Vaginal delivery is safely achieved in pregnancies complicated by spinal cord injury: a retrospective 25-year observational study of pregnancy outcomes in a national spinal injuries centre

Obstetric and neonatal outcomes in people who acquired a spinal cord injury during pregnancy

OBJECTIVE

(s):The objectives of this study were to determine the obstetric and neonatal outcomes of people who acquired spinal cord injuries (SCI) during pregnancy.

METHODS

This is part of an international observational questionnaire examining pregnancy outcomes of people with SCI. The outcome measures included demographics, such as level of injury and American Spinal Injury Association (ASIA) scores, prenatal and postnatal complications, and neonatal outcomes.

RESULTS

Of 780 responses, 14 (1.79%) participants reported acquiring an SCI while pregnant. 64.2% (9/14) of injuries were due to trauma. Of 14 pregnancies, 1 person miscarried and 3 pregnancies were terminated. There were 11 live births. One participant had twins and 9 live births were singletons. Six participants delivered vaginally, 3 had cesarean delivery (CD) and 1 was unreported. The preterm birth (PTB) rate was 54.5% (6/11). Approximately 36% (4/11) of newborns were admitted to the neonatal intensive care unit (NICU). The average birthweight reported was 2409.7g (453.6-3458.6g). Forty percent (4/10) of participants reported experiencing postpartum blues or depression. Sixty percent (6/10) of participants breastfed for over 2 weeks.

CONCLUSION

(s):This is the largest known cohort to date of individuals acquiring SCI during pregnancy. The most common cause of SCI was motor vehicle accident. Complications included PTB and NICU admission. People who have an SCI during pregnancy are at risk for complications, however positive pregnancy and neonatal outcomes are possible. Absolute small numbers of this event limit the ability to assess incidence of outcomes.

OBJECTIF

Les objectifs de cette étude étaient de déterminer les issues obstétricales et néonatales des personnes ayant subi une lésion de la moelle épinière pendant la grossesse. MéTHODOLOGIE: L'étude fait partie d'un questionnaire d'observation international examinant les issues de grossesse de personnes atteintes d'une lésion de la moelle épinière. Les critères de jugement concernaient les caractéristiques démographiques, telles que le niveau de la lésion et les scores de l'American Spinal Injury Association (ASIA), les complications prénatales et postnatales ainsi que les issues néonatales. RéSULTATS: Des 780 réponses, 14 (1,79 %) participantes ont signalé avoir subi une lésion de la moelle épinière pendant leur grossesse. De ce nombre, 64,2 % (9/14) des lésions étaient dues à un trauma. Pour ces 14 grossesses, 1 personne a eu un avortement spontané et 3 grossesses ont été interrompues. Il y a eu 11 naissances vivantes issues de 1 grossesse gémellaire et de 9 grossesses monofœtales. Les accouchements se sont faits par voie vaginale dans 6 cas et par césarienne dans 3 cas, le mode d'accouchement n'ayant pas été déclaré pour 1 de ces naissances vivantes. Le taux de prématurité était de 54,5 % (6/11). Environ 36 % (4/11) des nouveau-nés ont été admis aux soins intensifs néonataux. Le poids moyen rapporté à la naissance était de 2 409,7 g (453,6-3 458,6 g). Quarante pour cent (4/10) des participantes ont signalé avoir souffert de dépression ou du blues du post-partum. Soixante pour cent (6/10) des participantes ont allaité pendant plus de 2 semaines.

CONCLUSION

Il s'agit de la plus importante cohorte connue à ce jour de personnes ayant subi une lésion de la moelle épinière pendant la grossesse. L'accident d'automobile était la plus importante cause de lésion de la moelle épinière. Les complications observées comprennent l'accouchement prématuré et l'admission aux soins intensifs néonataux. Quoique les personnes qui subissent une lésion de la moelle épinière pendant la grossesse soient à risque de complications, les issues obstétricales et néonatales positives sont possibles. Le faible nombre absolu de ces événements limite la capacité d'évaluer la fréquence des issues.

Anaesthetic management of tetraplegic pregnant patients during child delivery: A systematic review

BACKGROUND

Pregnancy in spinal cord injured patients has specific issues that must be carefully addressed. However, guidelines for their management are scarce.

METHODS

A systematic review of the literature regarding the anaesthetic management during delivery of pregnant patients with cervical spinal cord injury was performed on the electronic databases of PubMed (Medline) and Cochrane.

RESULTS

Twenty-two papers were included. A higher incidence of preterm birth and caesarean delivery were seen. Anaesthetic management was diverse, although most pregnant patients received epidural analgesia. Autonomic dysreflexia symptoms were present in 51% of pregnancies.

CONCLUSION

Timely management of these patients could possibly reduce caesarean and preterm delivery rates, avoid or minimize common complications, as well as reduce costs. An early reference to anaesthesiology consultation and a multidisciplinary approach is recommended.

Pregnancy and multiple sclerosis: 2022 recommendations from the French multiple sclerosis society

OBJECTIVE

The objective of this study was to develop evidence-based recommendations on pregnancy management for persons with multiple sclerosis (MS).

BACKGROUND

MS typically affects young women in their childbearing years. Increasing evidence is available to inform questions raised by MS patients and health professionals about pregnancy issues.

METHODS

The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and university databases (January 1975 through June 2021). The RAND/UCLA appropriateness method was developed to synthesise the scientific literature and expert opinions on healthcare topics; it was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence.

RESULTS

A strong agreement was reached for all 104 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, locoregional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses and disease-modifying treatments.

CONCLUSION

The 2022 recommendations of the French MS society should be helpful to harmonise counselling and treatment practice for pregnancy in persons with MS, allowing for better and individualised choices.

Pregnancy, delivery, and neonatal outcomes among women with spinal cord injury in Sweden 1997-2015: A population-based cohort study

INTRODUCTION

The aim of this study was to describe the rate of pregnancy in spinal cord injured women in Sweden as well as pregnancy, delivery, and neonatal outcomes.

MATERIAL AND METHODS

This study was based on data from the Swedish Medical Birth Register and the National Patient Register. The study population included women with spinal cord injury who gave birth in Sweden during the period 1997 to 2015. The general population was used as reference and included all non-spinal cord injured patients who gave birth during the same period of time.

RESULTS

In the spinal cord injury group, 109 births were identified. Eighty-nine (82%) of them were among paraplegic women and 20 (18%) were among tetraplegic women. Women with spinal cord injury in our study population had urinary tract infections during pregnancy in five cases (5%) and anemia during pregnancy in nine cases (8%), compared with 0.2% and 4%, respectively, in the general population. Compared with the general population more deliveries were induced in the study population, 18 (17%) in the spinal cord injury group and 12% in the general population. Vaginal delivery was achieved in 52 (48%) of the births with 42 of them (39%) being non-instrumental and 10 (9%) being instrumental vaginal deliveries. Elective cesarean section rate was 34% (n = 37). Sixteen infants (15%) were born preterm (gestational week <37). We found an overall low rate of pregnancy and delivery complications.

CONCLUSIONS

Our results show predominantly favorable outcomes of pregnancy and delivery in women with spinal cord injury as well as their infants. These results are in concordance with previous research.

Pathophysiology, Classification and Comorbidities after Traumatic Spinal Cord Injury

The spinal cord is a conduit within the central nervous system (CNS) that provides ongoing communication between the brain and the rest of the body, conveying complex sensory and motor information necessary for safety, movement, reflexes, and optimization of autonomic function. After a spinal cord injury (SCI), supraspinal influences on the spinal segmental control system and autonomic nervous system (ANS) are disrupted, leading to spastic paralysis, pain and dysesthesia, sympathetic blunting and parasympathetic dominance resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions and uncontrolled bowel, bladder, and sexual dysfunction. This article outlines the pathophysiology of traumatic SCI, current and emerging methods of classification, and its influence on sensory/motor function, and introduces the probable comorbidities associated with SCI that will be discussed in more detail in the accompanying manuscripts of this special issue.

Autonomic Dysfunction and Management after Spinal Cord Injury: A Narrative Review

The autonomic nervous system (ANS), composed of the sympathetic and parasympathetic nervous systems, acts to maintain homeostasis in the body through autonomic influences on the smooth muscle, cardiac muscles, blood vessels, glands and organs of the body. The parasympathetic nervous system interacts via the cranial and sacral segments of the central nervous system, and the sympathetic nervous system arises from the T1–L2 spinal cord segments. After a spinal cord injury (SCI), supraspinal influence on the ANS is disrupted, leading to sympathetic blunting and parasympathetic dominance resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions and uncontrolled bowel, bladder, and sexual dysfunction. Further, afferent signals to the sympathetic cord elicit unabated reflex sympathetic outflow in response to noxious stimuli below the level of SCI. This article outlines the pathophysiology of SCI on the ANS, clinical ramifications of autonomic dysfunction, and the potential long-term sequelae of these influences following SCI.

Outcomes of pregnancy and delivery in women with continent lower urinary tract reconstruction: systematic review of the literature

INTRODUCTION AND HYPOTHESIS

The aim of this systematic review of the literature was to pool all the existing data regarding pregnancy and delivery in women with neurogenic bladder or bladder exstrophy who had undergone previous lower urinary tract reconstruction (LUTR).

METHODS

We conducted a systematic review of the literature from PubMed/MedLine, ClinicalTrials.gov and the Google Scholar database, from 1972 to July 2020. Fifty articles were included, of which 25 contained data that could be pooled (229 women representing 292 pregnancies).

RESULTS

Ninety-eight women had bladder exstrophy (43%), 58 had spinal dysraphism (25%), 14 had spinal cord injury (6%), and 59 presented other pathological conditions. Of these, 138 have had an augmentation cystoplasty (61%), 42 (18%) had a continent cutaneous urinary diversion, and 31 had an artificial urinary sphincter (14%). During their pregnancy, 97 women (33%) experienced at least one febrile urinary tract infection. Thirty-one women (11%) required ureteral stenting or nephrostomy placement for upper urinary tract dilatation. Forty-six pregnancies ended with premature delivery (16%). Delivery mode was by C-section for 108 patients (62%) and vaginal delivery for 104 (36%). Twenty complications were reported during delivery (mainly urological), of which 19 occurred during C-section. Nine women experienced postpartum urinary incontinence (4%); in 5 of then this was due to urinary fistulae secondary to complicated C-section.

CONCLUSIONS

Pregnancy and vaginal delivery are possible for women with LUTR who have no obstetric or medical contraindications, except for some particular cases of bladder exstrophy. However, these high-risk pregnancies and deliveries should be managed by a specialist multidisciplinary team.

Spinal cord injury and pregnancy

Pregnancy in women with spinal cord injury is considered high risk because it may exacerbate many of their existing problems, including autonomic dysreflexia, spasms, decubitus ulcers, urinary tract infections and respiratory infections. Due to the relative rarity of spinal cord injury in the general obstetric population, clinicians often lack familiarity of these specific problems and the women themselves are usually more experienced in their own management than their obstetric team. However, studies have demonstrated that pregnancy outcomes are generally good with appropriate and experienced obstetric care. In this review, we examine the available literature and provide advice on pre-conception counselling and the antenatal, intrapartum and postnatal management of pregnant women with spinal cord injury.

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.