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Prevention of AD during Pregnancy and Labour

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 10: Prevention of AD during Pregnancy and Labour

Author Year; Country
Score
Research Design
Sample Size
MethodsOutcome
Sharpe et al. 2015

USA

Case Series

N=8

Population: Eight patients with SCI undergoing nine deliveries

Median time from injury to time of delivery = 13 years (range 2–19 years)

ASIA A=6, ASIA B=1, ASIA D=1

Pre-pregnancy AD: n=4

 

Treatment: 5 with epidural anesthesia, 2 with spinal anesthesia, 2 with general anesthesia

 

Outcome Measures:

Outcomes of pregnancies, presence of AD

1.     Only patients with previous AD episodes presented AD symptoms during peripartum period.

2.     Of the 4 patients with pre-pregnancy AD, 3 had AD symptoms peripartum.

3.     One experienced AD during epidural placement, one during the second stage of labor, and all 3 experienced AD in the postpartum period.

4.     No blood pressure measurements were recorded during these episodes, suggesting staff may not be aware of risk of AD in SCI patients

Skowronski & Hartman 2008;

Australia

Case series

N=5

Population: 5 females with tetraplegia who gave birth a total of 7 times (two subjects gave birth twice).

Treatment: N/A

Outcome Measures: Complication, management, and outcomes of pregnancy; hospital records.

1.     AD occurred in 6 of 7 pregnancies.

2.     AD was managed pre-emptively by insertion of an epidural either before or in the early stages of labour, with generally good results

3.     Dangerously high peaks were managed by the administration of either sublingual nifedipine or intramuscular clonidine.

4.     Other major complications include urinary tract infection (present in all pregnancies) and muscle spasms (4 of 7 pregnancies).

Cross et al. 1992;

USA

Case series

N=22

Population: 22 women with SCI, 11 with cervical and 11 with thoracic injuries; 10 with incomplete and 12 with complete injuries.

Treatment: epidural anesthesia.

Outcome Measures: presence of autonomic hyperreflexia, type of anesthesia, type of delivery, complications.

1.     AD was experienced in 9/16 > T6.

2.     One patient had two grand mal seizures during labour, which may have been triggered by her severe AD and the subsequent intravenous administration of diazepam.

3.     Six patients had epidural anesthesia, which was effective for the control of AD.

Cross et al. 1991;

USA

Observational

N=16

Population: 7 subjects with cervical and 9 with thoracic injuries.

Treatment: questionnaire (in person or telephone) and hospital records review.

Outcome Measures: outcomes of pregnancies.

1.     Of the 16 women, 25 pregnancies occurred, resulting in 22 babies and 3 abortions.

2.     2/15 vaginal deliveries and 5/7 Caesarean section had AD during delivery with 4 of these receiving epidural anesthesia for the control of AD.

3.     1 patient required epidural catheter 5 days postpartum to control AD.

Hughes et al. 1991; UK

Observational

N=15

Population: 17 pregnancies in 15 women with SCI, level of injury: T4-L3.

Treatment: management and outcome of pregnancies in women with SCI.

Outcome Measures: antenatal care and problems, labour diagnosis and outcome.

1.     Labour tended to be diagnosed by dysreflexic symptoms or membrane rupture with confirmation by palpation of contractions and vaginal examination.

2.     Initial management of AD included elevation of head of the bed, nifedipine and nitrates.

3.     The most effective measure for controlling AD was to identify and interrupt the triggering afferent input to the spinal cord.

Ravindran et al. 1981; USA

Case report

N=1

Population: 19 yr-old female with C5 complete tetraplegia admitted to the obstetrical intensive care unit for intra-amniotic prostaglandin F2-alpha injection for uterine evacuation of a dead fetus of 20 wks gestation.

Treatment: Sodium nitroprusside (100 mg/min to 700 mg/min).

Outcome measures: BP and AD symptoms.

1.     100 mg/min of sodium nitroprusside decreased SBP from 170 mmHg to 120 mmHg caused by vaginal speculum introduction.

2.     Prostaglandin induced uterine contraction further elevated BP to 200/70 mmHg; headache and sweating.

3.     Administration of 700 mg/min of sodium nitroprusside decreased SBP and alleviated AD.

4.     Following cessation of uterine contraction, the patient developed hypotension (70/30 mmHg) requiring vasopressor therapy.

5.     Sodium nitropruside was stopped and epidural analgesia was initiated for further management of AD.

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 six studies (n=67) (Cross et al. 1992; Hughes et al. 1991; Cross et al. 1991; Ravindran et al. 1981; Skowronski & Hartman 2008, Sharpe et al. 2015) 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 3 case series and 2 observational studies) (Cross et al. 1992; Hughes et al. 1991; Cross et al. 1991; Showronski & Hartman 2008, Sharpe et al. 2015) 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.