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Pregnancy Following Spinal Cord Injury LELAND L. CROSS, MD, MPH; JAY M. MEYTHALER, JD, MD; STEPHEN M. TUEL, MS, MD; and AUDREY L CROSS, RN, Charlottesville, Virginia
Each year about 2,000 women of childbearing age in the United States have a spinal cord injury. Only a few mostly anecdotal reports describe pregnancy after such an injury. In a retrospective study of 16 women with a spinal cord injury, half of whom have a complete injury and about half quadriplegia, 25 pregnancies occurred, with 21 carried to full term. The women delayed pregnancy an average of 6.5 years after their injury, with an average age at first pregnancy of 26.8 years. Cesarean section was necessary in 4 patients because of inadequate progress of labor. In 5 deliveries an episiotomy and local anesthesia were required, 7 required epidural anesthesia, including all cesarean sections, and 10 did not require anesthesia. Several complications have been identified in the antepartum, intrapartum, and postpartum periods including autonomic hyperreflexia, premature labor, pressure sores, urinary tract infections, abnormal presentation, and failure to progress. Ultrasonography and amniocentesis were used selectively. Women with spinal cord injuries can have healthy children, although there are significant risks and these women have special needs. (Cross LL, MeythalerJM, Tuel SM, Cross AL: Pregnancy following spinal cord injury, In Rehabilitation Medicine-Adding Life to Years [Special Issue]. West J Med 1991 May; 154:607-61 1)
T he medical literature pertaining to pregnant women who have had a spinal cord injury (SCI) is largely anecdotal. In 1963 Robertson and Guttman reported on 28 pregnancies in women with SCI. I Since that report, the problems of pregnancy, labor, delivery, and the postpartum period have remained relatively unchanged. Our understanding, technology, and the management of the problems of women who have had SCI have improved considerably, however. For example, urinary tract management has progressed from the introduction of the Foley catheter in the 1940s to various other options, including the suprapubic catheter and ileal conduit (or loop). Although urinary tract infections persist, bladder management has improved, and there are newer antibiotics. A recent review article by Stover and co-workers covers many aspects of urologic care,2 but there is no current publication specifically addressing urinary tract infections in pregnant SCI women. Autonomic hyperreflexia (autonomic dysreflexia) was described in part as early as 1890 by Bowlby and later by Head and Riddock in 1917.3 The complete syndrome was described in 1947 by Guttman and Whitteridge.4 Erickson and Kewalramani have provided an excellent review and understanding of autonomic hyperreflexia.5'6 This condition may occur in patients with injury at the T-10 level or above, especially above T-6.' The syndrome is initiated by stimuli, usually below the level of the SCI. The characteristic symptoms and signs are excessive sweating, splotchy rash, pilomotor erection (usually above the level of injury), facial flush, congestion of nasal passages, paroxysmal hypertension, bradycardia, and a severe throbbing headache.5 The cases of two patients who have experienced intraventricular bleeding, one fatal, have been reported.8 These complications have been reported in pregnant women in whom severe hypertension developed without recognition or adequate
treatment of autonomic hyperreflexia.8'9 Many authors recommend epidural anesthesia for pregnant women with SCI to control autonomic dysreflexia during labor and delivery. 10-13 Cesarean section requires a level of anesthesia above T-10, which is also adequate for autonomic hyperreflexia control. Spinal anesthesia for cesarean section is as effective for preventing or terminating autonomic hyperreflexia but has administration problems over longer labor periods. Aside from the control of autonomic hyperreflexia, analgesic and anesthetic requirements for labor and delivery in women with SCI have only recently received adequate attention. Definitions of terms must be thoroughly understood. Tetraplegia or quadriplegia can be used interchangeably, but paraplegia must be reserved for patients with spinal TABLE 1.-Summary of Outcome of 25 Pregnancies in 16 Women With Spinal Cord Injury (SCI) Outcome
Babies ............................ Premature ....................... Abortions .......................... Induced .........................
Spontaneous .....................
Fetal birth weight, grams (Ib) 1,431 (3+) .......................
2,268 to 2,719 (5 to 6) ............. 2,720 to 3,174 (6 to 7) ....... ...... 3,175 to 3,629 (7 to 8) ...... ....... 3,630 to 4.082 (8 to 9) ....... ...... Apgar scores I at 1 min; 7 at 5 min; 9 at 10 min ... 7at 1 min;8ormoreat5min ....... 9or 10at 1 min ...........
.......
Number 22
1 3 2 1
1 4 4 11 2
1* 5 16
'The mother has C-2 Frankel classification D SC and is ventilator-dependent at night for sleep apnea. She was admitted through the emergency department with history of a 2-hour labor with 1 foot presenting. Delivery of a double-footling breech presentation was accomplished without anesthesia.
From the Department of Physical Medicine and Rehabilitation, University of Virginia Health Sciences Center, Charlottesville, Virginia. This study was supported in part by grant G008535 193 from the National Institute on Disability and Rehabilitation Research to the Virginia Regional Spinal Cord Injury Center of the University of Virginia Department of Orthopaedics, Charlottesville, and the Virginia Spinal Cord Injury System, Fishersville, Virginia. Reprint requests to Leland L. Cross, MD, MPH, Department of Physical Medicine and Rehabilitation, University of Virginia Health Sciences Center, Charlottesville, VA 22908.
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PREGNANCY AFTER SPINAL INJURY AFTER
TABLE 2.-Cause and Classification of Spinal Cord Injury and Patient Age Identification Code A
Cause
Spinal Cord Injury Neurologic Frankel Level Classification'
MVA
C-2
B .Gunshot wound
C-3 C-5
.Skydiving
D E F......
.MVA
C-5 C-6 C-6
G
MVA
C-6
MVA
O....
Diving
.....
.MVA
MVA
I.......
MVA
J.
MVA
H
T-2 T-4 T-8 T-10 T-10 T-10 T-10 T-12 T-12
K .MVA
L .MVA MVA N
MVA
0
MVA
P
.Fal
Fall
fromrhorse
D D B D B D D A A
Age at
Injury,
yr
21
23 24
18 18 16 15
16 18
A
25
B
16
A
17
A
20
A
27
A
22
A
19
MVA motor vehicle accident 'A: complete loss of motor and sensory function below the level of injury; B: partially preserved sensation below the level of injury; D: useful motor function below the level of injury.
cord dysfunction below T- 1-that is, no upper extremity involvement. Patients' sensations during labor and delivery are related to the level of injury and the completeness of the SCI. The highest entry level of sensation into the spinal cord from uterine contraction is T- 10.7 Cervical dilatation sensation is a level or two below this. Sensation in the vagina, perineum, and surrounding tissues send impulses through lumbosacral root afferents. Patients with complete T- 12 level dysfunction do feel uterine contractions as painful or uncomfortable. Patients with incomplete SCI usually have sensation, although it may be partial. Definitions of complete and incomplete SCI have been established by Frankel and associates in 1969 and will be discussed later. 14 Premature labor may occur with increased frequency in SCI women, especially in patients with upper dorsal and cervical SCI. l.15. 16 Early hospital admission or careful monitoring of the cervix for evidence of effacement, dilatation, or progression of labor is important to assure full-term pregnancies.
Fetal age determination using ultrasonography should be TABLE 3.-Time Span From Spinal Cord Injury to Delivery Date of Injury
Level Frankel of Injury Classification'
T-10 T-4 C-3 C-5
1950s 1972 . 1972 . 1973 . 1974 . 1974 . 1974 . 1976 . 1976 . 1978 .
T-10 T-12 T-10
1982 ..... 1983 . 1983 . 1984 . 1984 . 1984 .
C-6 T-12 C-5 C-6 T-2
.
'See Table 2.
C-6
T-10o T-8
C-2
A A D B A A B D A A
B A
D D A D
Date of
Delivery 1956
Years From Injury to Delivery
6 11 1978 6 1979,1t 1982,1985 9 3 1977,1979 9 1983 9 1983,1985,1986 4 1980,1982 1983 7 1987 9 Average... 7.1 7 1988, 1989 1 1984 5 1988,1989 5 1989 6 1990t 1989 5 Average ... 4.8
1983,1985
tSpontaneous abortion.
ltnduced abortion.
Age at Delivery 23 29 29 33 30 31 25 19 19 34 26.7 25 20 23 21 22 26 22.8
SPINAL
INJURY
done during the 18th to the 22nd week of gestation. 17 Amniocentesis has been used to provide evidence of pulmonary maturation through the lecithin:sphingomyelin ratio. This value can provide an indication for the safe timing of medical or obstetric interventions and allow for additional maturation if indicated. The use of tocolytic agents may postpone premature labor if needed, providing there are no contraindications for their use.
Patients and Methods The Virginia Regional Spinal Cord Injury System identified 16 women with SCI. A five-page questionnaire was used to gather the data by personal or telephone interview. Supplemental information was obtained from several ofthe patients' hospital records. We used the Frankel classification to interpret our data"4: Frankel classification A refers to a complete loss of motor and sensory function below the level of injury. Classification B refers to partially preserved sensation below the level of injury. Classification C refers to preserved, but not useful, motor function below the level of injury. Classification D refers to useful preserved motor function below the level of injury. Classification E refers to normal motor and sensory function but with possibly abnormal reflexes. The American Spinal Injury Association has defined the level of injury as "the lowest normal neurological segment with both motor and sensory function.""u Results There were 25 pregnancies in 16 women, resulting in 22 babies and 3 abortions, of which 2 were induced and 1 was spontaneous (Table 1). The causes of the spinal injuries included 12 motor vehicle accidents (1 involving a motorcycle) and 1 each due to a fall, skydiving, diving, and gunshot wound (Table 2). Seven patients had a cervical level of injury, and nine had a thoracic level (Table 2). All the cervical injuries were incomplete SCI. The two patients, one with C-S level and the other with C-6 level SCI, were Frankel class B (sensory incomplete). All others were Frankel class D (motor useful). The nine thoracic SCI patients were complete with one exception, a patient with T-10 Frankel class B. The decades of delivery included one in the 1950s, a patient with a T- 10 complete injury who had her baby after a premature precipitated labor at home, unattended. Her only awareness of labor and impending delivery was a bloody show. The amniotic sac was ruptured at delivery but still covered the baby. Both were taken to the hospital and ultimately both did well. There were no deliveries in the 1960s. Two babies were born in the 1970s, 19 in the 1980s, and so far only one in the 1990s (Table 3). For SCI women who were injured in the 1970s, the average age at delivery was 28 years, and for the mothers who were injured in the 1980s, the average age at delivery was 22.8 years. The 1970 group waited 7.3 years after SCI, and the 1980 group waited 4.8 years to deliver their first baby. Urinary tract management in this group of patients' pregnancies reflects almost the entire spectrum of methods (Tables 4 through 7). Normal voiding, six pregnancies; Crede's method, seven pregnancies; intermittent catheterization, six pregnancies; Foley catheter, three pregnancies; suprapubic catheter, two pregnancies; ileal conduit, one pregnancy.
THE WESTERN JOURNAL OF MEDICINE * MAY 1991
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TABLE 4.-Urinary Tract Management"Durng Pregnancy in Patients With Spinol Cord ry With Infections Identification Code
Level of Injury
0D D. F..... ....
....
Per Pregnancy.
Antibioti
No. 0
No
C-s
0
2
Yest
C-5
B
0
.......
T-10
K
....
T-10
....
ClssificationS
C-5
K
K.
Frnkel
T-10
B0
B:O
0
Yes$ YeS No
*D: motor function presrved below the evel of injurtyB: sensation partially presev blow the kve of injury. fIAntibiotics given for symptomatic infections onlytNitrofurantoin (Macrodantin), 50 mg twice a day, given for prophylaxis.
Symptomatic infections occurred in 100% of patients during pregnancy (fever, chills, and so forth) in the patients using Foley or suprapubic catheters or ileal conduits for bladder management. Only 5 of 19 patients (26%) using the Crede's method, having normal voiding, or doing intermittent catheterization had urinary tract infections that were symptomatic during the pregnancy, although 5 of 12 patients (42%) had infections during pregnancy. One patient with a Foley catheter was admitted to hospital with urinary sepsis requiring intravenous antibiotic treatment. No prophylactic antibiotics were used in the retention catheter and ileal conduit group. Only one patient reported significant premature labor. Two others were given terbutaline sulfate (10 days) or ritodrine (3 days) for tocolysis and without adverse effect and had full-term babies. The use of ultrasonography was found to be increasing since its introduction in the 1960s. In the 1970s, 1 of 4 (25%) pregnancies was assessed in this manner versus 14 of 16 (88%) in the 1980s and 1 of 1 (100%) in the 1990s. Amniocentesis is available primarily in major medical centers. Only two (9%) of these patients had this procedure. In nine medical inductions, oxytocin was used; four ofthese were without amniocentesis or ultrasonography before the induction. To control autonomic hyperreflexia during labor and cesarean section, four patients in five deliveries received epidural anesthesia (Table 8). One patient without autonomic hyperreflexia chose to have epidural anesthesia for both deliveries. Two patients, both cervical SCI and Frankel classification D, went untreated for autonomic hyperreflexia during labor and delivery. One of these two, however, did receive a local anesthetic for episiotomy and repair. For episiotomy and repair, only 5 of 15 deliveries required local anesthesia. Epidural anesthesia was used for all seven patients having cesarean sections. One patient required the epidural catheter to remain in place for five days postpartum to control autonomic hyperreflexia associated with pains after delivery. Various medications were used during pregnancy. One patient took oxybutynin chloride (Ditropan) throughout two pregnancies; imipramine hydrochloride, 50 mg at bedtime, was taken by one patient throughout two pregnancies; diazepam, 2.5 mg, was taken once daily throughout two pregnancies. Nitrofurantoin, 50 mg twice a day, was given to five patients throughout their eight pregnancies. Other medications were discontinued early or given only briefly, such as those given for urinary tract infections. Vitamins and minerals were often given. All mothers who chose to nurse their infants were able to
609
TABLE 5.-Urinary Tract Management During Pregnancy in Patients With Spinal Crd in Using Cred's Method f Blade Emptying Identification
Code
C ........ C. C .. L L...... N ..... N. 0.:
Level Of Injury
C-S C-5
-1O T-10 T-10 T-12
Frankel
Classifxvation' B B B A A A A
infections
Per Pregnancy,
No.
0 0 0 0 0Q 1 0
Antibiotics
U1sed 0Yesf
Yest Yesf No No
Yest No
B: sensation partiy psevt below the leve of injury; A: complete loss motor and sensory fuhnction below the level of injury. fNitrofurantoin (Macrodantin). 50 mg twice a day, given for prophylaxis
do so. One reported an increase in spasms and spasticity
during nursing. Numerous complications associated with pregnancies were noted in this study of SCI women. These are summarized in Table 9.
Discussion From the literature and our experience, it is apparent that spinal cord-injured women can give birth to healthy infants. Although temporarily altered in some women, menses usually return to normal six to nine months after injury, and subsequent fertility is not altered.'719 Contraception is practiced using a variety of methods with varied success as in able-bodied women."6 The concerns about the use of oral contraceptives in women with SCI are similar to those in able-bodied women. The use of oral contraceptives has increased risks for those who smoke, are older than 35 years, and who have a history of thromboembolism. Spinal cordinjured women are at a greater risk for thrombophlebitis and pulmonary embolism than the able-bodied population even without pregnancy. Even so, information from unpublished reports indicates that more than 50% of spinal cord-injured women use oral contraceptives after the injury. Once pregnancy has occurred, there may be concerns for women who require medications for spasticity. The medications most commonly used are baclofen and diazepam. A sudden withdrawal of baclofen can cause seizures, so this medication should be tapered. Anticonvulsant agents such as phenytoin or carbamazepine should also be tapered rather than suddenly discontinued. Diazepam has known addictive properties, and infants have experienced withdrawal after birth. Diazepam is associated with an increased incidence of
TABLE 6.-Urinary Tract Management During Pregnancy in Paibents With Spinal Cord Injury Using Intermittent Catheterization for Bladder Emptying Identificotion Level of Injury Code G ..... C-6 C-6 G ..... T-2 H. J ..... T-8 P ..... A .....
T-12 C-2
Infections
Frankel
Per Pregnancy,
Antibiotics Used
D D A A
1 0 0 0 2 0
Yest No
Clssification'
A D
No.
Yest
No YesI Yes§
D: motor function preserved below the level of injury; A: complete loss of motor and sensory function below: the keel of injury. tAntibiotics given for symptomatic infections only. tNorfloxacin, 400mg a day, given for prophylaxis. 1N1trofurantoin (Macrodantio). 50 mg twice a day, given for prophylaxis.
610
TABLE 7.-Method of Bladder Management During Pregnancy in Patients With Spinal Cord Injury and Use of Antibiotics Infections Per
IdentifiFrankel Pregnoncy, Antibiotics cation Level Bladder Emptying UdtXf No. Clsfication* Method Code of Injury
B. E. E.
I I
M
....
C-3 Urethral retention catheter C-6 Urethral retention catheter C-6 Urethral retention catheter T-4 Suprapubic catheter T-4 Suprapubic catheter T-10 Ileal conduit
D
2 1
Yes
B
x 1
Yes
B
21
Yes
A
>
1
Yes
A
21
Yes
A
>
1
Yes
'See Table 2. tNone of these patients were taking prophylactic antibiotics.
cleft palate. In studies of baclofen use in rats, there was an increased incidence of omphaloceles and failure in the development of some ossification sites. The use of baclofen in humans during pregnancy has not been reported. Many other drugs, including antibiotics, present an increased risk to a fetus. Current drug information must be reviewed to make certain a drug's use is warranted during pregnancy. The same is true of irradiation-for injuries, pelvimetry, or intravenous pyelography. Alcohol use and smoking are well known to cause substantial adverse effects on a fetus. These risks are not known to be greater in pregnant SCI women, but women should be counseled against their use. Urologic status should be addressed and, if needed, urologic consultation obtained. As gestation approaches 18 weeks, an ultrasonogram should be done to determine fetal age. As pregnancy reaches seven months, patients need inTABLE 8.-Incidence of Autonomic Hyperreflexia During Delivery in Persons With Spinal Cord Injury Frankel Level of Injury Classification'
cation Code
Delivery Route
A... C-2 B... C-3 C... C-S
D D B
Vaginal Vaginal
C... C-5
B
D... C-5
D
Cesarean section Cesarean
D... E... F... G...
C-5
D
C-6
B
C-6 C-6 G... C-6 I..... T-4
D D D A
I.....
T-4
A
J K ..
T-8 T-10
A B
..
K... T-10 K... T-10 L... T-10 M T-1o N... T-10 N... T-10 0... T-12 P... T-12 ..
'See Table 2.
B B A A A A A A
Cesarean section section Cesarean section Cesarean section
Vaginal Vaginal Vaginal
Cesarean section Cesarean section
Vaginal Vaginal Vaginal Vaginal Vaginal Vaginal Vaginal Vaginal Vaginal Vaginal
Autonomic Anesthesia
Hyperreflexia Used None No None Yes Yes Epidural
Yes No No Yes
Epidural Epidural Epidural Epidural
Yes No No Yes
Local None Local
Yes
Epidural
No No No No No No No No No No
None Local Local Local None None None None None None
Epidural
SCransetio4.
PREGNANCY AFTER SPINAL INJURY
TABLE 9.-Summary of Antepartum, Intrapartum, and Postpartum Complications Potients, No.
Antepartum Complication 7 Autonomic hyperreflexia ................. Symptomatic urinary tratt infctons ............... 11 Required hospital care and IVantibiotics .... . 2 2 Premature labor .......... I Prssure sore with sepsis ............... Cellulitis (from Abrasion) .t 1 Bleeding (not transfused). 1 Preeclampsia (delivered prematurely). 1 Bladder stone removed at 17 weeks. Pneumonia .lt 1 Anemia, Hematocrit 021. 1 Diabetes mellitus. lntrapartum Complications Abnormal presentation 2 Transverse. 1 Breech. .-. Failure to progress ............................... sections4. Cesarean 0 ..7 A.7 Autonomic hyperreflexia(A) 'Medical inductions (oXyocin) .. 9 Postpartum Complications t UITI.2 TI..... Uterine atony .2 1 Infected pilonidal cyst ............. 1 AH intermittently for 5 days. 1 Episiotomy dehiscence. ......
*..
w....... .....
......................
I.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
..
,
.
UTI - urinary tract infection Sepsis led to bilateral below-the-knee amputations. tRequired admission to hospital and intravenous antibiotic therapy. *Three patients had had a previous cesarean section.
struction on how to monitor uterine contractions because they may not perceive painful contractions at the start oflabor (T-10 and above complete SCI). Regular monitoring of the cervix by the physician for the state of effacement and amount of dilatation is needed, perhaps as much as twice a week. Developing a contingency plan regarding proximity to the delivery location, familiarity with the anesthesiologist, and anesthesia to be used is essential. If the patient has had autonomic hyperreflexia in the past, the pregnancy must be considered high risk and plans for delivery in a tertiary medical center are recommended. Obstetric hospital personnel must be aware of its occurrence, how to differentiate it from preeclampsia, and alternative treatment options. Once in the hospital, the routine care of an SCI woman must be understood by staff. Skin protection by turning the patient every two hours is essential to prevent pressure sores. The bowel program and bladder emptying method are usually well understood by the patient and should be continued except for those procedures necessary to and in preparation for delivery. Many patients reported that hospital staffdid not listen to them with regard to their disability and how they manage from day to day out of the hospital. If autonomic hyperreflexia occurs, and it will if it has in the past, it may be associated with almost any type of noxious stimuli below the level of injury. A full bladder, enema, bowel movement, uterine contractions, changing the Foley catheter, or a vaginal or rectal examination may cause it to occur. Treatment options are many but require the recognition thlat the symptoms and findings are intermittent and initiated by uterine contractions. Blood pressure elevation occurs most often during the stimulus time and may be accompanied by a headache with subsidence of symptoms between contractions.
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Control of a dangerously high blood pressure is necessary and usually possible using epidural anesthesia for labor and delivery. Oral nifedipine, 10 to 20 mg chewed and swallowed, may be used short term for a rapid response. This may be repeated in 30 minutes if the blood pressure remains elevated. Nifedipine also can be used 30 minutes before any procedure known by history to cause autonomic hyperreflexia.20 Blood pressure control is possible with the use of intravenous hydralazine hydrochloride or trimethaphan camsylate. The use of inhaled amyl nitrite to control autonomic hyperreflexia has been described by Verduyn.16 Spinal and general anesthesia are also effective but are used primarily for delivery and for a limited time. Because of poor abdominal muscle strength, vaginal delivery often requires second-stage assistance using forceps. Episiotomy closure should be with nonabsorbable sutures. Denervated areas do not absorb the catgut type sutures, which lead to sterile abscess or wound dehiscence.' Cesarean section in the presence of a suprapubic catheter will dictate a classic approach surgically. Patients may continue to have uterine contractions postpartum (after pains), causing autonomic dysreflexia. A continuous epidural anesthetic approach allows for the periodic use of medication to block the signs and symptoms of the disorder, such as hypertension and headache. In the Virginia Regional Spinal Cord Injury System, a course is taught to SCI pregnant women (and their significant other) in parenting from a wheelchair. Previous experiences of patients and staff have been well received and helpful to future parents. The scope of this article does not permit a discussion of other important issues for women with spinal cord injuries. For those who wish more information, a book by Becker, who has T-6 complete paraplegia, provides excellent physical, medical, and psychosocial information.21 She interviewed 19 women, who discuss their experiences and adjustment to SCI. Rabin, in The Sensuous Wheeler, addresses
611
sexual adjustment after SCI. A copy can be obtained by writing to Barry J. Rabin, PhD, Suite 353, 5595 East 7th Street, Long Beach, California 90804. REFERENCES 1. Robertson DNS, Guttman L: The paraplegic patient in pregnancy and labour. Proc R Soc Med 1963; 56:381-387 2. Stover SL, Lloyd K, Waites KB, Jackson AB: Urinary tract infection in spinal cord injury. Arch Phys Med Rehabil 1989; 70:47-54 3. Head H, Riddock G: Autonomic bladder, excessive sweating and some reflex conditions, in gross injuries of spinal cord. Brain 1917; 46:188-263 4. Guttman L, Whitteridge D: Effects of bladder distention on autonomic mechanism after spinal cord injuries. Brain 1947; 70:361-404 5. Erickson RP: Autonomic hyperreflexia: Pathophysiology and medical management. Arch Phys Med Rehabil 1980; 61:431-440 6. Kewalramani LS: Autonomic dysreflexia in traumatic myelopathy. Am J Phys Med 1980; 59:1-21 7. Berard EJJ: The sexuality of spinal cord injured women, physiology and pathophysiology: A review. Paraplegia 1989; 27:99-112 8. Abouleish E: Hypertension in a paraplegic parturient (Letter). Anesthesiology 1980; 53:348 9. McGregor JA, Meeuwsen J: Autonomic hyperreflexia: A mortal danger for spinal cord-damaged women in labor. Am J Obstet Gynecol 1985; 151:330-333 10. Stirt JA, Marco A, Conklin KA: Obstetric anesthesia for a quadriplegic patient with autonomic hyperreflexia. Anesthesiology 1979; 51:560-562 11. Watson DW, Downey GO: Epidural anesthesia for labor and delivery of twins of a paraplegic mother. Anesthesiology 1980; 52:259-261 12. Ravindran RS, Cummins DF, Smith IE: Experience with the use of nitroprusside and subsequent epidural analgesia in a pregnant quadriplegic patient. Anesth Anal 1981; 63:61-63 13. Brian J, Clark RB, Quirk JG: Autonomic hyperreflexia, cesarean section and anesthesia. J Reprod Med 1988; 33:645-649 14. Frankel HL, Hancock DO, Hyslop G, et al: The value of postural reductions in the initial management of closed injuries of the spine with paraplegia and tetraplegia. Paraplegia 1969; 7:179-192 15. Goller H, Paeslack V: Pregnancy damage and birth complications in children of paraplegic women. Paraplegia 1972; 10:213-217 16. Verduyn WH: Spinal cord injured women, pregnancy and delivery. Paraplegia 1986; 24:23140 17. Persson PH, Weldner BM: Reliability of ultrasound fetometry in estimating gestational age in the second trimester. Acta Obstet Gynecol 1986; 65:481-483 18. Donovan WH, Maynard FM, McCluer S, et al: Standards of Neurological Classification of Spinal Injuries and Facility Categorization. Chicago, Ill, American Spinal Injury Association, 1990 19. Comarr AE: Observations on menstruation and pregnancy among female spinal cord injury patients. Paraplegia 1966; 3:263-271 20. Lindan R, Lehler E, Freehafer A, Lyons AM, Coletta H: Further experience with nifedipine in the treatment of autonomic dysreflexia. ASIA [American Spinal Injury Association] Bull 1986; 4:10-15 21. Becker EF: Female Sexuality Following Spinal Cord Injury. Bloomington, Ill, Cheever Publishing, 1978
Pregnancy Following Spinal Cord Injury LELAND L. CROSS, MD, MPH; JAY M. MEYTHALER, JD, MD; STEPHEN M. TUEL, MS, MD; and AUDREY L CROSS, RN, Charlottesville, Virginia
Each year about 2,000 women of childbearing age in the United States have a spinal cord injury. Only a few mostly anecdotal reports describe pregnancy after such an injury. In a retrospective study of 16 women with a spinal cord injury, half of whom have a complete injury and about half quadriplegia, 25 pregnancies occurred, with 21 carried to full term. The women delayed pregnancy an average of 6.5 years after their injury, with an average age at first pregnancy of 26.8 years. Cesarean section was necessary in 4 patients because of inadequate progress of labor. In 5 deliveries an episiotomy and local anesthesia were required, 7 required epidural anesthesia, including all cesarean sections, and 10 did not require anesthesia. Several complications have been identified in the antepartum, intrapartum, and postpartum periods including autonomic hyperreflexia, premature labor, pressure sores, urinary tract infections, abnormal presentation, and failure to progress. Ultrasonography and amniocentesis were used selectively. Women with spinal cord injuries can have healthy children, although there are significant risks and these women have special needs. (Cross LL, MeythalerJM, Tuel SM, Cross AL: Pregnancy following spinal cord injury, In Rehabilitation Medicine-Adding Life to Years [Special Issue]. West J Med 1991 May; 154:607-61 1)
T he medical literature pertaining to pregnant women who have had a spinal cord injury (SCI) is largely anecdotal. In 1963 Robertson and Guttman reported on 28 pregnancies in women with SCI. I Since that report, the problems of pregnancy, labor, delivery, and the postpartum period have remained relatively unchanged. Our understanding, technology, and the management of the problems of women who have had SCI have improved considerably, however. For example, urinary tract management has progressed from the introduction of the Foley catheter in the 1940s to various other options, including the suprapubic catheter and ileal conduit (or loop). Although urinary tract infections persist, bladder management has improved, and there are newer antibiotics. A recent review article by Stover and co-workers covers many aspects of urologic care,2 but there is no current publication specifically addressing urinary tract infections in pregnant SCI women. Autonomic hyperreflexia (autonomic dysreflexia) was described in part as early as 1890 by Bowlby and later by Head and Riddock in 1917.3 The complete syndrome was described in 1947 by Guttman and Whitteridge.4 Erickson and Kewalramani have provided an excellent review and understanding of autonomic hyperreflexia.5'6 This condition may occur in patients with injury at the T-10 level or above, especially above T-6.' The syndrome is initiated by stimuli, usually below the level of the SCI. The characteristic symptoms and signs are excessive sweating, splotchy rash, pilomotor erection (usually above the level of injury), facial flush, congestion of nasal passages, paroxysmal hypertension, bradycardia, and a severe throbbing headache.5 The cases of two patients who have experienced intraventricular bleeding, one fatal, have been reported.8 These complications have been reported in pregnant women in whom severe hypertension developed without recognition or adequate
treatment of autonomic hyperreflexia.8'9 Many authors recommend epidural anesthesia for pregnant women with SCI to control autonomic dysreflexia during labor and delivery. 10-13 Cesarean section requires a level of anesthesia above T-10, which is also adequate for autonomic hyperreflexia control. Spinal anesthesia for cesarean section is as effective for preventing or terminating autonomic hyperreflexia but has administration problems over longer labor periods. Aside from the control of autonomic hyperreflexia, analgesic and anesthetic requirements for labor and delivery in women with SCI have only recently received adequate attention. Definitions of terms must be thoroughly understood. Tetraplegia or quadriplegia can be used interchangeably, but paraplegia must be reserved for patients with spinal TABLE 1.-Summary of Outcome of 25 Pregnancies in 16 Women With Spinal Cord Injury (SCI) Outcome
Babies ............................ Premature ....................... Abortions .......................... Induced .........................
Spontaneous .....................
Fetal birth weight, grams (Ib) 1,431 (3+) .......................
2,268 to 2,719 (5 to 6) ............. 2,720 to 3,174 (6 to 7) ....... ...... 3,175 to 3,629 (7 to 8) ...... ....... 3,630 to 4.082 (8 to 9) ....... ...... Apgar scores I at 1 min; 7 at 5 min; 9 at 10 min ... 7at 1 min;8ormoreat5min ....... 9or 10at 1 min ...........
.......
Number 22
1 3 2 1
1 4 4 11 2
1* 5 16
'The mother has C-2 Frankel classification D SC and is ventilator-dependent at night for sleep apnea. She was admitted through the emergency department with history of a 2-hour labor with 1 foot presenting. Delivery of a double-footling breech presentation was accomplished without anesthesia.
From the Department of Physical Medicine and Rehabilitation, University of Virginia Health Sciences Center, Charlottesville, Virginia. This study was supported in part by grant G008535 193 from the National Institute on Disability and Rehabilitation Research to the Virginia Regional Spinal Cord Injury Center of the University of Virginia Department of Orthopaedics, Charlottesville, and the Virginia Spinal Cord Injury System, Fishersville, Virginia. Reprint requests to Leland L. Cross, MD, MPH, Department of Physical Medicine and Rehabilitation, University of Virginia Health Sciences Center, Charlottesville, VA 22908.
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PREGNANCY AFTER SPINAL INJURY AFTER
TABLE 2.-Cause and Classification of Spinal Cord Injury and Patient Age Identification Code A
Cause
Spinal Cord Injury Neurologic Frankel Level Classification'
MVA
C-2
B .Gunshot wound
C-3 C-5
.Skydiving
D E F......
.MVA
C-5 C-6 C-6
G
MVA
C-6
MVA
O....
Diving
.....
.MVA
MVA
I.......
MVA
J.
MVA
H
T-2 T-4 T-8 T-10 T-10 T-10 T-10 T-12 T-12
K .MVA
L .MVA MVA N
MVA
0
MVA
P
.Fal
Fall
fromrhorse
D D B D B D D A A
Age at
Injury,
yr
21
23 24
18 18 16 15
16 18
A
25
B
16
A
17
A
20
A
27
A
22
A
19
MVA motor vehicle accident 'A: complete loss of motor and sensory function below the level of injury; B: partially preserved sensation below the level of injury; D: useful motor function below the level of injury.
cord dysfunction below T- 1-that is, no upper extremity involvement. Patients' sensations during labor and delivery are related to the level of injury and the completeness of the SCI. The highest entry level of sensation into the spinal cord from uterine contraction is T- 10.7 Cervical dilatation sensation is a level or two below this. Sensation in the vagina, perineum, and surrounding tissues send impulses through lumbosacral root afferents. Patients with complete T- 12 level dysfunction do feel uterine contractions as painful or uncomfortable. Patients with incomplete SCI usually have sensation, although it may be partial. Definitions of complete and incomplete SCI have been established by Frankel and associates in 1969 and will be discussed later. 14 Premature labor may occur with increased frequency in SCI women, especially in patients with upper dorsal and cervical SCI. l.15. 16 Early hospital admission or careful monitoring of the cervix for evidence of effacement, dilatation, or progression of labor is important to assure full-term pregnancies.
Fetal age determination using ultrasonography should be TABLE 3.-Time Span From Spinal Cord Injury to Delivery Date of Injury
Level Frankel of Injury Classification'
T-10 T-4 C-3 C-5
1950s 1972 . 1972 . 1973 . 1974 . 1974 . 1974 . 1976 . 1976 . 1978 .
T-10 T-12 T-10
1982 ..... 1983 . 1983 . 1984 . 1984 . 1984 .
C-6 T-12 C-5 C-6 T-2
.
'See Table 2.
C-6
T-10o T-8
C-2
A A D B A A B D A A
B A
D D A D
Date of
Delivery 1956
Years From Injury to Delivery
6 11 1978 6 1979,1t 1982,1985 9 3 1977,1979 9 1983 9 1983,1985,1986 4 1980,1982 1983 7 1987 9 Average... 7.1 7 1988, 1989 1 1984 5 1988,1989 5 1989 6 1990t 1989 5 Average ... 4.8
1983,1985
tSpontaneous abortion.
ltnduced abortion.
Age at Delivery 23 29 29 33 30 31 25 19 19 34 26.7 25 20 23 21 22 26 22.8
SPINAL
INJURY
done during the 18th to the 22nd week of gestation. 17 Amniocentesis has been used to provide evidence of pulmonary maturation through the lecithin:sphingomyelin ratio. This value can provide an indication for the safe timing of medical or obstetric interventions and allow for additional maturation if indicated. The use of tocolytic agents may postpone premature labor if needed, providing there are no contraindications for their use.
Patients and Methods The Virginia Regional Spinal Cord Injury System identified 16 women with SCI. A five-page questionnaire was used to gather the data by personal or telephone interview. Supplemental information was obtained from several ofthe patients' hospital records. We used the Frankel classification to interpret our data"4: Frankel classification A refers to a complete loss of motor and sensory function below the level of injury. Classification B refers to partially preserved sensation below the level of injury. Classification C refers to preserved, but not useful, motor function below the level of injury. Classification D refers to useful preserved motor function below the level of injury. Classification E refers to normal motor and sensory function but with possibly abnormal reflexes. The American Spinal Injury Association has defined the level of injury as "the lowest normal neurological segment with both motor and sensory function.""u Results There were 25 pregnancies in 16 women, resulting in 22 babies and 3 abortions, of which 2 were induced and 1 was spontaneous (Table 1). The causes of the spinal injuries included 12 motor vehicle accidents (1 involving a motorcycle) and 1 each due to a fall, skydiving, diving, and gunshot wound (Table 2). Seven patients had a cervical level of injury, and nine had a thoracic level (Table 2). All the cervical injuries were incomplete SCI. The two patients, one with C-S level and the other with C-6 level SCI, were Frankel class B (sensory incomplete). All others were Frankel class D (motor useful). The nine thoracic SCI patients were complete with one exception, a patient with T-10 Frankel class B. The decades of delivery included one in the 1950s, a patient with a T- 10 complete injury who had her baby after a premature precipitated labor at home, unattended. Her only awareness of labor and impending delivery was a bloody show. The amniotic sac was ruptured at delivery but still covered the baby. Both were taken to the hospital and ultimately both did well. There were no deliveries in the 1960s. Two babies were born in the 1970s, 19 in the 1980s, and so far only one in the 1990s (Table 3). For SCI women who were injured in the 1970s, the average age at delivery was 28 years, and for the mothers who were injured in the 1980s, the average age at delivery was 22.8 years. The 1970 group waited 7.3 years after SCI, and the 1980 group waited 4.8 years to deliver their first baby. Urinary tract management in this group of patients' pregnancies reflects almost the entire spectrum of methods (Tables 4 through 7). Normal voiding, six pregnancies; Crede's method, seven pregnancies; intermittent catheterization, six pregnancies; Foley catheter, three pregnancies; suprapubic catheter, two pregnancies; ileal conduit, one pregnancy.
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TABLE 4.-Urinary Tract Management"Durng Pregnancy in Patients With Spinol Cord ry With Infections Identification Code
Level of Injury
0D D. F..... ....
....
Per Pregnancy.
Antibioti
No. 0
No
C-s
0
2
Yest
C-5
B
0
.......
T-10
K
....
T-10
....
ClssificationS
C-5
K
K.
Frnkel
T-10
B0
B:O
0
Yes$ YeS No
*D: motor function presrved below the evel of injurtyB: sensation partially presev blow the kve of injury. fIAntibiotics given for symptomatic infections onlytNitrofurantoin (Macrodantin), 50 mg twice a day, given for prophylaxis.
Symptomatic infections occurred in 100% of patients during pregnancy (fever, chills, and so forth) in the patients using Foley or suprapubic catheters or ileal conduits for bladder management. Only 5 of 19 patients (26%) using the Crede's method, having normal voiding, or doing intermittent catheterization had urinary tract infections that were symptomatic during the pregnancy, although 5 of 12 patients (42%) had infections during pregnancy. One patient with a Foley catheter was admitted to hospital with urinary sepsis requiring intravenous antibiotic treatment. No prophylactic antibiotics were used in the retention catheter and ileal conduit group. Only one patient reported significant premature labor. Two others were given terbutaline sulfate (10 days) or ritodrine (3 days) for tocolysis and without adverse effect and had full-term babies. The use of ultrasonography was found to be increasing since its introduction in the 1960s. In the 1970s, 1 of 4 (25%) pregnancies was assessed in this manner versus 14 of 16 (88%) in the 1980s and 1 of 1 (100%) in the 1990s. Amniocentesis is available primarily in major medical centers. Only two (9%) of these patients had this procedure. In nine medical inductions, oxytocin was used; four ofthese were without amniocentesis or ultrasonography before the induction. To control autonomic hyperreflexia during labor and cesarean section, four patients in five deliveries received epidural anesthesia (Table 8). One patient without autonomic hyperreflexia chose to have epidural anesthesia for both deliveries. Two patients, both cervical SCI and Frankel classification D, went untreated for autonomic hyperreflexia during labor and delivery. One of these two, however, did receive a local anesthetic for episiotomy and repair. For episiotomy and repair, only 5 of 15 deliveries required local anesthesia. Epidural anesthesia was used for all seven patients having cesarean sections. One patient required the epidural catheter to remain in place for five days postpartum to control autonomic hyperreflexia associated with pains after delivery. Various medications were used during pregnancy. One patient took oxybutynin chloride (Ditropan) throughout two pregnancies; imipramine hydrochloride, 50 mg at bedtime, was taken by one patient throughout two pregnancies; diazepam, 2.5 mg, was taken once daily throughout two pregnancies. Nitrofurantoin, 50 mg twice a day, was given to five patients throughout their eight pregnancies. Other medications were discontinued early or given only briefly, such as those given for urinary tract infections. Vitamins and minerals were often given. All mothers who chose to nurse their infants were able to
609
TABLE 5.-Urinary Tract Management During Pregnancy in Patients With Spinal Crd in Using Cred's Method f Blade Emptying Identification
Code
C ........ C. C .. L L...... N ..... N. 0.:
Level Of Injury
C-S C-5
-1O T-10 T-10 T-12
Frankel
Classifxvation' B B B A A A A
infections
Per Pregnancy,
No.
0 0 0 0 0Q 1 0
Antibiotics
U1sed 0Yesf
Yest Yesf No No
Yest No
B: sensation partiy psevt below the leve of injury; A: complete loss motor and sensory fuhnction below the level of injury. fNitrofurantoin (Macrodantin). 50 mg twice a day, given for prophylaxis
do so. One reported an increase in spasms and spasticity
during nursing. Numerous complications associated with pregnancies were noted in this study of SCI women. These are summarized in Table 9.
Discussion From the literature and our experience, it is apparent that spinal cord-injured women can give birth to healthy infants. Although temporarily altered in some women, menses usually return to normal six to nine months after injury, and subsequent fertility is not altered.'719 Contraception is practiced using a variety of methods with varied success as in able-bodied women."6 The concerns about the use of oral contraceptives in women with SCI are similar to those in able-bodied women. The use of oral contraceptives has increased risks for those who smoke, are older than 35 years, and who have a history of thromboembolism. Spinal cordinjured women are at a greater risk for thrombophlebitis and pulmonary embolism than the able-bodied population even without pregnancy. Even so, information from unpublished reports indicates that more than 50% of spinal cord-injured women use oral contraceptives after the injury. Once pregnancy has occurred, there may be concerns for women who require medications for spasticity. The medications most commonly used are baclofen and diazepam. A sudden withdrawal of baclofen can cause seizures, so this medication should be tapered. Anticonvulsant agents such as phenytoin or carbamazepine should also be tapered rather than suddenly discontinued. Diazepam has known addictive properties, and infants have experienced withdrawal after birth. Diazepam is associated with an increased incidence of
TABLE 6.-Urinary Tract Management During Pregnancy in Paibents With Spinal Cord Injury Using Intermittent Catheterization for Bladder Emptying Identificotion Level of Injury Code G ..... C-6 C-6 G ..... T-2 H. J ..... T-8 P ..... A .....
T-12 C-2
Infections
Frankel
Per Pregnancy,
Antibiotics Used
D D A A
1 0 0 0 2 0
Yest No
Clssification'
A D
No.
Yest
No YesI Yes§
D: motor function preserved below the level of injury; A: complete loss of motor and sensory function below: the keel of injury. tAntibiotics given for symptomatic infections only. tNorfloxacin, 400mg a day, given for prophylaxis. 1N1trofurantoin (Macrodantio). 50 mg twice a day, given for prophylaxis.
610
TABLE 7.-Method of Bladder Management During Pregnancy in Patients With Spinal Cord Injury and Use of Antibiotics Infections Per
IdentifiFrankel Pregnoncy, Antibiotics cation Level Bladder Emptying UdtXf No. Clsfication* Method Code of Injury
B. E. E.
I I
M
....
C-3 Urethral retention catheter C-6 Urethral retention catheter C-6 Urethral retention catheter T-4 Suprapubic catheter T-4 Suprapubic catheter T-10 Ileal conduit
D
2 1
Yes
B
x 1
Yes
B
21
Yes
A
>
1
Yes
A
21
Yes
A
>
1
Yes
'See Table 2. tNone of these patients were taking prophylactic antibiotics.
cleft palate. In studies of baclofen use in rats, there was an increased incidence of omphaloceles and failure in the development of some ossification sites. The use of baclofen in humans during pregnancy has not been reported. Many other drugs, including antibiotics, present an increased risk to a fetus. Current drug information must be reviewed to make certain a drug's use is warranted during pregnancy. The same is true of irradiation-for injuries, pelvimetry, or intravenous pyelography. Alcohol use and smoking are well known to cause substantial adverse effects on a fetus. These risks are not known to be greater in pregnant SCI women, but women should be counseled against their use. Urologic status should be addressed and, if needed, urologic consultation obtained. As gestation approaches 18 weeks, an ultrasonogram should be done to determine fetal age. As pregnancy reaches seven months, patients need inTABLE 8.-Incidence of Autonomic Hyperreflexia During Delivery in Persons With Spinal Cord Injury Frankel Level of Injury Classification'
cation Code
Delivery Route
A... C-2 B... C-3 C... C-S
D D B
Vaginal Vaginal
C... C-5
B
D... C-5
D
Cesarean section Cesarean
D... E... F... G...
C-5
D
C-6
B
C-6 C-6 G... C-6 I..... T-4
D D D A
I.....
T-4
A
J K ..
T-8 T-10
A B
..
K... T-10 K... T-10 L... T-10 M T-1o N... T-10 N... T-10 0... T-12 P... T-12 ..
'See Table 2.
B B A A A A A A
Cesarean section section Cesarean section Cesarean section
Vaginal Vaginal Vaginal
Cesarean section Cesarean section
Vaginal Vaginal Vaginal Vaginal Vaginal Vaginal Vaginal Vaginal Vaginal Vaginal
Autonomic Anesthesia
Hyperreflexia Used None No None Yes Yes Epidural
Yes No No Yes
Epidural Epidural Epidural Epidural
Yes No No Yes
Local None Local
Yes
Epidural
No No No No No No No No No No
None Local Local Local None None None None None None
Epidural
SCransetio4.
PREGNANCY AFTER SPINAL INJURY
TABLE 9.-Summary of Antepartum, Intrapartum, and Postpartum Complications Potients, No.
Antepartum Complication 7 Autonomic hyperreflexia ................. Symptomatic urinary tratt infctons ............... 11 Required hospital care and IVantibiotics .... . 2 2 Premature labor .......... I Prssure sore with sepsis ............... Cellulitis (from Abrasion) .t 1 Bleeding (not transfused). 1 Preeclampsia (delivered prematurely). 1 Bladder stone removed at 17 weeks. Pneumonia .lt 1 Anemia, Hematocrit 021. 1 Diabetes mellitus. lntrapartum Complications Abnormal presentation 2 Transverse. 1 Breech. .-. Failure to progress ............................... sections4. Cesarean 0 ..7 A.7 Autonomic hyperreflexia(A) 'Medical inductions (oXyocin) .. 9 Postpartum Complications t UITI.2 TI..... Uterine atony .2 1 Infected pilonidal cyst ............. 1 AH intermittently for 5 days. 1 Episiotomy dehiscence. ......
*..
w....... .....
......................
I.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
..
,
.
UTI - urinary tract infection Sepsis led to bilateral below-the-knee amputations. tRequired admission to hospital and intravenous antibiotic therapy. *Three patients had had a previous cesarean section.
struction on how to monitor uterine contractions because they may not perceive painful contractions at the start oflabor (T-10 and above complete SCI). Regular monitoring of the cervix by the physician for the state of effacement and amount of dilatation is needed, perhaps as much as twice a week. Developing a contingency plan regarding proximity to the delivery location, familiarity with the anesthesiologist, and anesthesia to be used is essential. If the patient has had autonomic hyperreflexia in the past, the pregnancy must be considered high risk and plans for delivery in a tertiary medical center are recommended. Obstetric hospital personnel must be aware of its occurrence, how to differentiate it from preeclampsia, and alternative treatment options. Once in the hospital, the routine care of an SCI woman must be understood by staff. Skin protection by turning the patient every two hours is essential to prevent pressure sores. The bowel program and bladder emptying method are usually well understood by the patient and should be continued except for those procedures necessary to and in preparation for delivery. Many patients reported that hospital staffdid not listen to them with regard to their disability and how they manage from day to day out of the hospital. If autonomic hyperreflexia occurs, and it will if it has in the past, it may be associated with almost any type of noxious stimuli below the level of injury. A full bladder, enema, bowel movement, uterine contractions, changing the Foley catheter, or a vaginal or rectal examination may cause it to occur. Treatment options are many but require the recognition thlat the symptoms and findings are intermittent and initiated by uterine contractions. Blood pressure elevation occurs most often during the stimulus time and may be accompanied by a headache with subsidence of symptoms between contractions.
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Control of a dangerously high blood pressure is necessary and usually possible using epidural anesthesia for labor and delivery. Oral nifedipine, 10 to 20 mg chewed and swallowed, may be used short term for a rapid response. This may be repeated in 30 minutes if the blood pressure remains elevated. Nifedipine also can be used 30 minutes before any procedure known by history to cause autonomic hyperreflexia.20 Blood pressure control is possible with the use of intravenous hydralazine hydrochloride or trimethaphan camsylate. The use of inhaled amyl nitrite to control autonomic hyperreflexia has been described by Verduyn.16 Spinal and general anesthesia are also effective but are used primarily for delivery and for a limited time. Because of poor abdominal muscle strength, vaginal delivery often requires second-stage assistance using forceps. Episiotomy closure should be with nonabsorbable sutures. Denervated areas do not absorb the catgut type sutures, which lead to sterile abscess or wound dehiscence.' Cesarean section in the presence of a suprapubic catheter will dictate a classic approach surgically. Patients may continue to have uterine contractions postpartum (after pains), causing autonomic dysreflexia. A continuous epidural anesthetic approach allows for the periodic use of medication to block the signs and symptoms of the disorder, such as hypertension and headache. In the Virginia Regional Spinal Cord Injury System, a course is taught to SCI pregnant women (and their significant other) in parenting from a wheelchair. Previous experiences of patients and staff have been well received and helpful to future parents. The scope of this article does not permit a discussion of other important issues for women with spinal cord injuries. For those who wish more information, a book by Becker, who has T-6 complete paraplegia, provides excellent physical, medical, and psychosocial information.21 She interviewed 19 women, who discuss their experiences and adjustment to SCI. Rabin, in The Sensuous Wheeler, addresses
611
sexual adjustment after SCI. A copy can be obtained by writing to Barry J. Rabin, PhD, Suite 353, 5595 East 7th Street, Long Beach, California 90804. REFERENCES 1. Robertson DNS, Guttman L: The paraplegic patient in pregnancy and labour. Proc R Soc Med 1963; 56:381-387 2. Stover SL, Lloyd K, Waites KB, Jackson AB: Urinary tract infection in spinal cord injury. Arch Phys Med Rehabil 1989; 70:47-54 3. Head H, Riddock G: Autonomic bladder, excessive sweating and some reflex conditions, in gross injuries of spinal cord. Brain 1917; 46:188-263 4. Guttman L, Whitteridge D: Effects of bladder distention on autonomic mechanism after spinal cord injuries. Brain 1947; 70:361-404 5. Erickson RP: Autonomic hyperreflexia: Pathophysiology and medical management. Arch Phys Med Rehabil 1980; 61:431-440 6. Kewalramani LS: Autonomic dysreflexia in traumatic myelopathy. Am J Phys Med 1980; 59:1-21 7. Berard EJJ: The sexuality of spinal cord injured women, physiology and pathophysiology: A review. Paraplegia 1989; 27:99-112 8. Abouleish E: Hypertension in a paraplegic parturient (Letter). Anesthesiology 1980; 53:348 9. McGregor JA, Meeuwsen J: Autonomic hyperreflexia: A mortal danger for spinal cord-damaged women in labor. Am J Obstet Gynecol 1985; 151:330-333 10. Stirt JA, Marco A, Conklin KA: Obstetric anesthesia for a quadriplegic patient with autonomic hyperreflexia. Anesthesiology 1979; 51:560-562 11. Watson DW, Downey GO: Epidural anesthesia for labor and delivery of twins of a paraplegic mother. Anesthesiology 1980; 52:259-261 12. Ravindran RS, Cummins DF, Smith IE: Experience with the use of nitroprusside and subsequent epidural analgesia in a pregnant quadriplegic patient. Anesth Anal 1981; 63:61-63 13. Brian J, Clark RB, Quirk JG: Autonomic hyperreflexia, cesarean section and anesthesia. J Reprod Med 1988; 33:645-649 14. Frankel HL, Hancock DO, Hyslop G, et al: The value of postural reductions in the initial management of closed injuries of the spine with paraplegia and tetraplegia. Paraplegia 1969; 7:179-192 15. Goller H, Paeslack V: Pregnancy damage and birth complications in children of paraplegic women. Paraplegia 1972; 10:213-217 16. Verduyn WH: Spinal cord injured women, pregnancy and delivery. Paraplegia 1986; 24:23140 17. Persson PH, Weldner BM: Reliability of ultrasound fetometry in estimating gestational age in the second trimester. Acta Obstet Gynecol 1986; 65:481-483 18. Donovan WH, Maynard FM, McCluer S, et al: Standards of Neurological Classification of Spinal Injuries and Facility Categorization. Chicago, Ill, American Spinal Injury Association, 1990 19. Comarr AE: Observations on menstruation and pregnancy among female spinal cord injury patients. Paraplegia 1966; 3:263-271 20. Lindan R, Lehler E, Freehafer A, Lyons AM, Coletta H: Further experience with nifedipine in the treatment of autonomic dysreflexia. ASIA [American Spinal Injury Association] Bull 1986; 4:10-15 21. Becker EF: Female Sexuality Following Spinal Cord Injury. Bloomington, Ill, Cheever Publishing, 1978
