Doctor's Corner - Women with Spinal Cord Injury (SCI) and pregnancy
96% of women with SCI said becoming a parent improved their quality of life. Therefore parenthood is still a possibility and with some special precautions an uneventful pregnancy and delivery can be achieved.
Pregnancy exacerbate most problems affecting women with SCI. Injuries resulting in lesions higher then T6 predisposes to autonomic dysreflexia (AD), increased spasms, breathing difficulties, bradycardia (reduced heart rate) and hypotension. Higher risk of pressure sores, recurrent bladder infections (UTI’s) and anemia.
In the United Kingdom there are 40 000 people with SCI and 26% are female. There is a chance of becoming pregnant due to difficulties with contraception, interaction with chronic medication and social situations putting them at risk of unwanted/unplanned pregnancies. Falling pregnant has a high risk due to other co-morbidities associated with spinal cord injuries.
A person with a SCI that is pregnant should be cared for by a team familiar with such high risk pregnancies and should include the following: an obstetrician, midwife, physiotherapist, occupational therapist and psychologist/psychiatrist if needed.
These pregnancies need to be planned after complete physical and emotional rehabilitation. It requires special care like continued physiotherapy, skin and bowel care. Women with SCI do not have an increased risk of miscarriages, congenital abnormalities or stillbirths. It is important to know where such a woman will deliver and what the mode of delivery most likely will be. If there are risks of unsuccessful normal delivery like the position of the baby, the size of the pelvis and in women who may have sustained the injury at a young age, a planned caesarean section need to be considered.
The antenatal care need to be individualized depending on many factors related to the pregnant woman and her injury. An injury above T3 will need admission and care in hospital until after the delivery. Fetal movement may be difficult to appreciate in women with a lesion above T10. There is a higher risk of malpresentation like breech, transverse lie due to lack of abdominal muscle control assisting with keeping baby in the correct position.
There may be an increased risk of blood clots in women where the injury is recent. The first 6 months carries the highest risk and will require blood thinning medication. Pregnancy is another very high risk for the development of deep vein thrombosis and immobility.
Lesions above T6 may need extra physiotherapy and even oxygen by using a pressure system and in severe cases mechanical ventilation may become necessary. This is decided by investigating lung volumes and capacity especially later in pregnancy where the increasing size of baby compromise breathing.
Blood pressure and pulse rates need to be taken at each consultation, tetraplegia (quads) have greater risk of these changes that may lead to a compromised baby.
Normal physiological changes during pregnancy may increase the risk of incontinence. Bladder infections due to increased need for emptying, repeated catheterization and the increasing size of the pregnancy. There may be a need for an indwelling catheter later in pregnancy due to decreased mobility, while a supra pubic catheter will need to be replaced closer to the time of a planned caesarean section to avoid contamination of the wound.
During pregnancy a bowel care routine becomes very important, especially because pregnancy and SCI cause significant constipation. This can be corrected by increasing fluid intake, fibre and occasionally laxatives or even digital evacuation
Pregnancy increases the likelihood of development of decubitus ulcers. This is due to the increased weight gain, relative immobility and tissue swelling. Prevention is better than cure so regular skin inspections, pressure relieving mattresses and regular turning for women spending more time in bed or are admitted to hospital.
Autonomic dysreflexia (AD)
AD is caused by a noxious stimulus below the lesion resulting in bradycardia and blood pressure changes, which can lead to an emergency. It can result in maternal intracranial bleeding, severe blood pressure changes causing fetal bradycardia and hypertensive episodes in the baby if untreated. Often an early labour epidural may prevent the above complications.
There is a 12% increase in spasms in pregnant women and the usual treatment of baclofen works better if administered via an intrathecal pump. Oral administration may result in neonatal withdrawal, irritability, poor feeding and even life threatening seizures.
Labour and delivery
There is no evidence to suggest women with SCI have an increased risk of preterm labour, but severe infection like a UTI or pressure sores can cause labour to commence. Low spinal lesions will have fairly painful contractions and the higher lesions make assessment of labour difficult and increase the risk of AD and spasms.
Some units would admit women at 36 weeks 6 days, in order to closely monitor for signs of labour as it may be difficult for women with SCI to appreciate labour. Women can also be given home monitors to demonstrate labour, or teach them what signs of labour are and show them how to palpate and feel for contractions.
First stage of labour (from onset of labour till full dilatation of the cervix)
Women who present early to hospital can have an early epidural done. This will assist with pain control.
During labour, bladder care is essential to avoid over distension and the side effects of bladder infection.
Pelvic examinations are done with great care and gently with a topical anesthetic cream. Electronic fetal monitoring can be used to monitor fetal well being; in some women the more accurate fetal scalp monitoring is performed. Fetal scalp pH can also be used with great accuracy to decide the safest time to deliver the baby.
Care should be taken to identify, treat and prevent bladder infections, spasms, AD and pressure care.
Second stage of labour (from full dilatation to delivery)
Spasms may complicate delivery and as such the correct position makes everything easier. Lithotomy position may be the best way to ensure safe delivery of the baby. Instrumental delivery like vacuum and forceps may become necessary especially if the person is not able to help with pushing.
Third stage and fourth
(from delivery of baby until 1 hour after the delivery of the placenta)
The delivery of the placenta is done with active maneuvers and potent uterotonic drugs. If not, it can lead to postpartum hemorrhage, a leading cause of maternal mortality.
Caesarean section should only be done for obstetric indications. The recovery after a surgical delivery requires meticulous nursing care to prevent a UTI, pressure sores and AD. Early mobilization can be achieved by the use of a physiotherapist. Thromboprophylaxis is important and after 10 days sutures need to be removed.
Breastfeeding can be achieved as normal, but in lesions above T4 will need extra help, and baclofen is safe during breastfeeding. Contraception is important and as previously discussed is required to prevent unwanted pregnancies.
SCI during pregnancy
In a country like ours the possibility of someone being pregnant and sustaining a SCI is not impossible. Important things include the increased risk of having a miscarriage, because rehab will not have been completed as yet and the best way to manage such a pregnancy is safer as an inpatient. Blood thinners are important, especially in the early stages of the injury.
Higher lesions are more likely to the development of complications. This situation is best handled in a multi disciplinary unit and if indicated the services of a psychiatrist may be needed.