SMFM Consult Series

Pregnancy in women with spinal cord injuries

Society of Maternal Fetal Medicine with the assistance of Caroline Signore, MD

Published in Contemporary Obgyn Febbruary 2012

Antenatal Care: SCI

Most gravidas with SCI will experience few serious complications of pregnancy and will deliver healthy infants.

No Reason to discourage or terminate a pregnancy simply on the basis of a maternal SCI.

Antenatal care should be provided by a multidisciplinary teaam: Obstetrician and/or maternal-fetal medicine specialist Neurologist Physiatrist, Urologist Obstetric anesthesiologist Nurses Physical and occupational therapists

Antenatal Care SCI Management: Urinary dysfunction

Chronic urinary dysfunction related to neurogenic bladder Many women with lower lesions are capable of, and should perform,

intermittent self-catheterization. Indwelling urethral or suprapubic catheters are the norm among women with tetraplegia (eg, quadriplegia: loss of sensory and muscular use of both upper and lower extremities).

Women with SCI may experience pregnancy-related changes in bladder function and management: Increases in bladder spasms Need for more frequent catheterization Leakage around indwelling catheters

Self-catheterization is the preferred approach throughout pregnancy because of the increased risks of urinary tract infection (UTI) with chronic indwelling catheters.

Up to 25% of women with SCI may require a change in bladder management because of chronic urine leakage and/or bladder spasms (eg, expelling indwelling catheter); thus, referral for urology or urogynecology consultation may be useful in these situations

Antenatal Care SCI Management: UTI

Asymptomatic bacteriuria occurs in the majority of pregnant women with SCI.

In a general obstetric population, the frequency of asymptomatic bacteriuria is 2% to 7%, and without treatment, 30% to 40% of these women will progress to UTI.

American College of Obstetricians and Gynecologists (ACOG) Committee Opinion on SCI in pregnancy suggests that frequent urine cultures or antibiotic suppression are indicated

Urine cultures for the detection of asymptomatic bacteriuria can be done monthly or once per trimester, depending on the frequency of positive cultures and prior infections

Chronic antibiotic suppression may be considered for women with recurrent UTIs and/or indwelling catheters.

Antibiotic regimens should be directed on the basis of culture results; commonly used agents include nitrofurantoin and trimethoprim-sulfamethoxazole

Antenatal Care SCI Management: Decubitus Ulcer

Decubitus ulcers occur in 5% to 10% of women with SCI Contributing factors that increase risk of skin breakdown in pregnancy

include: Gestational weight gain Inadequately sized or cushioned wheelchairs or other medical

equipment Dependent edema Anemia Poor nutrition Smoking

Patients should be advised to change positions and perform pressure-relief maneuvers regularly and to inspect equipment for appropriate fit and padding

Frequent skin inspections at home and during office visits are recommended.

If there is evidence or concern for skin breakdown or potential injury, communication with the patient's physical medicine and/or rehabilitation team is warranted

Antenatal Care SCI Management: Respiratory System

Baseline respiratory function may be impaired in SCI because of weakened respiratory musculature or chest deformity from posttraumatic kyphoscoliosis, especially those women with higher thoracic or cervical lesions (eg, above T5).

Respiratory impairment may be exacerbated by pregnancy, with the gravid uterus further limiting diaphragmatic excursion. Supine positioning may worsen symptoms.

In selected women with SCI, baseline and serial pulmonary function tests may be performed to assess vital capacity and the possible need for ventilator support during labor (eg, if vital capacity is <13 mL/kg)

Referral to a pulmonologist may be appropriate for women with chronic respiratory symptoms and those with lower vital capacity

Antenatal Care SCI Management: Preterm labor

Women with SCI above T10 may not perceive the pain of uterine contractions and are therefore at risk of unattended preterm or term birth.

Increased risk of preterm birth (21% to 27%) among women with SCI

Women and/or their caregivers should be instructed how to palpate for uterine contractions

They also should be advised they may experience unique indicators of labor, such as increases in spasticity, symptoms of autonomic dysreflexia (AD), referred pain above-the-cord lesion, or shortness of breath.

Antenatal Care SCI Management: Venous Tromboembolism

The combination of impaired mobility and the hypercoagulable state of pregnancy raises concern for thromboembolic disease in women with SCI

There is insufficient data to recommend universal pharmacological thromboprophylaxis (eg, low molecular weight heparin) during pregnancy of all women with SCI

Pharmacologic treatment should be individualized based on patient medical history and physical limitations

Antenatal Care SCI Management: Fetal Risks

Among women with SCI prior to conception, there does not appear to be an increased risk of fetal malformations, miscarriage, or stillbirth

Common concern in SCI pregnancy is fetal exposure to maternal medications. Ideally, women with SCI should receive preconception counseling so that risks and benefits of continuing medication use can be discussed.

In general, most medications given to women with SCI can be safely continued during pregnancy, but the maternal-fetal medicine specialist should be contacted when new medications are considered or with changes in dosing regimens

Intrapartum Management: Autonomic Dysreflexia

AD, is a potentially life-threatening syndrome AD: marked hypertension and cardiac dysrhythmias AD is common during pregnancy in women with spinal cord lesions at T6 or higher (85%),

but has been reported with lower-level injuries (20% of women with thoracic lesions) The condition is precipitated by a strong or noxious stimulus below the level of the spinal

lesion (eg, distension of bladder or bowel, or vaginal examination) that initiates an uncontrolled reflex sympathetic response. Uterine contractions also can be a potent inciting factor.

The hypertension associated with AD can be extreme and must be differentiated from that of preeclampsia so that appropriate therapy can be initiated. A key difference is that in AD, blood pressure tends to normalize between

contractions, whereas blood pressure elevations in preeclampsia are more persistent. Other signs and symptoms of AD include maternal bradycardia or tachycardia, headache,

flushing, piloerection, nasal congestion, diaphoresis, and anxiety. The severity of AD can range from mildly aggravating symptoms to a hypertensive crisis

leading to encephalopathy, cerebral or retinal hemorrhage, coma, and death. Maternal vasoconstriction can lead to acute uteroplacental insufficiency.

Prevention should be the first goal of management of AD Induction of regional anesthesia early in labor is the preferred preventive strategy, and has

been shown to be effective in decreasing the severity of AD. Because of the risk of AD, several experts recommend that women with SCI should deliver in a unit capable of invasive hemodynamic monitoring.1,13 Cesarean delivery may be required if AD symptoms, especially malignant hypertension, cannot be controlled with pharmacotherapy.

Intrapartum Management: Labor & Delivery

If cervical ripening is required, regional anesthesia should be considered at the outset.

Proper cushioning in bed, regular changes in position, and frequent skin inspections during labor are imperative to avoid skin breakdown and/or decubitus ulceration.

Women with SCI are capable of vaginal delivery, though some may require operative vaginal delivery to compensate for weaker voluntary expulsive ability in the second stage and/or to manage autonomic dysreflexia.

A number of reports suggest an increased rate of cesarean delivery among parturients with SCI, but it is not clear whether these are performed for standard obstetric indications, especially malignant hypertension, cannot be controlled with pharmacotherapy.

Postpartum Care: Patients with SCI

Postpartum autonomic dysreflexia Careful blood pressure monitoring should continue after delivery. Care should be taken to avoid bladder distension, another

common precipitant of AD. During the immediate recovery phase (12 hours for vaginal and

24 hours for cesarean delivery), short-term placement of an indwelling Foley catheter may decrease this risk.

Bowel regimen should be restarted to avoid complications related to constipation.

Perineal care Because of diminished perineal sensation in women with SCI, ice

packs or heating pads for perineal care in the postpartum unit should be used with caution. A bowel program that relies on digital stimulation will need to be modified in the setting of a third- or fourth-degree laceration repair to permit adequate healing.

Lactation Breastfeeding should be encouraged for women with SCI.

Management: Summary

References

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Society for Maternal-Fetal Medicine

The practice of medicine continues to evolve, and individual circumstances will vary. This opinion reflects information available at the time of its submission for publication and is neither designed nor intended to establish an exclusive standard of perinatal care. This presentation is not expected to reflect the opinions of all members of the Society for Maternal-Fetal Medicine.

These slides are for personal, non-commercial and educational use only

Disclaimer

Disclosures

This opinion was developed by the Publications Committee of the Society for Maternal Fetal Medicine with the assistance of Stanley M. Berry, MD, Joanne Stone, MD, Mary Norton, MD, Donna Johnson, MD, and Vincenzo Berghella, MD, and was approved by the executive committee of the society on March 11, 2012. Dr Berghella and each member of the publications committee (Vincenzo Berghella, MD [chair], Sean Blackwell, MD [vice-chair], Brenna Anderson, MD, Suneet P. Chauhan, MD, Jodi Dashe, MD, Cynthia Gyamfi-Bannerman, MD, Donna Johnson, MD, Sarah Little, MD, Kate Menard, MD, Mary Norton, MD, George Saade, MD, Neil Silverman, MD, Hyagriv Simhan, MD, Joanne Stone, MD, Alan Tita, MD, Michael Varner, MD) have submitted a conflict of interest disclosure delineating personal, professional, and/or business interests that might be perceived as a real or potential conflict of interest in relation to this publication.