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Prevention of AD during Pregnancy and Labour

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In North America, women represent a third of the SCI population (Ackery et al. 2004).  Approximately 3,000 American women of childbearing age are affected by SCI (Cross et al. 1992).  The ability of women to have children is not usually affected by SCI once their menstrual cycle resumes (Jackson & Wadley 1999).  There are increasing numbers of women with SCI who have healthy babies (Cross et al. 1992).  However, during labour and delivery, susceptible women with SCI are at high risk of developing uncontrolled AD (Sipski 1991; Sipski & Arenas 2006).  Recognition and prevention of this life threatening emergency is critical for managing labour in women with SCI (McGregor & Meeuwsen 1985). The majority of women with SCI above T10 experience uterine contractions as only abdominal discomfort, an increase in spasticity and AD (Hughes et al. 1991).

Table 9:  Prevention of AD during Pregnancy and Labour

Discussion

Numerous observational studies, case reports and expert opinions recommend adequate anesthesia in women with SCI during labour and delivery despite the apparent lack of sensation.  However, there are only five studies (n=59) (Cross et al. 1992; Hughes et al. 1991; Cross et al. 1991; Ravindran et al. 1981; Skowronski & Hartman 2008) with observational evidence recording the management specific to AD during labour.  The American College of Obstetrics and Gynecology emphasized that it is important that obstetricians caring for these patients be aware of the specific problems related to SCI (American College of Obstetrics and Gynecology 2002).

Conclusion

There is level 4 evidence that women with SCI may safely give birth vaginally.  With vaginal delivery or when Caesarean delivery or instrumental delivery is indicated, adequate anesthesia (spinal or epidural if possible) is needed to reduce the episodes of AD associated with birth. 

There is level 4 and 5 evidence (from 2 case series and 2 observational studies) (Cross et al. 1992; Hughes et al. 1991; Cross et al. 1991; Showronski & Hartman 2008) that epidural anesthesia is preferred and effective for most patients with AD during labour and delivery.

  • Adequate anesthesia (spinal or epidural if possible) is needed with vaginal delivery,
    Caesarean delivery or instrumental delivery.

    Epidural anesthesia is preferred and effective for most women
    with AD during labour and delivery.