres include vaginal examination, Foley catheter placement or rectal examination. It is recommended that these procedures should be preceded by topical application of anaesthetic jelly to reduce neural stimulation. Mandatory indwelling bladder catheter drainage throughout labour is suggested to avoid obstruction with bladder distention and the development of autonomic hyper-reflexia. Epidural anaesthesia has been shown to be effective in preventing autonomic hyper-reflexia. 20 In patients known or suspected to have a spinal cord lesion above T7, an anaesthetic consultation and commitment to start epidural anaesthesia with the onset of spontaneous labour, or prior to the induction of labour, are strongly advised. This can facilitate the prevention of a potentially
JOURNAL SOGe
POST-PARTUM CARE
The risk of post-partum haemorrhage is not increased in the spinal cord injured patient, however phlebitis and sepsis occur more frequently. Intensive physiotherapy is required to prevent the development of new decubitus ulcers or to treat those that may already have developed, as well as to avoid the risks of phiebitis and embolism. Anaemia and urinary infection must be treated. Prior to discharge from hospital it should be ascertained that there is adequate physical assistance for the new mother in the home environment. If this is not
886
SEPTEMBER 1996
(flucon
ole I pfizer)
, , , 13. Wanner MB, Rageth CJ, Zach GA. Pregnancy and autonomic hyperreflexia in patients with spinal cord lesions. Paraplegia 1972; 10:209-12. 14. Robertson DNS, Guttman L. The paraplegic patient in pregnancy and labour. Proc R Soc Med 1963;56:381-7. 15. Verduyn WHo Spinal cord injured women, pregnancy and delivery. Paraplegia 1986;24:231-40. 16. Baker ER, Cardenas DD, Benedetti TJ. Risks associated with pregnancy in spinal cord injured women. Obstet Gynecol 1992;80:425-8. 17. Head H, Riddoch G. The autonomic bladder, excessive sweating and some other reflex conditions in gross injuries of the spinal cord. Brain 1917;40:188-263. 18. McGregor JA, Meeuwsen J. Autonomic hyperreflexia: a mortal danger for spinal cord-damaged women in labor. Am J Obstet Gynecol 1985 Feb:330-2. 19. Abouleish E. Hypertension in a paraplegic parturient. Anesthesiology 1980;53:348-9. 20. Abouleish El, Hanley ES, Palmer SM. Can epidural fentanyl control autonomic hyperreflexia in a quadriplegic parturient? Anesth Analg 1989;68:523-6. 21. Buchan PC, Milne MK, Browning MCK. The effect of continuous epidural blockade on plasma 11-hydroxysteroid concentrations in labour. Obstet Gynaecol Br Commonw 1973;80:974-7. 22. Cooperman LH, Strobel GE, Kennel EM. Massive hyperkalemia after administration of succinylcholine. Anesthesiology 1970;32:161-4. 23. Cooperman LH. Succinylcholine induced hyperkalemia in neuromuscular disease. JAMA 1970;213:1867-71. 24. Young BK, Katz M, Klein SA. Pregnancy after spinal cord injury: altered maternal and fetal response to labor. Obstet Gynecol 1983;62:59-63.
available, then the appropriate social agencies should be contacted. Paraplegic and quadriplegic patients can breastfeed successfully and have a nonnallet down reflex during suckling. 2 CONCLUSION
Spinal cord injured obstetrical patients are becoming more common. They have specific problems in pregnancy and delivery related to their condition, the most important of which is autonomic hyper-reflexia. Autonomic hyper-reflexia can be controlled effectively by the use of epidural anaesthesia. Optimal care of the spinal cord injured parturient requires close liaison between the obstetrician, the anaesthetist, the neurologist, and nursing services. REFERENCES 1.
Hughes Se. Anesthesia for the pregnant patient with neuromuscular disorders. In: Schnider SM. Levinson G (Eds). Anesthesia for obstetrics. Baltimore. Williams and Wilkins 1993: 563-80. 2. Robertson DNS. Pregnancy and labour in the paraplegic. Paraplegia 1972; 10:209-12. 3. Berard EJ. The sexuality of spinal cord injured women: physiology and pathophysiology. A review. Paraplegia 1989;27:99-112. 4. Siosteen A, Lundqvist C, Blomstrand C, Sullivan L, Sullivan M. Sexual ability, activity, attitudes and satisfaction as part of adjustment in spinal cord-injured subjects. Paraplegia 1990;28:289-95. 5. Beretta G, Chelo E, Zanola A. Reproductive aspects in spinal cord injured males. Paraplegia 1989;27:113-18. 6. Geller H, Paeslack V. Our experiences about pregnancy and delivery of the paraplegic woman. Paraplegia 1971 ;8:61. 7. Comarr AE. Observations on menstruation and pregnancy among female spinal cord injured patients. Paraplegia 1966;3:263. 8. Aminoff JA. Neurologic disorders. In: Creasy RK, Resnik R (Eds). Maternal fetal medicine, principles and practice. Philadelphia. Saunders. 1989;1073-1109. 9. Shellcock FG, Kanal E. Policies, guidelines, and recommendations for MR imaging safety and patient management. J Magn Reson Imaging 1991;1 :97-101. 10. Shellcock FG, Kanal E. MR procedures and pregnancy. In: Magnetic Resonance. Bioeffects, Safety, and Patient Management. New York. Raven Press. 1994;41-7. 11. Kanal E, Gillen J, Evans JA, Savitz DA, Shellcock FG. Survey of reproductive health among female MR workers. Radiology 1993;187:395-9. 12. Young BK. Pregnancy in women with paraplegia. In: Devinsky 0, Feldman E, Hainline B (Eds). Neurologic complications of pregnancy. New York. Raven Press Ltd. 1994;209-14.
JOURNAL SOGC
888
SEPTEMBER 1996
OBSTETR
C 5
, , , , , , ,
PREGNANCY IN THE SPINAL CORD INJURED PATIENT William G. Kingston, MB, DRCOG,l Ian R. Lange, MD, FRCSC,2 1Resident,
2Associate
Professor, University of Calgary, Chief, Division of Obstetrics, 1,2Department of Obstetrics and Gynaecology, Foothills Hospital, Calgary, Alberta
ABSTRACT
With improved trauma and rehabilitation services, more spinal cord injured women are entering the reproductive age group. These women continue to have a normal potential for reproduction and their fecundity rates are unchanged. They are, however, predisposed to a number of complications during pregnancy induJing decubitus ulcers, anaemia, urinary tract infections, sepsis, precipitous unattended delivery, and autonomic hyper-reflexia. The attending obstetncian should be aware of the clinical manifestations of autonomic hyper-reflexia and be able to provide optimal management to prevent the development of this potentiaUy fatal condition. This requires a team approach involving obstetrical, anaesthetic, neurologic, and nursing services. RESUME
Grace it /' amelioration des services de traitement des traumatismes et de readaptation, un nombre croissant de femmes souffrant d'un traumatisme de la moelle epimere envisagent de devenir enceintes. Ces femmes presentent un potentiel de reproduction et un taux de [econdite normaux. Toutefois, elles sont exposers it un certain nombre de complications pendant leur grossesse, y compris les u/.ceres de decubitus, l'anemie, les infections des voies urinaires, la septicemie, l'accouchement precipice et l'hyper;reactivite du systeme nerwux vegetatif. L' obstetricien devrait etre conscient des manifestations diniques de l' hyper-reactivice du sysceme nerveux vegetatif et capable de proposer un traitement optimal pour la prevention de ce probleme qui peut avoir des consequences fatales. Il convient it cette fin de favoriser la cooperation des services d' obscetrique, d' anesmesie, de neurologie et de soins infirmiers.
J SOGe KEY WORDS Paraplegia, pregnancy, autonomic, hyperreflexia. Received on April 3rd, 1996. Revised and accepted on May 15th, 1996.
JOURNAL SOGe
881
SEPTEMBER 1996
1996;18:881-88
No two women have the same story. Why should they have the same estrogen patch?
Emma McCulloch, age 50, Vivelle 100
Anna \Vanless, age 60, Viuelle 75
Introducing Vivelle. The widest range of dosage strengths available in an estrogen patch. Cross section of Vivelle matrix system. Backing membrane
r
:; ;~ ::;.·:.,,, :-,. ).:.;. :;.:-•.-.-: :.:o,-:., ...:t,.• >t:-;-:.'.•.:,..;.. :.~: ) ~~ i!·:
/>dhesive matrix containing estradiol
• Vivelle comes in strengths of 37.5, 50, 75, 100 pg/day for increased dosing flexibility.' • New midrange doses for additional titration options 1
Estradiol is uniformly distributed within the adhesive matrix on a thin single membrane
• Vivelle offers:
-start with Vivelle 50 twice-weekly -adjust dose to achieve effective control with a minimum dose.
- high level of cosmetic appeal -thin, almost invisible patch - reliable skin adhesiod - good skin tolerability.3 • Convenient twice-weekly dosage regimen.1 For more information call: 1-800-387-8396
ivelleM (estrad ioi-17B)
37.5
50
75
100
Estrogen therapy designed to meet a woman's needs.
CIBA Mississauga, Ontario l5N2W5 or Dorval, Quebec H9S 181
Emma McCulloch. Nad•a Hale, Anna Wanless and jocelyn Laporte are fictitious characters used to show the benefits of ViveUe. Vivelle should be used in conjunction with progeuins in women with an intact uterus. Adverse reactions generally reponed with ERT
include breast tenderness. bloating, and weight changes. Vivelle, like other estrogens, should be prescribed only after consulting the ProduC-t Monograph for warnings, precautions, and contra indications.
C96021 E
mill 8
, , , INTRODUCTION
may return home following treatment in a rehabilitation unit. Many are anxious to re-establish a sense of normality in their lives which could extend to recommencing sexual relationships. In the presence of amenorrhoea, many patients may be unaware of the need for effective contraception. Contraceptive counselling is, therefore, an essential part of the care of women with recent cord injury who are in the reproductive age group.
Trauma, infection, tumours, and vascular lesions are the most common causes of spinal cord injury.! Paraplegia describes paralysis of the lower limbs, and quadriplegia (tetraplegia) is paralysis of all four limbs. As these conditions have diverse aetiologies, it has proved difficult for the authors to obtain accurate prevalence or incidence statistics about such Canadian women within the reproductive age group. Prior to 1945, little was known of the measures required to rehabilitate spinal cord injured women who were often permanently bedridden. Not surprisingly, during the decade of 1940 to 1950 there were only two cases of pregnancy in paralysed women reported in the world literature. Subsequently, the treatment offered to these people has transformed their lives, marriage is not discouraged, and pregnancy is not banned merely because they are paralysed. 2 The goals of this review are to present and discuss the acute and chronic pathophysiological changes associated with spinal cord injury and also to discuss the obstetrical management of these patients. The clinical presentation and management of autonomic hyper-reflexia will be emphasized. A knowledge of issues related to sexuality in the spinal cord injured patient (both male and female) is considered important for the obstetrician/gynaecologist, however it is an area, which alone, is deserving of a full review, and therefore beyond the scope of this article. The interested reader may wish to consult references. 'A.I
EFFECT ON ABORTION RATE
The spontaneous abortion rate in the paraplegic patient may be influenced by the timing of the spinal cord injury in relation to gestational age. When cord injury occurs prior to conception, the pregnancy rate and risk of spontaneous abortion remain as they were before the injury.6.1 When spinal cord injury occurs during the course of an established pregnancy, it may be followed by spontaneous abortion or stillbirth. If the pregnancy continues, the detailed radiological investigations that are often required to determine the nature and extent of the spinal injury may be hazardous to the developing fetus. In such circumstances, however, the interests of the mother are of paramount importance." Magnetic resonance imaging (MRI) may assist in determining the extent of spinal cord injury without radiation exposure. Whilst the safety of MRI in pregnancy has not been proven, to date there has been no indication that it has produced deleterious effects in the fetus. This diagnostic method may be used more frequently in the future, with concomitant reduction in the exposure of fetuses to ionizing radiation."!!
PATHOPHYSIOLOGY
ANTEPARTUM CARE
Acute transection of the spinal cord produces a flaccid paralysis and loss of sensation below the lesion. The initial phase is characterized by hypotension, bradycardia, ECG abnormalities suggestive of myocardial damage, loss of tendon reflexes, atonicity of the bladder, and faecal retention. This phase lasts for days or weeks. The cord below the level of transection then recovers reflex function, the paralysis becomes spastic, the patient is prone to muscle spasms, the plantar responses become extensor, and the bladder and bowel begin to empty reflexly.!
Urinary infections are common and often recurrent in spinal cord injured women, especially those patients with in-dwelling urinary catheters. Cystitis may be ineradicable. Urinary stasis and bacteruria lead frequently to pyelonephritis as well as the formation of renal and bladder calculae. For these reasons, frequent urine cultures, antibiotic prophylaxis, and serial renal ultrasound to detect calculae are recommended. Long term antibiotic prophylaxis may be necessary. Examples of suitable drugs for this purpose are nitrofurtantoin and ampicillin.!2 Decubitus ulcers may be exacerbated by pregnancy due to increased maternal weight, reduced mobility, stasis, and tissue oedema.12 If these lesions are neglected,
CONTRACEPTION
Women in the reproductive age group often experience amenorrhoea for two to three months following injury. It is often towards the end of this time that they
JOURNAL SOGC
884
SEPTEMBER 1996
, , , The onset of labour may be silent or may result in autonomic hyper-reflexia. The sensory (pain) innervation of the uterus is derived from TlO, 11, 12, and Ll. Therefore, if the spinal cord lesion is at or above the tenth thoracic vertebra, uterine contractions may not be appreciated by the patient. Any patient with complaints of spotting, leakage of fluid, or increased discharge per vagina, with or without pelvic, back or abdominal pressure, requires an urgent obstetrical assessment. It is important that the patient be familiar with the subtle signs and symptoms of impending labour, and should be educated to seek rapid assessment in the presence of these symptoms. Robertson described a hospitalized patient at 34 weeks gestation who gave birth unaware that labour had started. She rang the bell at 0400 hours to tell the nurse that she could hear a baby crying. When the nurse pulled back the bed clothes there was no doubt about which baby was crying. Z
they may be a source of cellulitis, necrotising infection, and sepsis. It is the author's experience that referral to and regular follow up by a health care professional who specialises in skin care may be of great benefit. For example, an ostomy nurse may help to prevent the occurrence of decubitus ulcers and provide optimal therapy should they occur. In addition, limiting the time spent sitting in a wheel chair during the day, especially in the third trimester, is often beneficial. For those patients who find such limitations intrusive, the provision of a timing device with an auditory alarm can be of assistance. The device is set to activate every ten to fifteen minutes, and can provide the necessary cue to remind the patient to elevate the dependent parts from the seat cushion and allow re-establishment of blood flow to the area. Anaemia due to chronic low grade infection is common before pregnancy and is often exacerbated by pregnancy. Anaemia predisposes to slow healing, decubitus ulcer formation, and decreased resistance to infection. 1z Oral iron therapy is recommended and should be supplemented with stool softeners and bulk forming agents. In addition to the routine antepartum surveillance of the fetus, consultation with an anaesthetist at 34 to 36 weeks gestation is advised. The aim of this meeting is to facilitate discussion of the possible use of epidural anaesthesia during labour. Previous series and case reports have suggested that the spinal cord injured patient has an increased risk of preterm labour and deliveryYl1 This has been disputed by Baker et al. who felt, following critical review of these data, that the rate of preterm delivery was similar to that of the general population. 16 These authors argued against the widespread use of prolonged hospitalization and home tocodynamometry to detect preterm delivery. As an alternative, they suggested weekly cervical examination as surveillance of premature cervical ripening. Assessment of the cervix should be started after the 24th to 26th week of gestation. 8 The authors noted, however, that this method failed to prevent unsupervised term delivery in one of their eleven patients.
AUTONOMIC HYPER-REFLEXIA
Autonomic hyper-reflexia (also known as autonomic dysreflexia) was first described by Head and Riddoch in 1917Y It is a condition that has the potential for maternal and perinatal mortality and morbidity. The obstetrician supervising the labour of any spinal cord injured parturient should have a good understanding of the pathophysiology of this condition and knowledge of its optimal management. Autonomic hyper-reflexia (whether during or remote from labour) presents with pilomotor erection, excessive sweating, facial flushing, dilated pupils, severe headache, bradycardia, and severe paroxysmal hypertension. If the stimulus is not removed, the increase in blood pressure can result in loss of consciousness and convulsions. Retinal haemorrhages and fatal cerebral and subarachnoid haemorrhages have been reported. The syndrome does not occur if the spinal lesion is below the T7 level but does occur in over 85 percent of patients with a cord injury above this level. If there is any doubt concerning the level of the spinal insult, the obstetrician is advised to seek a neurological opinion. It must be remembered that the cord may be traumatized at different levels and at different parts of the cord. The aetiology of autonomic hyper-reflexia is described in Figure l. In essence, it is the result of afferent impulses reaching an isolated spinal cord uninhibited and unmodulated by higher centres.
LABOUR
In 1872, Sir James Young Simpson showed that an intact spinal cord was not necessary for the initiation and progress of labour. He demonstrated normal parturition in pigs following removal of the thoracic and lumbar cord. 2
JOURNAL SOGe
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, , , catastrophic rise in blood pressure. An epidural anaesthetic, using a locally acting agent, blocks the afferent nerves during the first and second stages of labour. Supplementation of the epidural anaesthetic may be required for a vaginal or abdominal instrumental delivery. Epidural fentanyl alone has not been shown to be effective in preventing the development of autonomic hyper-reflexia. 20 Epidural meperidine, probably because of its local anaesthetic effect, can prevent its development.2l If autonomic hyper-reflexia is not controlled adequately by regional anaesthesia, or access to the epidural space is impeded by previous vertebral trauma, short acting antihypertensive agents should be given under careful control. 18 Safe vaginal delivery is the desired goal. Instrumental delivery (either vaginally or abdominally) is reserved for the usual obstetrical indications. Whenever possible, epidural anaesthesia should also be used for Caesarian section. If this is not possible and if general anaesthesia is required, it is important to note that severe hyperkalaemia may result from the use of succinylcholineY A denervated or degenerating muscle may leak potassium, and is especially sensitive to the chemical stimulation of acetylcholine or succinylcholine. The serum potassium levels may rise to a point which is sufficient to produce fatal cardiac arrhythmiae. This may occur up to a year following acute spinal cord injury. In cases where paralysis is progressive, hyperkalaemia remains a risk. 22,23 If autonomic hyper-reflexia is not controlled adequately, the fetus may exhibit tachycardia and variable decelerations during paroxysms of hyper-reflexia. 24 Despite the maternal catecholamine surge and resultant maternal hypertension, the fetal pH is usually normal and the stress is tolerated by the fetus. '5
FIGUREl AETIOLOGY AN D CLINICAL SIGNS OF AN EPISODE OF AUTONOMIC HYPER·REFLEXIA
Afferent impulses arising from stimulation of the skin below the level of the cord lesion or distention and contraction of a hollow viscus such as the urinary bladder, uterus or bowel. J.Massive stimulation of the sympathetic nervous system. J.Efferent impulses travel from spinal cord segments T5 to T9 to the adrenal medulla causing discharge of catecholamines.
+ Efferent impulses from the sympathetic centres from T1 to L1 travel directly to the vasculature . J.SEVERE HYPERTENSION
J.Hypertension detected at the carotid sinus and aortic arch which send afferent impulses to the cardiac centres in the medulla oblongata. Efferent impulses then travel via the vagus nerve to the heart. J.BRADYCARDIA
Acute hypertension is mediated by splanchnic vasoconstriction and commonly reaches levels of 200/150 mm Hg.181t is important to note that autonomic hyperreflexia has been reported to be mistaken for preeclampsia, with lethal consequences. Abouleish reported a maternal death from intracranial haemorrhage due to autonomic hyper-reflexia which was misdiagnosed as pre-eclampsia. 19 Overall, there is no increase in the incidence of pre-eclampsia in these patients. Obstetrical procedures that are commonly employed in the conduct of labour and delivery can precipitate autonomic hyper-reflexia. These manoeuvres include vaginal examination, Foley catheter placement or rectal examination. It is recommended that these procedures should be preceded by topical application of anaesthetic jelly to reduce neural stimulation. Mandatory indwelling bladder catheter drainage throughout labour is suggested to avoid obstruction with bladder distention and the development of autonomic hyper-reflexia. Epidural anaesthesia has been shown to be effective in preventing autonomic hyper-reflexia. 20 In patients known or suspected to have a spinal cord lesion above T7, an anaesthetic consultation and commitment to start epidural anaesthesia with the onset of spontaneous labour, or prior to the induction of labour, are strongly advised. This can facilitate the prevention of a potentially
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The risk of post-partum haemorrhage is not increased in the spinal cord injured patient, however phlebitis and sepsis occur more frequently. Intensive physiotherapy is required to prevent the development of new decubitus ulcers or to treat those that may already have developed, as well as to avoid the risks of phiebitis and embolism. Anaemia and urinary infection must be treated. Prior to discharge from hospital it should be ascertained that there is adequate physical assistance for the new mother in the home environment. If this is not
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(flucon
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, , , 13. Wanner MB, Rageth CJ, Zach GA. Pregnancy and autonomic hyperreflexia in patients with spinal cord lesions. Paraplegia 1972; 10:209-12. 14. Robertson DNS, Guttman L. The paraplegic patient in pregnancy and labour. Proc R Soc Med 1963;56:381-7. 15. Verduyn WHo Spinal cord injured women, pregnancy and delivery. Paraplegia 1986;24:231-40. 16. Baker ER, Cardenas DD, Benedetti TJ. Risks associated with pregnancy in spinal cord injured women. Obstet Gynecol 1992;80:425-8. 17. Head H, Riddoch G. The autonomic bladder, excessive sweating and some other reflex conditions in gross injuries of the spinal cord. Brain 1917;40:188-263. 18. McGregor JA, Meeuwsen J. Autonomic hyperreflexia: a mortal danger for spinal cord-damaged women in labor. Am J Obstet Gynecol 1985 Feb:330-2. 19. Abouleish E. Hypertension in a paraplegic parturient. Anesthesiology 1980;53:348-9. 20. Abouleish El, Hanley ES, Palmer SM. Can epidural fentanyl control autonomic hyperreflexia in a quadriplegic parturient? Anesth Analg 1989;68:523-6. 21. Buchan PC, Milne MK, Browning MCK. The effect of continuous epidural blockade on plasma 11-hydroxysteroid concentrations in labour. Obstet Gynaecol Br Commonw 1973;80:974-7. 22. Cooperman LH, Strobel GE, Kennel EM. Massive hyperkalemia after administration of succinylcholine. Anesthesiology 1970;32:161-4. 23. Cooperman LH. Succinylcholine induced hyperkalemia in neuromuscular disease. JAMA 1970;213:1867-71. 24. Young BK, Katz M, Klein SA. Pregnancy after spinal cord injury: altered maternal and fetal response to labor. Obstet Gynecol 1983;62:59-63.
available, then the appropriate social agencies should be contacted. Paraplegic and quadriplegic patients can breastfeed successfully and have a nonnallet down reflex during suckling. 2 CONCLUSION
Spinal cord injured obstetrical patients are becoming more common. They have specific problems in pregnancy and delivery related to their condition, the most important of which is autonomic hyper-reflexia. Autonomic hyper-reflexia can be controlled effectively by the use of epidural anaesthesia. Optimal care of the spinal cord injured parturient requires close liaison between the obstetrician, the anaesthetist, the neurologist, and nursing services. REFERENCES 1.
Hughes Se. Anesthesia for the pregnant patient with neuromuscular disorders. In: Schnider SM. Levinson G (Eds). Anesthesia for obstetrics. Baltimore. Williams and Wilkins 1993: 563-80. 2. Robertson DNS. Pregnancy and labour in the paraplegic. Paraplegia 1972; 10:209-12. 3. Berard EJ. The sexuality of spinal cord injured women: physiology and pathophysiology. A review. Paraplegia 1989;27:99-112. 4. Siosteen A, Lundqvist C, Blomstrand C, Sullivan L, Sullivan M. Sexual ability, activity, attitudes and satisfaction as part of adjustment in spinal cord-injured subjects. Paraplegia 1990;28:289-95. 5. Beretta G, Chelo E, Zanola A. Reproductive aspects in spinal cord injured males. Paraplegia 1989;27:113-18. 6. Geller H, Paeslack V. Our experiences about pregnancy and delivery of the paraplegic woman. Paraplegia 1971 ;8:61. 7. Comarr AE. Observations on menstruation and pregnancy among female spinal cord injured patients. Paraplegia 1966;3:263. 8. Aminoff JA. Neurologic disorders. In: Creasy RK, Resnik R (Eds). Maternal fetal medicine, principles and practice. Philadelphia. Saunders. 1989;1073-1109. 9. Shellcock FG, Kanal E. Policies, guidelines, and recommendations for MR imaging safety and patient management. J Magn Reson Imaging 1991;1 :97-101. 10. Shellcock FG, Kanal E. MR procedures and pregnancy. In: Magnetic Resonance. Bioeffects, Safety, and Patient Management. New York. Raven Press. 1994;41-7. 11. Kanal E, Gillen J, Evans JA, Savitz DA, Shellcock FG. Survey of reproductive health among female MR workers. Radiology 1993;187:395-9. 12. Young BK. Pregnancy in women with paraplegia. In: Devinsky 0, Feldman E, Hainline B (Eds). Neurologic complications of pregnancy. New York. Raven Press Ltd. 1994;209-14.
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