Intrathecal baclofen pump implantation during pregnancy

Intrathecal baclofen pump in pregnancy: case report, literature review, and management considerations

BACKGROUND

Baclofen, a gamma-aminobutyric acid receptor type B agonist in the central nervous system, is the first-line medication among central nervous system modulating agents for the treatment of neurogenic muscle spasticity. While baclofen is most often administered enterally, patients with severe spasticity may be candidates for baclofen delivered by intrathecal pump. Currently, there are only nine studies reporting on the use of intrathecal baclofen (ITB) during pregnancy and childbirth.

CASE PRESENTATION

We described a female patient with a history of childhood idiopathic spasticity of the bilateral lower extremities that was controlled by ITB pump who became pregnant in her late third decade of life and delivered a healthy infant. The patient required multiple increases of her baclofen course over the course of her pregnancy.

DISCUSSION

Our case, alongside the existing literature on ITB during pregnancy, suggests that ITB therapy in pregnancy poses a low risk of teratogenicity and infant withdrawal seizures; however, larger, controlled studies are necessary to make those conclusions with confidence. Healthcare providers caring for pregnant ITB patients should be cognizant of the potential for such patients to require increased doses of ITB during pregnancy to achieve adequate symptom control.

Neonatal baclofen withdrawal following intrauterine exposure

BACKGROUND

Pregnant women with spinal cord injuries are often advised to continue oral baclofen during pregnancy to manage spasticity, though the potential for adverse events in neonates is not well understood.

OBJECTIVE

Here, a case is described in which a male neonate with intrauterine baclofen exposure, born at 34 3/7 weeks via Cesarean section, demonstrated a two-minute episode of extensor posturing at fifteen minutes of life possibly concerning for baclofen withdrawal. His mother had taken baclofen 30 milligrams orally four times per day throughout pregnancy for management of spasticity associated with a remote cervical spinal cord injury. Due to concern for possible withdrawal, the neonate was started on a baclofen taper beginning within hours of birth while evaluation for alterative etiologies was underway. Symptoms were monitored using the Finnegan Neonatal Abstinence Scale. The neonate tolerated the baclofen taper well and was successfully tapered off by the fourteenth day of life with full resolution of symptoms and no apparent neurologic deficits.

CONCLUSION

Further research is needed to assess the incidence of neonatal baclofen withdrawal with regard to maternal dosage and route of administration, and to determine the most appropriate monitoring and management protocols for the neonate.

Preconception, Antepartum, and Peripartum Care for the Woman With a Spinal Cord Injury: A Review of the Literature

Importance

Spinal cord injury (SCI) may result in temporary or permanent loss of sensory, motor, and autonomic function, presenting unique medical and psychosocial challenges in women during their childbearing years.

Objective

The aim of this study was to review the literature and describe the spectrum of pregnancy considerations, complications, and evidence-based obstetric practices in women with SCI.

Evidence Acquisition

A literature search was undertaken using the search engines of PubMed and Web of Science using the terms "spinal cord injury" or "spinal cord complications" and "pregnancy outcomes" or "pregnancy complications." The search was limited to the English language, and there was no restriction on the years searched.

Results

The search identified 174 abstracts, 50 of which are the basis for this review. Pregnancy in women who have experienced an SCI requires a multidisciplinary approach. Common complications during pregnancy include recurrent urinary tract infection, upper respiratory tract infection, hypertension, venous thromboembolism, and autonomic dysreflexia (AD), which is a potentially life-threatening complication. Obstetricians should avoid potential triggers and be familiar with acute management of AD. Postpartum complications include difficulty initiating and maintaining breastfeeding and increased risk of postpartum depression and other mental health issues.

Conclusions and Relevance

Obstetricians caring for women with an SCI must be familiar with the unique challenges and complications that may occur during pregnancy and puerperium.

Relevance Statement

An evidence-based literature review of the care of pregnant women with spinal cord injury.

Pregnancy and Breastfeeding during Intrathecal Baclofen Therapy - A Case Study and Review

We report the case of a young woman who received intrathecal baclofen therapy (ITB) and subsequently became pregnant and had a normal delivery. A 28-year-old woman with flexion myelopathy had anterior decompression with fusion at C4/5 and C5/6 levels. Clinical symptoms improved after surgery. However, when she was 29 years old, her symptoms steadily advanced to Modified Ashworth Scale 3 spasticity level in the lower legs, with pain in both of them and urinary retention tendency. Since a 25 μg intrathecal baclofen injection improved her symptoms, an ITB pump system was implanted. After surgery, lower limb spasticity and urinary retention improved. Two years after ITB pump implantation, the patient married and became pregnant. The patient intended to have normal delivery but the induction of labor was ineffective and childbirth was completed by Cesarean section with lumbar anesthesia. The infant's Apgar score was 8 at 1 min and 9 at 5 min, and birth-weight was 2,704 g. We measured the baclofen concentration in the patient's breast milk using high-performance liquid chromatography/tandem mass spectrometry. The level of baclofen in the breast milk was very low (0.617 ng/ml) and the predicted pharmacological effect on the infant was judged to be negligible. No withdrawal symptoms or muscle tone abnormalities were found after birth. Our findings indicate that ITB therapy could be considered for young women with severe spasticity, even if they plan to have children.

Patient experiences with intrathecal baclofen as a treatment for spasticity - a pilot study

PURPOSE

This study describes how patients experience intrathecal baclofen (ITB) treatment.

METHODS

Data were collected from interviews with 14 patients (19-76 years old) who were diagnosed with spinal cord injury (SCI), multiple sclerosis (MS), or cerebral palsy (CP). Data were analyzed using conventional content analysis.

RESULT

The analysis resulted in 16 subcategories arranged into five main categories: procedures before treatment, the effect of ITB on daily life and activities, continuous follow-up, expected and unexpected consequences of ITB, and overall level of satisfaction with ITB. Together these categories described the patients' experiences with ITB treatment. When the patients were asked whether they would undergo ITB again, they all stated that they would.

CONCLUSION

Patients stated that they were highly satisfied with the ITB treatment. However, the patients identified several areas that could be improved. Specifically, the patients wanted more information about the different steps in the treatment process and what to expect from ITB treatment.

Intrathecal baclofen pump - a viable therapeutic option in pregnancy

Baclofen, a gamma-aminobutyric acid analogue, is used as a muscle relaxant and antispasmodic to relieve symptoms in patients with intractable spasticity arising from cerebral or spinal aetiology such as in traumatic brain injury or multiple sclerosis. As it is often used in women of reproductive age, it is imperative to know the safety and associated maternal and fetal risks. The Food and Drug Administration has assigned the drug to Pregnancy Category C because of the lack of controlled data in humans. Animal studies have revealed an increased incidence of omphalocele if used in doses several times the recommended human dose. Baclofen should only be given during pregnancy when the benefits outweigh the risks. Baclofen is considered compatible with breast feeding by the American Academy of Pediatrics.

The safety of baclofen in pregnancy: intrathecal therapy in multiple sclerosis

Intrathecal baclofen is a GABA-receptor agonist and one of the mainstay treatments of severe spasticity due to multiple sclerosis (MS). The authors report a case on the use of intrathecal baclofen administered using a Medtronic Synchromed II infusion pump. A healthy male infant (2.68 kg, Apgars 9 and 10) was born at 36 weeks gestation by cesarean section, under general anesthetic. This is the fifth reported case of intrathecal baclofen administered during pregnancy and adds to the knowledge that thus far it is relatively safe in pregnancy and may in fact be safer for the infant than oral baclofen. This is the first case report of the use of intrathecal baclofen in pregnancy and MS.

A benefit-risk assessment of baclofen in severe spinal spasticity

Baclofen is used for treatment of the spasticity of spinal origin that is a common sequela of spinal cord injury and multiple sclerosis; spasticity occurs in about 50% of patients affected by these disorders. In open-label studies of oral baclofen, the drug improved spasticity in 70-87% of patients; additionally, improvement in spasms was reported in 75-96% of patients. In double-blind, crossover, placebo-controlled trials, baclofen was reported to be effective, producing statistically significant improvements in spasticity. Tizanidine is the antispasticity drug that has been most widely compared with oral baclofen; studies have generally found the two drugs to have equivalent efficacy. However, tizanidine has better tolerability, in particular weakness was reported to be occur less frequently with tizanidine than with baclofen. The main adverse effects of oral baclofen include: sedation or somnolence, excessive weakness, vertigo and psychological disturbances. The incidence of adverse effects is reported to range from 10% to 75%. The majority of adverse effects are not severe; most are dose related, transient and/or reversible. The main risks of oral baclofen administration are related to withdrawal: seizures, psychic symptoms and hyperthermia can occur. These symptoms improve after the reintroduction of baclofen, usually without sequelae. When not related to withdrawal; these symptoms mainly present in patients with brain damage and in the elderly. The limited data on baclofen toxicity in patients with renal disease suggest that administration of the drug in these persons may carry an unnecessarily high risk. Intrathecal baclofen is indicated for use in patients with spasticity of spinal origin unresponsive to treatment with maximum doses of oral baclofen, tizanidine and/or dantrolene. The benefits of continuous intrathecal baclofen infusion have been demonstrated: >80% and >65% of patients have improvement in tone and spasms, respectively. The main risks of intrathecal baclofen infusion are symptoms related to overdose or withdrawal; the latter is more important because of the associated severe effects on clinical status and the possibility of death, but it is responsive to rapid treatment. Overdose primarily arises from drug test doses or human error during refill and programming of the pump, and withdrawal most commonly occurs as a result of a problem with the delivery system. Since the adverse consequences do not exceed the benefits of oral and intrathecal baclofen for patients with spinal spasticity, the benefit/risk assessment is favourable.

Intrauterine baclofen exposure: a multidisciplinary approach

Maternal use of the antispasmodic baclofen during pregnancy is an uncommon clinical scenario and leads to uncertainty regarding neonatal risks. We present a team-based, peripartum management plan designed for safe monitoring and minimizing the risk of neonatal withdrawal after unusual drug exposure. Incorporating the expertise of neonatology, nursing, pharmacy, neurology, and the lactation service, as well as parental input, this consensus approach was implemented in a case of maternal oral baclofen use with a successful outcome for the infant and family.