Common Problems During Pregnancy: Canadian Paraplegic Association

Common Problems During Pregnancy

Exerpt from Journal: Arch Phys Med Rehabil 1996; 77:501-7
Baker E, Cardenas D

Some of the problems spinal cord injured women face in pregnancy are the same as those faced by other women, but occur with greater frequency.

It's essential that physicians who treat pregnant women for spinal cord injury bear in mind what every obstetrician knows: that pregnant women are not like other people, and their physiological functions -- even the composition of their blood -- is different from what would normally be expected. They should not be unduly alarmed by a drop in blood pressure in their spinal cord injured patient during the second trimester, since that, too, is a normal and temporary condition of pregnancy. Urinary tract infections

Infections of the urinary tract are more common in women with spinal cord injury because they do not empty their bladders as completely as other women. Moreover, the presence of catheters and other foreign elements used to control or divert urine flow makes some form of infection more likely than not. The infection is generally harmless but can lead to pyelonephritis, an inflammatory infection of the pelvis and kidneys that can bring on premature labour. Pyelonephritis can even cause sepsis (pus-forming infection) or respiratory distress in some cases. The best way to avoid this condition is to check for the presence of bacteria in the urine even when there is no evidence of symptoms, because this "asymptomatic bacteruria" usually precedes a more serious infection. In some cases, antibiotics may be called for.

Anemia

The blood of pregnant women is generally more diluted than that of other adults, and that is generally believed to be beneficial. But when there are too few red blood cells, it means that not enough oxygen is being carried in the blood. This condition is called anemia, and is often a result of an iron deficiency. In and of itself, anemia does not appear to have a dramatic impact on pregnancy, but it does fatigue the patient and greatly increases the chances of bedsores and pressure sores appearing -- no laughing matter in a pregnant woman with spinal cord injury (see below). Anemia also compounds the problems caused by the blood loss associated with delivering a child, and may make transfusion necessary. Anemia is usually treated with iron supplements, but such supplements can aggravate constipation, often already a problem in people with spinal cord injury.

Spasticity

Spasticity means a tendency to spasm; it refers to the state of activation that comes over muscles at times, and is the opposite of elasticity. There are medications that treat spasticity and restore normal muscle tone, but some of these drugs are not compatible with pregnancy or breast-feeding. Special care must be taken in choosing the correct treatment.

Decubitus ulcers

The technical term for what most people call bedsores. This is an example of a complication that really has more to do with spinal cord injury, rather than pregnancy. Pregnancy, however, increases the weight load and decreases mobility, both factors that contribute to bedsores. This preventable infection became so severe in one reported case that a woman was forced to undergo below-knee amputation. The solution is frequent skin examinations, pressure relief techniques, and attention to patient comfort. A more accommodating wheelchair, for example, can reduce risk.

Deep venous thrombosis and pulmonary embolism

Although pregnant women's blood has lower hematocrit (i.e. fewer red blood cells) and is more diluted, it is also more prone to clotting. Theoretically, that should increase the risk of thromboembolic disease, or clots and blockages of blood vessels. In practice, however, this problem does not appear to be so common as to justify the use of anticoagulant drugs on a prophylactic basis unless other risk factors, such as a history of such problems or oral contraceptive use, are also present. If such treatment is needed, the drug of choice is heparin, because it doesn't cross the placenta to the fetus.

Pulmonary function

Spinal cord injury can impair breathing in patients if the lesions are on the thoracic or cervical spine (the parts of the spine that support the thorax and neck, respectively). Pregnancy and labour impose an extra demand for oxygen that may make some kind of support necessary. This may mean a mechanical ventilator.

Autonomic hyperreflexia

This is the most significant complication associated with spinal cord injury, affecting at some point as many as 85% of patients with injury above the fifth and sixth vertebrae. The condition also commonly affects pregnant patients with spinal cord injury. This syndrome's effects range from mildly annoying symptoms to possible intracranial hemorrhage, resulting in death. There is little evidence that the fetus suffers any harm during bouts of hyperreflexia. Anti-hypertensive drugs can be used to reduce the risk of serious complications arising from this condition, which can also be treated with anesthesia. Care must be taken, however, to avoid hypotension or hypoxemia (lack of oxygen in blood), both of which the fetus is ill-equipped to handle. Over the years, a consensus has arisen among physicians that local anesthetic, administered epidurally, is the best course for treating this condition. Women with injuries above the sixth vertebrae should be cared for, and give birth in, a hospital with the equipment and physicians needed to deal with autonomic hyperreflexia, just in case.

Preterm labour

The great fear of physicians monitoring spinal cord injury patients who are pregnant is that they will go into labour while unattended, particularly because premature delivery is more common in such patients. Most spinal cord injury patients can perceive the beginnings of labour, though they experience it differently from uninjured women unless the degree of paraplegia is very low. Physicians should offer advice on what sensations might indicate labour, and possibly training in the technique of uterine palpation. Other options for surveillance for labour include routine weekly cervical examinations, hospitalization late in the pregnancy, or home uterine contraction monitoring.

Delivery

When the time to deliver the baby finally arrives, most spinal cord injured women will find that they do not need cesarean section; the proportion is only slightly higher than the 25% or so among the general population. The uterus should be able to its job normally, though pushing power may be lacking for the final delivery. In such cases, forceps delivery or vacuum extraction are sometimes used to bring the baby through the last part of the journey.

Questions for Dr. Baker:

1. What causes hyperreflexia?

Hyperreflexia refers to the deep tendon reflexes; we colloquially describe it as having "too brisk" reflexes. That's just a physical finding and must not be confused with autonomic hyperreflexia, which is a term for a physiological process that only people with spinal cord injuries are prone to. In the spinal cord there are nerve connections for the autonomic nervous system that don't require messages from the brain to get triggered. If something is sensed in your skin or your gut, the message goes back through the peripheral nerves to the spinal cord, which makes the autonomic nervous system send out information telling, for example, the pores to dilate or the blood vessels to constrict. Normally, there's feedback loops from what's going on in the body with the blood pressure, heart rate, temperature, etc. that the brain senses, and it sends signals back down to modulate the response. When you have a spinal cord injury that's above where the fibres from the brain come down and tell the body what to do, that information never gets back down, so you have an uncontrolled reflex. It is life-threatening because of the profound high blood pressure that comes with it, which can cause stroke. People get headaches and flushing above the injury, because the brain is desperately trying to dilate the blood vessels to lower the blood pressure and overdoes it in the part of the body it can communicate with. It's an extremely serious threat. That's why you have to look at blood pressure control in people with high spinal cord injury. Labour is one intense set of stimulations, and it is one of the things that can very likely trigger this in people who are susceptible. If the injury is low on the spine, it doesn't happen because the signals can get out, so it's more likely and more serious the higher up the injury is. Not everyone who has spinal cord injury gets this; somehow the body may get around it.

2. Can any woman with spinal cord injury become pregnant?

We hardly ever tell people not to get pregnant. We give them preconception counselling where we tell them "This is where the lesion is, this is the risk that you'd be taking." Of course, those people generally would know they're at risk anyway in their daily lives. These patients have to make the choice themselves whether to undertake the added risk of pregnancy. If they decide to go through with it, there are things we can do to decrease the risk. During labour we give them an epidural analgesia, which seems to be very effective. What you do is stop the pain fibre stimulation telling the reflex to start, and block the sympathetic nervous system. If this doesn't work, you may have to go to general anaesthesia.

3. What can the mother do to reduce risk of infection, ulcers, and other problems?

Meticulous skin care and good, solid prenatal care, and the usual techniques to release pressure on their back, changing positions, making sure they're not being rubbed on, getting an appropriately sized wheelchair, good diet. Frequent self-catheterization, for people who can manage their urine system, is better than an indwelling catheter to reduce the risk of urinary tract infection. But some people can't manage self-catheterization -- especially if they have a really high lesion, they need an indwelling catheter. These patients need frequent medical visits and urine cultures, and antibiotics at the first sign of infection. Basically they just have to take good care of themselves and get good medical care.