Transcript Postpartum autonomic dysreflexia

S
M
M
SMFM Consult Series
Pregnancy in women with
spinal cord injuries
Society of Maternal Fetal Medicine with the assistance of
Caroline Signore, MD
Published in Contemporary Obgyn Febbruary 2012
Antenatal Care: SCI
 Most gravidas with SCI will experience few serious
complications of pregnancy and will deliver healthy
infants.
 No Reason to discourage or terminate a pregnancy
simply on the basis of a maternal SCI.
 Antenatal care should be provided by a
multidisciplinary teaam:
 Obstetrician and/or maternal-fetal medicine
specialist
 Neurologist
 Physiatrist,
 Urologist
 Obstetric anesthesiologist
 Nurses
 Physical and occupational therapists
S
M
M
Antenatal Care SCI Management: Urinary dysfunction





Chronic urinary dysfunction related to neurogenic bladder
Many women with lower lesions are capable of, and should perform,
intermittent self-catheterization. Indwelling urethral or suprapubic
catheters are the norm among women with tetraplegia (eg,
quadriplegia: loss of sensory and muscular use of both upper and
lower extremities).
Women with SCI may experience pregnancy-related changes in
bladder function and management:
 Increases in bladder spasms
 Need for more frequent catheterization
 Leakage around indwelling catheters
Self-catheterization is the preferred approach throughout pregnancy
because of the increased risks of urinary tract infection (UTI) with
chronic indwelling catheters.
Up to 25% of women with SCI may require a change in bladder
management because of chronic urine leakage and/or bladder
spasms (eg, expelling indwelling catheter); thus, referral for urology or
urogynecology consultation may be useful in these situations
S
M
M
Antenatal Care SCI Management: UTI
 Asymptomatic bacteriuria occurs in the majority of
pregnant women with SCI.
 In a general obstetric population, the frequency of
asymptomatic bacteriuria is 2% to 7%, and without
treatment, 30% to 40% of these women will progress to UTI.
 American College of Obstetricians and Gynecologists
(ACOG) Committee Opinion on SCI in pregnancy suggests
that frequent urine cultures or antibiotic suppression are
indicated
 Urine cultures for the detection of asymptomatic bacteriuria
can be done monthly or once per trimester, depending on
the frequency of positive cultures and prior infections
 Chronic antibiotic suppression may be considered for
women with recurrent UTIs and/or indwelling catheters.
 Antibiotic regimens should be directed on the basis of
culture results; commonly used agents include nitrofurantoin
and trimethoprim-sulfamethoxazole
S
M
M
Antenatal Care SCI Management: Decubitus Ulcer
 Decubitus ulcers occur in 5% to 10% of women with SCI
 Contributing factors that increase risk of skin breakdown in
pregnancy include:
 Gestational weight gain
 Inadequately sized or cushioned wheelchairs or other
medical equipment
 Dependent edema
 Anemia
 Poor nutrition
 Smoking
 Patients should be advised to change positions and perform
pressure-relief maneuvers regularly and to inspect equipment
for appropriate fit and padding
 Frequent skin inspections at home and during office visits are
recommended.
 If there is evidence or concern for skin breakdown or potential
injury, communication with the patient's physical medicine
and/or rehabilitation team is warranted
S
M
M
Antenatal Care SCI Management: Respiratory System
 Baseline respiratory function may be impaired in SCI
because of weakened respiratory musculature or
chest deformity from posttraumatic kyphoscoliosis,
especially those women with higher thoracic or
cervical lesions (eg, above T5).
 Respiratory impairment may be exacerbated by
pregnancy, with the gravid uterus further limiting
diaphragmatic excursion. Supine positioning may
worsen symptoms.
 In selected women with SCI, baseline and serial
pulmonary function tests may be performed to assess
vital capacity and the possible need for ventilator
support during labor (eg, if vital capacity is <13 mL/kg)
 Referral to a pulmonologist may be appropriate for
women with chronic respiratory symptoms and those
with lower vital capacity
S
M
M
Antenatal Care SCI Management: Preterm labor
 Women with SCI above T10 may not perceive the
pain of uterine contractions and are therefore at
risk of unattended preterm or term birth.
 Increased risk of preterm birth (21% to 27%)
among women with SCI
 Women and/or their caregivers should be
instructed how to palpate for uterine contractions
 They also should be advised they may experience
unique indicators of labor, such as increases in
spasticity, symptoms of autonomic dysreflexia
(AD), referred pain above-the-cord lesion, or
shortness of breath.
S
M
M
Antenatal Care SCI Management: Venous
Tromboembolism
 The combination of impaired mobility and the
hypercoagulable state of pregnancy raises
concern for thromboembolic disease in women
with SCI
 There is insufficient data to recommend universal
pharmacological thromboprophylaxis (eg, low
molecular weight heparin) during pregnancy of
all women with SCI
 Pharmacologic treatment should be
individualized based on patient medical history
and physical limitations
S
M
M
Antenatal Care SCI Management: Fetal Risks
 Among women with SCI prior to conception,
there does not appear to be an increased risk of
fetal malformations, miscarriage, or stillbirth
 Common concern in SCI pregnancy is fetal
exposure to maternal medications. Ideally,
women with SCI should receive preconception
counseling so that risks and benefits of continuing
medication use can be discussed.
 In general, most medications given to women
with SCI can be safely continued during
pregnancy, but the maternal-fetal medicine
specialist should be contacted when new
medications are considered or with changes in
dosing regimens
S
M
M
Intrapartum Management: Autonomic Dysreflexia









AD, is a potentially life-threatening syndrome
AD: marked hypertension and cardiac dysrhythmias
AD is common during pregnancy in women with spinal cord lesions at T6 or higher (85%), but
has been reported with lower-level injuries (20% of women with thoracic lesions)
The condition is precipitated by a strong or noxious stimulus below the level of the spinal
lesion (eg, distension of bladder or bowel, or vaginal examination) that initiates an
uncontrolled reflex sympathetic response. Uterine contractions also can be a potent inciting
factor.
The hypertension associated with AD can be extreme and must be differentiated from that
of preeclampsia so that appropriate therapy can be initiated.
 A key difference is that in AD, blood pressure tends to normalize between contractions,
whereas blood pressure elevations in preeclampsia are more persistent.
Other signs and symptoms of AD include maternal bradycardia or tachycardia, headache,
flushing, piloerection, nasal congestion, diaphoresis, and anxiety.
The severity of AD can range from mildly aggravating symptoms to a hypertensive crisis
leading to encephalopathy, cerebral or retinal hemorrhage, coma, and death. Maternal
vasoconstriction can lead to acute uteroplacental insufficiency.
Prevention should be the first goal of management of AD
Induction of regional anesthesia early in labor is the preferred preventive strategy, and has
been shown to be effective in decreasing the severity of AD. Because of the risk of AD,
several experts recommend that women with SCI should deliver in a unit capable of invasive
hemodynamic monitoring.1,13 Cesarean delivery may be required if AD symptoms,
especially malignant hypertension, cannot be controlled with pharmacotherapy.
S
M
M
Intrapartum Management: Labor & Delivery
 If cervical ripening is required, regional anesthesia
should be considered at the outset.
 Proper cushioning in bed, regular changes in position,
and frequent skin inspections during labor are
imperative to avoid skin breakdown and/or decubitus
ulceration.
 Women with SCI are capable of vaginal delivery,
though some may require operative vaginal delivery
to compensate for weaker voluntary expulsive ability
in the second stage and/or to manage autonomic
dysreflexia.
 A number of reports suggest an increased rate of
cesarean delivery among parturients with SCI, but it is
not clear whether these are performed for standard
obstetric indications, especially malignant
hypertension, cannot be controlled with
pharmacotherapy.
S
M
M
Postpartum Care: Patients with SCI



Postpartum autonomic dysreflexia
 Careful blood pressure monitoring should continue after delivery.
 Care should be taken to avoid bladder distension, another
common precipitant of AD.
 During the immediate recovery phase (12 hours for vaginal and 24
hours for cesarean delivery), short-term placement of an indwelling
Foley catheter may decrease this risk.
 Bowel regimen should be restarted to avoid complications related
to constipation.
Perineal care
 Because of diminished perineal sensation in women with SCI, ice
packs or heating pads for perineal care in the postpartum unit
should be used with caution. A bowel program that relies on digital
stimulation will need to be modified in the setting of a third- or
fourth-degree laceration repair to permit adequate healing.
Lactation
 Breastfeeding should be encouraged for women with SCI.
S
M
M
Management: Summary
S
M
M
S
M
M
References



















1. Pereira L. Obstetric management of the patient with spinal cord injury. Obstet Gynecol Surv. 2003;58(10):678-687.
2. Signore C, Spong CY, Krotoski D, Shinowara NL, Blackwell SC. Pregnancy in women with physical disabilities. Obstet Gynecol. 2011;117(4):935-947.
3. American College of Obstetricians and Gynecologists. ACOG Committee Opinion: No. 275, September 2002. Obstetric management of patients
with spinal cord injuries. Obstet Gynecol. 2002;100(3):625-627.
4. Jackson AB, Wadley V. A multicenter study of women's self-reported reproductive health after spinal cord injury. Arch Phys Med Rehabil.
1999;80(11):1420-1428.
5. Pannek J, Bertschy S. Mission impossible? Urological management of patients with spinal cord injury during pregnancy: a systematic review. Spinal
Cord. 2011;49(10):1028-1032.
6. Gilstrap LC 3rd, Ramin SM. Urinary tract infections during pregnancy. Obstet Gynecol Clin North Am. 2001;28(3):581-591.
7. Jackson AB, Lindsey LL, Klebine PL, Poczatek RB. Reproductive health for women with spinal cord injury: pregnancy and delivery. SCI Nurs.
2004;21(2):88-91.
8. James A; American College of Obstetricians and Gynecologists, Committee on Practice Bulletins—Obstetrics. ACOG Practice bulletin no. 123:
thromboembolism in pregnancy. (Replaces Practice Bulletin No. 19, August 2000). Obstet Gynecol. 2011;118(3):718-729.
9. Teasell RW, Hsieh JT, Aubut JA, Eng JJ, Krassioukov A, Tu L; Spinal Cord Injury Rehabilitation Evidence Review Research Team. Venous
thromboembolism after spinal cord injury. Arch Phys Med Rehabil. 2009;90(2):232-245.
10. Krassioukov A, Eng JJ, Warburton DE, Teasell R; Spinal Cord Injury Rehabilitation Evidence Research Team. A systematic review of the management
of orthostatic hypotension after spinal cord injury. Arch Phys Med Rehabil. 2009;90(5):876-885.
11. Gimovsky ML, Ojeda A, Ozaki R, Zerne S. Management of autonomic hyperreflexia associated with a low thoracic spinal cord lesion. Am J Obstet
Gynecol. 1985;153(2):223-224.
12. Krassioukov A, Warburton DE, Teasell R, Eng JJ; Spinal Cord Injury Rehabilitation Evidence Research Team. A systematic review of the management
of autonomic dysreflexia after spinal cord injury. Arch Phys Med Rehabil. 2009;90(4):682-695.
13. Baker ER, Cardenas DD, Benedetti TJ. Risks associated with pregnancy in spinal cord-injured women. Obstet Gynecol. 1992;80(3 Pt 1):425-428.
14. Hughes RB, Nosek MA, Robinson-Whelen S. Correlates of depression in rural women with physical disabilities. J Obstet Gynecol Neonatal Nurs.
2007;36(1):105-114.
15. Alexander CJ, Hwang K, Sipski ML. Mothers with spinal cord injuries: impact on marital, family, and children's adjustment. Arch Phys Med Rehabil.
2002;83(1):24-30.
16. Ghidini A, Healey A, Andreani M, Simonson MR. Pregnancy and women with spinal cord injuries. Acta Obstet Gynecol Scand. 2008;87(10):10061010.
17. Burns AS, Jackson AB. Gynecologic and reproductive issues in women with spinal cord injury. Phys Med Rehabil Clin N Am. 2001;12(1):183-199.
18. Westgren N, Hultling C, Levi R, Westgren M. Pregnancy and delivery in women with a traumatic spinal cord injury in Sweden, 1980-1991. Obstet
Gynecol. 1993;81(6):926-930.
19. Westgren N, Levi R. Motherhood after traumatic spinal cord injury. Paraplegia. 1994;32(8):517-523.
Society for Maternal-Fetal Medicine
Disclaimer
 The practice of medicine continues to
evolve, and individual circumstances will
vary. This opinion reflects information
available at the time of its submission for
publication and is neither designed nor
intended to establish an exclusive
standard of perinatal care. This
presentation is not expected to reflect the
opinions of all members of the Society for
Maternal-Fetal Medicine.
 These slides are for personal, noncommercial and educational use only
S
M
M
Disclosures
 This opinion was developed by the Publications Committee
of the Society for Maternal Fetal Medicine with the
assistance of Stanley M. Berry, MD, Joanne Stone, MD, Mary
Norton, MD, Donna Johnson, MD, and Vincenzo Berghella,
MD, and was approved by the executive committee of the
society on March 11, 2012. Dr Berghella and each member
of the publications committee (Vincenzo Berghella, MD
[chair], Sean Blackwell, MD [vice-chair], Brenna Anderson,
MD, Suneet P. Chauhan, MD, Jodi Dashe, MD, Cynthia
Gyamfi-Bannerman, MD, Donna Johnson, MD, Sarah Little,
MD, Kate Menard, MD, Mary Norton, MD, George Saade,
MD, Neil Silverman, MD, Hyagriv Simhan, MD, Joanne Stone,
MD, Alan Tita, MD, Michael Varner, MD) have submitted a
conflict of interest disclosure delineating personal,
professional, and/or business interests that might be
perceived as a real or potential conflict of interest in relation
to this publication.
S
M
M