Pregnancy, labor and delivery post spinal cord injury

A physiatrist's role in managing unique challenges in pregnancy and delivery in a patient with incomplete lumbar SCI: a case report

INTRODUCTION

Women of childbearing age make up around 5-10% of individuals with spinal cord injury (SCI) and may face unique medical and functional complications during pregnancy, including prolonged hospitalization and increased risk of early rehospitalization due to falls.

CASE PRESENTATION

Here, we discuss a case of a young ambulatory woman with a lumbar motor incomplete spinal cord injury who underwent successful delivery via cesarean section and the role of the physiatrist in the management of the patient's antepartum, intrapartum, and postpartum complications. The patient faced significant antepartum challenges secondary to her neurogenic bladder and pelvic floor weakness, resulting in increased use of her manual wheelchair. The physiatry team assisted with the co-development of a multidisciplinary bladder plan for increased urinary frequency and urinary tract infection prevention with the patient's obstetrics physician (OB). In addition, the physiatry team assisted with the procurement of a new wheelchair suited for the patient's pregnancy and childcare needs in anticipation of decreased mobility during this time. Regarding intrapartum challenges, the physiatry team worked with the patient and her OB to develop a safe birth plan considering the method of delivery, epidural usage, and the need for pelvic floor therapy before and after childbirth.

DISCUSSION

The patient had a successful cesarean section delivery, with return to independent mobility soon after childbirth. In summary, this case demonstrates that there is a need for a multidisciplinary approach to patients with SCI during pregnancy and that the role of physiatry is critical to optimizing medical and functional outcomes.

Consequences of spinal cord injury on the sympathetic nervous system

Spinal cord injury (SCI) damages multiple structures at the lesion site, including ascending, descending, and propriospinal axons; interrupting the conduction of information up and down the spinal cord. Additionally, axons associated with the autonomic nervous system that control involuntary physiological functions course through the spinal cord. Moreover, sympathetic, and parasympathetic preganglionic neurons reside in the spinal cord. Thus, depending on the level of an SCI, autonomic function can be greatly impacted by the trauma resulting in dysfunction of various organs. For example, SCI can lead to dysregulation of a variety of organs, such as the pineal gland, the heart and vasculature, lungs, spleen, kidneys, and bladder. Indeed, it is becoming more apparent that many disorders that negatively affect quality-of-life for SCI individuals have a basis in dysregulation of the sympathetic nervous system. Here, we will review how SCI impacts the sympathetic nervous system and how that negatively impacts target organs that receive sympathetic innervation. A deeper understanding of this may offer potential therapeutic insight into how to improve health and quality-of-life for those living with SCI.

Case Report: Anesthetic Management of Cesarean Section in a Patient With Paraplegia

Background

With the advancement of medical science and rehabilitative care, more women with spinal cord injury (SCI) can conceive. However, autonomic hyperreflexia due to SCI complicates anesthesia management during cesarean sections.

Case Presentation

This study reports the anesthesia management in a woman with paraplegia with a T6 SCI lesion who underwent a cesarean section. It also reviews the anesthesia strategies used in other studies. Spinal anesthesia with a low concentration of ropivacaine was administered along with dexmedetomidine for sedation. Stable hemodynamics were achieved without complications.

Conclusions

Based on the reported case and literature review, we conclude that the intrathecal block is the preferred choice for women with paraplegia who require cesarean section if the lumbar bone structure allows puncture attempts.

Dystocia and cesarean section in a free-ranging ocelot (Leopardus pardalis) after traumatic spinal cord injury resulting from dog (Canis familiaris) attack

Background:

Ex situ breeding programs are essential to establish genetic resource banks and produce offspring to strengthen the in situ conservation of endangered species. However, many programs fail to maintain viable ex situ populations due to reproductive problems, including dystocia in pregnant females. Dystocia encompasses different emergency obstetric situations for the lives of dams and fetuses that require urgent intervention. This condition has been studied in domesticated species but published records in wildlife, specifically in felines species, are scarce.

Case Description:

An adult female ocelot (Leopardus pardalis) was referred to the wildlife hospital of the Universidad San Francisco de Quito after being attacked by dogs (Canis familiaris). Neurological tests revealed traumatic spinal cord injury at a thoracolumbar level. Complementary tests (laboratory exams, radiographs, and ultrasound) revealed a full-term pregnancy, failure in the labor progress, and critical fetal stress. A cesarean section was performed, and the newborns received resuscitation care after assessing their viability using the Apgar score system. The neonate with the lowest Apgar score died within the first hour after birth, while the second one showed an increase in Apgar score after resuscitation care and survived the procedure.

Conclusion:

We provide new obstetric data that could be relevant to save the lives of dams and newborns in related cases for ocelots and other species of wild felids. Furthermore, this study confirms the adverse effects that domestic dogs have on wildlife species.

The Intersection of Disability and Pregnancy: Risks for Maternal Morbidity and Mortality

It is estimated that 1 in 4 women in the United States live with a disability, and using population-based estimates, 10–12% of women of childbearing age have a disability. There are limited data to suggest that women with disabilities experience higher rates of or risks for adverse outcomes related to pregnancy, delivery, and access to appropriate postpartum care. Research on specific disabling conditions demonstrates variable risk for syndromes that threaten the health of the mother, such as preeclampsia, infection, and coagulation disorders. Much of the literature suggests that normal, healthy pregnancy is possible but points to the need for tailored information for patients and providers about the intersection of their condition with pregnancy and specific care needs. Given the lack of systematic evidence in this area across conditions and functional impairments, more research is needed to clarify the interaction of specific disabilities with pregnancy and provide evidence-based information to the field to decrease the risks to mothers and their infants. This article will provide an overview of conditions that contribute to maternal morbidity and mortality as they relate to pregnancy in women with disabilities and provide resources to the field to further the investigation of this area.

Spinal cord injury and diaphragm neuromotor control

Introduction: Neuromotor control of diaphragm muscle and the recovery of diaphragm activity following spinal cord injury have been narrowly focused on ventilation. By contrast, the understanding of neuromotor control for non-ventilatory expulsive/straining maneuvers (including coughing, defecation, and parturition) is relatively impoverished. This variety of behaviors are achieved via the recruitment of the diverse array of motor units that comprise the diaphragm muscle.Areas covered: The neuromotor control of ventilatory and non-ventilatory behaviors in health and in the context of spinal cord injury is explored. Particular attention is played to the neuroplasticity of phrenic motor neurons in various models of cervical spinal cord injury.Expert opinion: There is a remarkable paucity in our understanding of neuromotor control of maneuvers in spinal cord injury patients. Dysfunction of these expulsive/straining maneuvers reduces patient quality of life and contributes to severe morbidity and mortality. As spinal cord injury patient life expectancies continue to climb steadily, a nexus of spinal cord injury and age-associated comorbidities are likely to occur. While current research remains concerned only with the minutiae of ventilation, the major functional deficits of this clinical cohort will persist intractably. We posit some future research directions to avoid this scenario.

Pregnancy Outcomes in Women with Spinal Cord Injuries: A Population-Based Study

BACKGROUND

Pregnant women with congenital or acquired spinal cord injury face challenges due to compromised neurologic function and mobility, factors that may also affect fetal/infant health. Few studies have examined pregnancy course and longer-term outcomes in this population.

OBJECTIVE

To assess pregnancy outcomes among women with spinal cord injury, paralysis, or spina bifida using population-based data.

DESIGN

Retrospective cohort study.

SETTING

Washington state linked birth-hospital discharge records.

PARTICIPANTS

All women (N = 529) with spinal cord injury, paralysis, or spina bifida with singleton live birth deliveries 1987-2012, and a comparison group of women without disabilities (N = 5282).

METHODS

Diagnosis codes were screened to identify cases and a 10:1 random sample of comparison women. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated overall and separately for each condition using multivariable regression. Subsequent hospitalizations or death were identified via linkage to hospital discharge/death records for 2 years after delivery.

MAIN OUTCOME MEASUREMENTS

Pregnancy course (weight gain, gestational diabetes, preeclampsia, infection, venous thromboembolism), delivery/labor characteristics, infant characteristics (birthweight/size, gestational age), and longer-term outcomes (occurrence/reasons for maternal/infant rehospitalization, mortality).

RESULTS

Women with these spinal conditions had increased adjusted risks of prenatal urinary tract infection/pyelonephritis (RR 26.43, 95% CI 13.97-49.99), venous thromboembolism (RR 9.16, 95% CI 2.17-38.60), preterm rupture of membranes (RR 2.15, 95% CI 1.18-3.90), and cesarean delivery (RR 1.88, 95% CI 1.70-2.09). They had longer hospitalizations and increased rehospitalization (RR 1.54, 95% CI 1.28-1.87), including for postpartum depression (RR 8.15, 4.29-15.48) or injury (RR 13.05, 95% CI 6.60-25.81). Their infants were more often small for gestational age (RR 1.65, 95% CI 1.33-2.06), but had no increased risk of rehospitalization or death.

CONCLUSIONS

We observed no increased long-term morbidity among infants of women with these conditions. Possible increased maternal morbidities during the first postpartum years indicate areas for intervention.

LEVEL OF EVIDENCE

III.

Anesthetic management in a spinal cord-injured parturient woman with a left hip resection and secondary scoliosis: A case report

RATIONALE

Pregnancy after spinal cord injury, hip resection, leg amputation, and scoliosis is an uncommon event. Given the specific pathophysiological changes in this patient, an aesthetic management presented a particular challenge. The effects on the physiological changes associated with pregnancy, aesthetic methods, blood loss, autotransfusion from uterine contractions and thrombotic risk had to be considered.

PATIENT CONCERNS

A 25-year-old female earthquake survivor was admitted at 36.4 weeks of pregnancy for preterm labor. She had suffered from a spinal cord injury and complex trauma and had subsequently undergone left hip resection, bilateral amputations, and multiple surgical procedures during the previous 6 years. Additionally, she had developed severe scoliosis due to her weight-bearing posture.

DIAGNOSES

High amputation after earthquake injury; Scoliosis; Vulvar reconstruction; Intrauterine pregnancy (35.6 weeks) with a single live fetus with possible premature delivery.

INTERVENTIONS

We administered general anesthesia during a cesarean section for the parturient woman. Both the central venous pressure and pleth variability index were used to continuously evaluate intraoperative fluid management and blood loss.

OUTCOMES

Delivery and patient recovery were uneventful.

LESSONS

Anesthetic management of a pregnant woman with a spinal injury, scoliosis, left total leg and right below-knee amputations, and left hip resection requires considerable attention. Advances in medical technology have provided clinicians with insights into managing patients with this condition.

Bladder Stone in Pregnancy: A Case Report and Review of the Literature

BACKGROUND Bladder stones are rare in pregnancy, and can be associated with adverse outcomes such as recurrent urinary tract infection and obstruction of labor. Management of bladder stones discovered in pregnancy has traditionally been done via open techniques such as cystolithotomy or with percutaneous removal. Our objective was to present a case of bladder stone in pregnancy and review prior reports on bladder stones and management in pregnancy. CASE REPORT A 28-year-old gravida 4 para 3 at 10 weeks gestation presented with dysuria, bladder spasm, weak urinary stream, and positional voiding. On first trimester ultrasound, a bladder stone (sized 3.7 cm) was identified and was confirmed by x-ray (KUB). Urology was consulted and removed the stone via cystolitholapaxy with holmium laser. Her symptoms subsequently resolved, and she went on to have an uncomplicated term spontaneous vaginal delivery. The removal of the stone enabled her to have a subsequent vaginal delivery without the potential for obstruction of labor. CONCLUSIONS Based on our review of the literature and this case report, laser cystolitholapaxy is a safe alternative to open surgery for the management of bladder stones in pregnancy. When discovered at the time of delivery, vaginal delivery is feasible if the stone is small or can be displaced. If encountered at time of cesarean delivery, then cystotomy with stone removal is recommended provided inflammation is not present.

Fertility and sexuality in the spinal cord injury patient

BACKGROUND

After a spinal cord injury, patients have different perceptions of sexuality, sexual function, and potential for fertility. These changes can greatly impact quality of life over a lifetime.

PURPOSE

The purpose of this workgroup was to identify common evidence based or expert opinion themes and recommendations regarding treatment of sexuality, sexual function and fertility in the spinal cord injury population.

METHODS

As part of the SIU-ICUD joint consultation of Urologic Management of the Spinal Cord Injury (SCI), a workgroup and comprehensive literature search of English language manuscripts regarding fertility and sexuality in the spinal cord injury patient were formed. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for levels of evidence (LOEs) and grades of recommendation (GORs).

RESULTS

Genital arousal, ejaculation, and orgasm are significantly impacted after spinal cord injury in both male and female SCI patients. This may have a more significant impact on potential for fertility in male spinal cord injury patients, particularly regarding ability of generate erection, semen quantity and quality. Female patients should be consulted that pregnancy is still possible after injury and a woman should expect resumption of normal reproductive function. As a result, sexual health teaching should be continued in women despite injury. Pregnancy in a SCI may cause complications such as autonomic dysreflexia, so this group should be carefully followed during pregnancy.

CONCLUSIONS

By understanding physiologic changes after injury, patients and care teams can work together to achieve goals and maximize sexual quality of life after the injury.

Bladder management during pregnancy in women with spinal-cord injury: an observational, multicenter study

INTRODUCTION AND HYPOTHESIS

Pregnancy in women with spinal-cord injury (SCI) poses a clinical challenge. We hypothesized that changes in the management of neurogenic bladder during pregnancy are commonly required and should receive more attention.

METHODS

Data were collected by retrospective analysis of medical records and via cross-sectional survey of 52 women with SCI, representing 67 pregnancies, at ten Italian neurourological clinics. All participants provided informed consent.

RESULTS

Between 1976 and 2013, 39 participants had one child, 11 had two children, and two had three children. Mean age at the time of SCI was 18 years and at the time of first pregnancy was 30 years. Delivery occurred from weeks 32 to 40 in 98% of first and second pregnancies, and 94% of neonates were healthy. Oxybutynin was used by four women during five pregnancies, which resulted in delivery of healthy babies. Intermittent catheterization was used before 54% of first pregnancies and 39% of second pregnancies. Bladder management was altered during 45% of these pregnancies, and the most common changes were increased use or frequency of intermittent catheterization or use of an indwelling catheter. Urinary tract infections occurred in 48% of pregnancies, and an irregular course was reported in 13% of pregnancies mainly related to tetraplegia and urological complications.

CONCLUSIONS

Pregnancy in women with SCI generally has good outcomes and limited risks but frequently necessitates changes in the management of neurogenic bladder. High levels of awareness and focused monitoring of bladder issues are recommended.

Prevalence of parenthood in wheelchair-dependent persons with long-term spinal cord injury in the Netherlands

STUDY DESIGN

Multicenter  cross-sectional study.

OBJECTIVES

To determine the prevalence of parenthood in long-term wheelchair-dependent persons who sustained a spinal cord injury (SCI) during their reproductive years. Secondary aims were to (1) explore patient-specific and disease-related factors associated with parenthood after SCI; and (2) quantify fertility aids used by men with SCI.

SETTING

Eight specialized SCI rehabilitation centers in the Netherlands.

METHODS

Questionnaires and physical examination were applied in 255 persons with SCI. Prevalence rates of parenthood among the general Dutch population were used for comparison. Logistic regression analyses were used to explore factors associated with parenthood after SCI.

RESULTS

Prevalence of parenthood in SCI was 50% in men and 45% in women, which was significantly (P < 0.05) lower than rates in the general population (74% in men and 81% in women). Among the parents with SCI, most (66% of males and 72% of females) of them had children after SCI. Parenting children after SCI was associated with partnership (OR = 14.5, P < .001 [men]; OR = 3.7, P = .05 [women]), normal micturition (OR = 4.9, P = .02 [men]), incomplete lesion (OR = 5.4, P = .03 [women]), and paraplegia (OR = 7.3, P = .02 [women]). The most frequently used methods for ejaculation and fertilization were electroejaculation (29%) and intracytoplasmatic sperm injection (23%).

CONCLUSIONS

Prevalence of parenthood in SCI persons is low. However, half of the persons with SCI do become parents, with most doing so following SCI. Demographic and disease-related factors may contribute to this.

Spinal cord injury during the second trimester of pregnancy

INTRODUCTION

Pregnancies in women with spinal cord injury (SCI) are at greater risk of morbidity and mortality. Although pregnancy after SCI is well elaborated in the literature, SCI occurring during pregnancy is rarely reported. Abrupt changes in the body physiology because of SCI and the resulting disability add a risk to maternal and fetal well-being. Not only is the burden of care increased but there is also a higher risk of developing pressure ulcers, urinary tract infections, autonomic instability, intrauterine growth retardation and venous thromboembolism.

CASE PRESENTATION

We report a case of a 32-year-old lady who had a traumatic SCI at C6 level during the second trimester of her pregnancy. She was admitted to a tertiary care rehabilitation facility after 2 months of her injury. This case highlights the comprehensive approach toward her management, including rehabilitation, spinal intervention and obstetrical care. To the best of our knowledge, this is the first case report of its kind from the Middle East.

DISCUSSION

Multi-system involvement due to SCI during pregnancy results in intense physiological changes that affect the treatment options for anesthesia, surgery, labor and comprehensive rehabilitation. This case report emphasizes the need for well-equipped, specialized centers for similar patients in developing health systems and aims to increase the awareness for management of SCI during pregnancy using a comprehensive approach.

Pregnancy in spinal cord-injured women, a cohort study of 37 pregnancies in 25 women

STUDY DESIGN

A retrospective observational study.

OBJECTIVE

To describe specificities of pregnancy in a traumatic spinal cord-injured (SCI) population managed by a coordinated medical care team involving physical medicine and rehabilitation (PMR) physicians, urologists, infectious diseases' physicians, obstetricians and anaesthesiologists.

SETTING

NeuroUrology Department in a University Hospital, France.

METHODS

All consecutive SCI pregnant women managed between 2001 and 2014 were included. A preconceptional consultation was proposed whenever possible. Obstetrical and urological outcomes, delivery mode and complications were reported.

RESULTS

Overall, thirty-seven pregnancies in 25 women, of a mean age of 32±4 years, were included. Thirty-five children were born alive (three miscarriages, a twin pregnancy) without complications except for a case of neonatal respiratory distress in premature twins born at 33 weeks. The mean birth weight was 2979±599 g. Twenty-one (57%) pregnancies benefited from preconceptional care. A weekly oral cyclic antibiotic programme was prescribed in 28 (75%) pregnancies. The main complications during pregnancy included pyelonephritis (30%), lower urinary tract infections (UTI) (32%), pressure sores (8.8%) and prematurity (12% deliveries before 37 weeks, with only one delivery before 36 weeks). Two patients suffered from autonomic dysreflexia, one with serious complication (brain haematoma). Caesarean sections were performed for 68% of deliveries (23/34) to prevent syringomyelia deterioration (n=10), stress urinary incontinence aggravation (n=3) or for obstetrical reasons (n=7).

CONCLUSIONS

Mothers' and infants' outcomes were satisfying after pregnancy in SCI women, but required many adjustments. Pregnancy must be prepared by a preconceptional consultation, and managed by a multidisciplinary team involving specialists of neurological disability and pregnancy.

[Anesthesiological approach for patients with spinal cord injuries]

Spinal cord injuries (SCI) are serious medical conditions, which are associated with severe and potentially fatal risks and complications depending on the location and extent of injury. Traffic accidents, falls and recreational activities are the leading causes for traumatic SCI (TSCI) worldwide whereas non-traumatic spinal cord injuries (NTSCI) are mostly due to tumors and congenital diseases. As chronification of the injuries progresses other organ systems are affected including anatomical changes, the respiratory and cardiovascular systems and endocrinological pathways. All these effects have to be considered in the anesthesiological management of patients with SCI. Autonomic dysreflexia (AD) is the most dangerous and life-threatening complication in patients with chronic SCI above T6 that results from an overstimulation of sympathetic reflex circuits in the upper thoracic spine and can be fatal. This article summarizes the specific pathophysiology of SCI and how AD can be avoided as well as also providing anesthetists with strategies for perioperative and intensive care management of patients with SCI.

Control Cross-sectional Study Evaluating an Antibiotic Prevention Strategy in 30 Pregnancies Under Clean Intermittent Self-catheterization and Review of Literature

OBJECTIVE

To assess the efficacy and safety of a weekly oral cycling antibiotic (WOCA) strategy to prevent UTI in women.

MATERIALS AND METHODS

We performed a monocentric, comparative, retrospective, cross-sectional study on pregnant women under clean intermittent self catheterization between January 2008 and December 2014. WOCA consisted the administration of a single-dose antibiotic, alternating antibiotic A and B once every 2 weeks, according to previous urine cultures.

RESULTS

Twenty-five women carried out 30 pregnancies. Thirteen pregnancies (43.3%) were in the WOCA group (WCG) strategy and 17 were in the non-WOCA group (NWCG) (56.7%). In the 19 (63.3%) pregnancies with urinary tract infection (UTI), 5 (38.4%) were in WCG, 14 (82.3%) were not (P = .023). There were more cystitis in NWCG (76.5% vs 23.1% P = .009) but more colonization in WCG (46.2% vs 5.8% P = .025). UTIs were due to Escherichia coli, Enterobacter cloacae, and Klebsiella pneumoniae. There was a nonsignificant increase in preterm birth in NWCG (35.3% vs 7.7% P = .10), no small for gestational age neonates, and no significant difference for the mode of delivery, birthweight, and neonatal outcome.

CONCLUSION

According to our result, WOCA seems safe and effective on symptomatic UTI frequency and could be promoted to help physicians to manage specific risks in pregnancy.

Personal experiences of pregnancy and fertility in individuals with spinal cord injury

Individuals with spinal cord injuries (SCIs) often face a number of barriers in family planning and pregnancy. These barriers can be structural (i.e. inaccessible health care provider offices and providers unfamiliar with fertility, pregnancy, and SCI) or social (i.e. friends, family, and even providers suggesting that individuals with SCI should not have children), and can affect both men and women. Additionally, much of the information about SCI and pregnancy is from a medical perspective and the psychosocial aspects of pregnancy for individuals with SCI have not been considered. 253 men and women with SCI were asked about the information they received about SCI and pregnancy, where they received this information, and how their SCI affected their family planning. The responses shared in this study can be used to inform individuals who work with people with SCI to better assist their clients or patients who have sustained SCI and are considering pregnancy.

Transection of the pelvic or vagus nerve forestalls ripening of the cervix and delays birth in rats

Innervation of the cervix is important for normal timing of birth because transection of the pelvic nerve forestalls birth and causes dystocia. To discover whether transection of the parasympathetic innervation of the cervix affects cervical ripening in the process of parturition was the objective of the present study. Rats on Day 16 of pregnancy had the pelvic nerve (PnX) or the vagus nerve (VnX) or both pathways (PnX+VnX) transected, sham-operated (Sham) or nonpregnant rats served as controls. Sections of fixed peripartum cervix were stained for collagen or processed by immunohistochemistry to identify macrophages and nerve fibers. All Sham controls delivered by the morning of Day 22 postbreeding, while births were delayed in more than 75% of neurectomized rats by more than 12 h. Dystocia was evident in more than 25% of the PnX and PnX+VnX rats. Moreover, on prepartum Day 21, serum progesterone was increased severalfold in neurectomized versus Sham rats. Assessments of cell nuclei counts indicated that the cervix of neurectomized rats and Sham controls had become equally hypertrophied compared to the unripe cervix in nonpregnant rats. Collagen content and structure were reduced in the cervix of all pregnant rats, whether neurectomized or Shams, versus that in nonpregnant rats. Stereological analysis of cervix sections found reduced numbers of resident macrophages in prepartum PnX and PnX+VnX rats on Day 21 postbreeding, as well as in VnX rats on Day 22 postbreeding compared to that in Sham controls. Finally, nerve transections blocked the prepartum increase in innervation that occurred in Sham rats on Day 21 postbreeding. These findings indicate that parasympathetic innervation of the cervix mediates local inflammatory processes, withdrawal of progesterone in circulation, and the normal timing of birth. Therefore, pelvic and vagal nerves regulate macrophage immigration and nerve fiber density but may not be involved in final remodeling of the extracellular matrix in the prepartum cervix. These findings support the contention that immigration of immune cells and enhanced innervation are involved in processes that remodel the cervix and time parturition.

A systematic review of the management of autonomic dysreflexia after spinal cord injury

OBJECTIVE

To review systematically the clinical evidence on strategies to prevent and manage autonomic dysreflexia (AD).

DATA SOURCES

A key word search of several databases (Medline, CINAHL, EMBASE, and PsycINFO), in addition to manual searches of retrieved articles, was undertaken to identify all English-language literature evaluating the efficacy of interventions for AD.

STUDY SELECTION

Studies selected for review included randomized controlled trials (RCTs), prospective cohort studies, and cross-sectional studies. Treatments reviewed included pharmacologic and nonpharmacologic interventions for the management of AD in subjects with spinal cord injury. Studies that failed to assess AD outcomes (eg, blood pressure) or symptoms (eg, headaches, sweating) were excluded.

DATA EXTRACTION

Studies were critically reviewed and assessed for their methodologic quality by 2 independent reviewers.

DATA SYNTHESIS

Thirty-one studies were assessed, including 6 RCTs. Preventative strategies to reduce the episodes of AD caused by common triggers (eg, urogenital system, surgery) primarily were supported by level 4 (pre-post studies) and level 5 (observational studies) evidence. The initial acute nonpharmacologic management of an episode of AD (ie, positioning the patient upright, loosening tight clothing, eliminating any precipitating stimulus) is supported by clinical consensus and physiologic data (level 5 evidence). The use of antihypertensive drugs in the presence of sustained elevated blood pressure is supported by level 1 (prazosin) and level 2 evidence (nifedipine and prostaglandin E(2)).

CONCLUSIONS

A variety of options are available to prevent AD (eg, surgical, pharmacologic) and manage the acute episode (elimination of triggers, pharmacologic); however, these options are predominantly supported by evidence from noncontrolled trials, and more rigorous trials are required.

Ascending spinal pathways from sexual organs: effects of chronic spinal lesions

A recent survey of paraplegics indicates that regaining sexual function is of the highest priority for both males and females (Anderson, K.D. (2004) Targeting recovery: priorities of the spinal cord-injured population J. Newrotrauma, 21: 1371-1383). Our understanding of the neural pathways and mechanisms underlying sexual behavior and function is limited at the present time. More studies are obviously needed to direct experiments geared toward developing effective therapeutic interventions. In this chapter, a review of studies on the processing of sensory inputs from the male and female reproductive organs is presented with a review of what is known about the location of ascending spinal pathways conveying this information. The effect of spinal cord injury on sexual function and the problems that ensue are discussed.

[The impact of spinal cord injury on sexuality and reproduction]

Spinal cord injury is known to have a major impact on human sexual function. The disturbances depend on the level and completeness of the lesion. The majority of people affected by spinal cord injury are young and in their reproductive years. In these cases sexuality reflects an important aspect of personality, and therefore special attention needs to be given to this issue during rehabilitation. Sexual rehabilitation encompasses both comprehensive information and consultation as well as diagnosis and treatment of disturbed sexual functions. Successful rehabilitation and integration depend also on restoration of sexual function or adequate therapy of sexual dysfunction. This review will consider the present knowledge about the impact of spinal cord injury on female and male sexual function, the currently available treatment options as well as the aspects of fertility and reproduction in this patient population.

Epidural anaesthesia for caesarean section in a patient with quadriplegia and autonomic hyperreflexia

The anaesthetic management of a pregnant quadriplegic woman with a history of autonomic hyperreflexia is discussed. Autonomic hyperreflexia is a life-threatening complication of high spinal cord transection, for which labour is a well known stimulus. It can lead to uncontrolled hypertension. We discuss the anaesthetic considerations in planning the care of this patient, who was managed for elective caesarean section and post partum hypertension with epidural anaesthesia.

Obstetric Management of the Patient With Spinal Cord Injury

Pregnancies in spinal cord-injured patients present unique clinical challenges to obstetric providers. Spinal cord injury (SCI) alters the function of multiple organ systems, and chronic medical conditions are extremely common in this patient population. Autonomic dysreflexia (ADR) is a potentially life-threatening complication of SCI, usually involving patients with spinal cord lesions at or above the T6 level. Intrapartum care of women with SCI is particularly complicated, and labor is the period during which ADR is most likely to arise. A multidisciplinary team in a unit capable of invasive hemodynamic monitoring should deliver these patients. Epidural anesthesia should be administered early in labor to prevent ADR. If proper precautions are taken, most patients with SCI will have successful vaginal deliveries at term.

[Paraplegia and pregnancy: anaesthesic management]

Pregnancy is a rare occurrence in patient suffering from spinal cord lesion. The authors report the case of labour and delivery in a paraplegic patient who was suffering from lesion located T6 level. In early labour epidural analgesia was maintained and the vaginal delivery was successful without associated fluctuation of blood pressure or other signs of autonomic hyperreflexia. The epidural catheter was maintained for 48 h post-partum. The main risks and anaesthesic management of pregnancy in paraplegic patients are discussed.

Autonomic dysreflexia

The purpose of this article is to help perinatal nurses understand how to more effectively care for women in labor who have spinal cord injuries (SCIs), especially those women who develop the complication of autonomic dysreflexia (AD). AD is a syndrome that can occur in patients with SCIs above the level of T6. Its symptoms include dangerous paroxysmal hypertension, resulting from abnormal interplay between the parasympathetic and sympathetic nervous systems. While this syndrome was not commonly encountered by perinatal nurses in childbirth settings in the past, the dramatic improvements in both acute care and rehabilitation for women with SCI has increased the numbers of women with SCI who become pregnant and experience childbirth. Therefore, it is essential that perinatal nurses be made aware of how to effectively identify AD, and what steps to take should it occur.

Possible explanation of cephalic and noncephalic presentation during pregnancy: a theoretical approach

This paper is based on fact that the fetus is exposed to gravity. The hypothesis is that from the 24th week of gestation an increasing percentage of fetuses occupies an exclusively cephalic presentation, since it allows an uncompromised posture in the caudal direction of body segments whose muscles are first affected by the occurrence and progressive increase of tone. Being in cephalic presentation, in a caudal direction, the fetus relieves body segments of the weight of the hypotonic-atonic part of the body in the cranial direction. In other words, cephalic presentation presents a body axis posture along the line of gravity. When the body axis posture along gravity is absent, the fetus simply fills the intrauterine cavity. In many such cases, the results are transverse lie, breech presentation and also cephalic presentation.

Cardiovascular consequences of loss of supraspinal control of the sympathetic nervous system after spinal cord injury

Spinal cord injury (SCI) with resultant quadriplegia or high paraplegia is associated with significant dysfunction of the sympathetic nervous system. This alteration of sympathetic nervous system activity occurs as a consequence of loss of supraspinal control of the sympathetic nervous system and is further complicated by at least three subsequent phenomena that occur below the level of SCI: reduced overall sympathetic activity, morphologic changes in sympathetic preganglionic neurons, and peripheral alpha-adrenoceptor hyperresponsiveness. Reduced sympathetic activity below the level of SCI appears to result in orthostatic hypotension, low resting blood pressure, loss of diurnal fluctuation of blood pressure, reflex bradycardia, and, rarely, cardiac arrest. Peripheral alpha-adrenoceptor hyperresponsiveness likely accounts for some, if not the majority, of the excessive pressor response in autonomic dysreflexia and may also contribute to decreased blood flow in the peripheral microcirculation, potentially increasing susceptibility to pressure sores. What has yet to be established is whether this alpha-adrenoceptor hyperresponsiveness is a consequence of receptor hypersensitivity or a failure of presynaptic reuptake of noradrenaline at the receptor level. Better understanding of the pathophysiology of sympathetic nervous system dysfunction after high-level SCI should allow development of more effective measures to manage clinical complications.

A multicenter study of women's self-reported reproductive health after spinal cord injury

OBJECTIVE

Little attention has been given to women's reproductive health issues in the disabled population. This study documents the unique reproductive health conditions, complications, and behaviors in women with spinal cord injury (SCI).

SUBJECTS

A total of 472 women at least 18 years of age who were at least 1 year post-SCI. Their average age at injury was 32 years.

DESIGN

An extensive questionnaire regarding gynecologic, sexual, obstetric, and menopausal health issues was developed and piloted. The questionnaire was then administered by a trained woman health care clinician to women who agreed to participate in the study.

SETTING

Private outpatient clinics at 10 regional model SCI systems of care.

RESULTS

Women reported similar gynecologic problems in both preinjury and postinjury time periods. Exceptions were urinary tract infections and vaginal yeast infections. Sexually transmitted infections appear to be less common after injury, but the difference was not statistically significant. The number of hysterectomies was similar both before and after injury, but reasons differed greatly. Women with SCI were less likely to have routine mammograms. They reported similar preventive practices such as performing self-breast examinations and obtaining Papanicolaou smears. Almost 14% of women with SCI became pregnant after injury (101 pregnancies). Complications from pregnancy, labor, and delivery were reported to be more frequent in their postinjury than in their preinjury obstetric experiences. They tended to have babies of lower birth weight and with more complications at time of delivery. Of the sample, 87% reported having sexual intercourse before injury, with only 67% having intercourse after injury. Years postinjury and level of injury were predictive of intercourse; extent of injury was not. Experience of orgasms and methods of contraception varied among the two groups. There were significant complaints of dysreflexia and bladder incontinence with sexual function. Menopause after injury was reported by 14.6% of the women. Postinjury menopausal symptoms were of low frequency, but more than those reported by women who had undergone menopause before injury. Only 19% of women who had menopause after SCI were placed on hormone replacement therapy. Almost one third of the women who had menopause after injury reported new bone fractures.

CONCLUSION

This study illustrates the unique reproductive health concerns of women with SCI. Many pregnancy, labor, and delivery experiences in these women are different. Sexual activity and function have several disability-related consequences and the effects of menopause are still unknown, but may be more problematic than for able-bodied women.

Effects of laparotomy, cage type, gestation period and spaceflight on abdominal muscles of pregnant rodents

We studied the effects of four variables on the histological properties of three body wall muscles-rectus abdominis (RA), transversus abdominis (TA), and external oblique (EO)-from pregnant rats. The variables examined were (1) gestation period; (2) cage design; (3) the effect of a midline laparotomy, performed to determine fetus numbers; and (4) exposure to a nine-day spaceflight. We measured fiber cross-sectional area (CSA), metabolic enzyme levels (succinate dehydrogenase, glycerophosphate dehydrogenase), and myosin heavy chain (MHC) immunoreactivity in samples from each muscle. A major effect of spaceflight was an increase of 42-171% in fibers double-labeled for MHC in all three muscles. Based on fiber CSA, the TA and RA muscles showed signs of stretching with increased gestation; i.e., the CSA decreased 11-12% over a nine-day period. The EO, a torso rotator, hypertrophied by 9% in rats group-housed in cages with a complex 3-D structure, compared to controls housed singly in standard flat-bottom cages. The TA and EO, whose contractions would pull on the suture line, showed signs of atrophy in laparotomized animals, exhibiting a 12% decrease in muscle fiber CSA. Exposure to weightlessness is known to induce atrophy in most skeletal muscles. Surprisingly, the EO actually hypertrophied 11% in our flight animals; however, this can be explained by the fact that those rats actively rotated their torsos seven times more often than ground controls. The flight rats also had twice as many contractions as controls. However, they were still able to give birth on time postflight.

Forceps-assisted vaginal delivery

Operative vaginal delivery using forceps has been an important part of obstetric practice for nearly 400 years. Countless women and their children have benefited from timely and expertly performed procedures. Physicians must, therefore, make every effort to retain these skills, to modify and improve them in every possible way, and to pass them on. In this way, women and children of future generations will benefit from the many years of experience that have gone before them.

Anaesthesia for chronic spinal cord lesions

Increasing numbers of patients with spinal cord injury present for surgery or obstetric care. Spinal cord injury causes unique pathophysiological changes. The most important peri-operative dangers are autonomic dysreflexia, bradycardia, hypotension, respiratory inadequacy and muscle spasms. Autonomic dysreflexia is suggested by headache, sweating, bradycardia and severe hypertension and may be precipitated by surgery, especially bladder distension. Patients with low, complete lesions, undergoing surgery below the level of injury, may safely do so without anaesthesia provided there is no history of autonomic dysreflexia or troublesome spasms. An anaesthetist should be present to monitor the patient in this situation. General anaesthesia of sufficient depth is effective at controlling spasms and autonomic dysreflexia but hypotension and respiratory dysfunction are risks. There is a growing consensus that spinal anaesthesia is safe, effective and technically simple to perform in this group of patients. We present a survey of 515 consecutive anaesthetics in cord-injured patients and a review of the current literature on anaesthesia for patients with chronic spinal cord lesions.

Spinal cord injury rehabilitation. 2. Medical complications

This self-directed learning module highlights new advances in understanding medical complications of spinal cord injury through the lifespan. It is part of the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article covers reasons for transferring patients to specialized spinal cord injury centers once they have been stabilized, and the management of common medical problems, including fever, autonomic dysreflexia, urinary tract infection, acute and chronic abdominal complications, deep vein thrombosis, pulmonary complications, and heterotopic ossification. Formulation of an educational program for prevention of late complications is also discussed, including late renal complications, syringomyelia, myelomalacia, burns, pathologic fractures, pressure ulcers, and cardiovascular disease. New advances covered in this section include new information on old problems, and a discussion of exercise tolerance in persons with tetraplegia, the pathophysiology of late neurologic deterioration after spinal cord injury, and a view of the care of these patients across the lifespan.

Spinal cord injury rehabilitation. 4. Individual experience, personal adaptation, and social perspectives

This learner-directed module highlights contemporary perspectives on personal success in the adjustment and adaptation of patients with spinal cord injury (SCI). It is the fourth in a series of five modules within the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This module explores models of the multisystem effects on a person after SCI, disablement, theories of adjustment, patient autonomy, quality of life, community experience, adaptations enhancing sexuality, and minimization of pain after SCI. Perspectives of the patient's experience in disablement, interdisciplinary person-centered rehabilitation, and success of the individual in chosen life roles are emphasized. The module is designed to update SCI issues reviewed in past syllabi.

Pregnancy in spinal cord injured women

The management of pregnancy, labor, and delivery in women with spinal cord injury (SCI) has received increased attention by investigators and clinicians in recent years. Physicians who care for women with SCI need to become familiar with the general principles of care during pregnancy. This article presents a summary of publications identified by a MEDLINE search of the topics spinal cord injury, paraplegia, tetraplegia, and pregnancy, and by reviewing the reference lists of these articles. The current medical literature suggests excellent overall maternal and neonatal outcome. Certain medical complications such as urinary tract infections and autonomic hyperreflexia are predictable and can be managed successfully. Obstetrical management is changed little by SCI but needs to account for the risk of unattended delivery in the patient with a high level of lesion.

Acute spinal cord injury and neurogenic shock in pregnancy

A case of a pregnant woman with a subluxation of C-6 on C-7 with acute quadriplegia and sensory loss to the T-10 dermatome is described. Hemodynamic and fetal monitoring during the 3-week period of neurogenic shock resulted in good maternal and fetal outcomes. Pulmonary complications and anesthetic issues are important aspects of the care of these critically ill patients. Major trauma is a common cause of death and disability in young adults and may contribute to as much as 15 percent of nonobstetric maternal deaths. Spinal cord injuries involve young women in 15 percent of cases. The literature is replete with information on the obstetric management of patients with preexisting spinal cord injury (1-4) but there is little on the management and special problems of the pregnant patient with acute spinal cord trauma. We report here the management of a case of acute cord transection accompanied by spinal shock and discuss the specific maternal as well as fetal considerations in this syndrome.