Improving outcomes during and after pregnancy for patients with spinal cord injury
Women with spinal cord injury (SCI) face many challenges during pregnancy and throughout the physically demanding years of early parenthood. But awareness and monitoring of risk factors for secondary complications, the patient's commitment to self-care, and guidance from a collaborative rehabilitation and obstetrics team can help patients achieve successful outcomes throughout the pregnancy, delivery and postpartum periods.
The first trimester
During any pregnancy, each patient's individual need for medications should be weighed against their possible risk(s) to the fetus. When possible, patients should be weaned from medications such as antispasmodics, anticholinergics and anticonvulsants, all of which may compromise fetal growth, before pregnancy or as early in the pregnancy as possible.
Because they can worsen constipation, the use of iron supplements to address anemia during pregnancy may complicate a previously effective bowel program. Patients may need to alter dietary and fluid intake, as well as frequency of bowel care. Stool softeners and stimulants can also help re-establish an effective bowel program if diet and fluid intake changes are ineffective. Some patients may also require topical anesthetic gels to reduce the risk of autonomic dysreflexia during bowel care.
Headaches also are common in the first trimester of pregnancy. Patients with spinal cord injury at or above T-6 who experience severe headache, high blood pressure or bradycardia, however, should be evaluated to differentiate between autonomic dysreflexia and preecamplsia.
"Autonomic dysreflexia can be triggered throughout pregnancy and delivery with stimuli such as pelvic examinations, full bladder or bowel, uterine contractions, and delivery," says Lisa A. Beck, R.N., C.N.S., a member of the Mayo Clinic team in Rochester, Minn., that guides women with spinal cord injury through pregnancy. "The health care team can assist in reducing the stimuli by using warm, small speculums, bladder and bowel management programs, and collaborative labor and delivery planning," says Beck.
The second trimester
Bladder management may need to change sometime during the second trimester. Decreased bladder capacity and increased risk of bladder spasms and infection, especially in women using indwelling catheters, are potential problems. Severe bladder spasms may also cause expulsion of the catheter.
As with any pregnancy, care providers must consider the potential risk to the fetus when considering treatment for bladder infection. "To reduce the risk of bladder infections, we advise re-evaluating and, when needed, adjusting bladder management and urine continence methods on an as needed basis," says Beck. Methods to reduce bladder complications include:
- Aseptic technique with intermittent catheterization
- More frequent bladder emptying
- Increased size of indwelling catheter
- Maintaining adequate fluid intake
Weight gain, edema and anatomic changes that accompany a progressing pregnancy make providing proper pressure-relieving and transfer techniques more difficult. Daily skin inspection as well as regular seating system and cushion evaluations by seating clinic specialists can be helpful.
Increased spasticity in women with upper motor lesions also is a very common problem. A twice-daily at-home stretching program can help reduce spasticity in patients who have been weaned off their antispasmodics. Implantation of an intrathecal baclofen pump has been a reported consideration for patients with severe spasticity during pregnancy.
Body changes and fatigue that occur during pregnancy in women with SCI also can cause difficulty with activities of daily living, driving, transfers and their ability to propel a wheelchair. Outpatient therapy can help patients increase endurance and strength and learn new techniques to compensate for changes in function and body habitus.
The third trimester
Decreased diaphragm movement that occurs as the fetus grows can lead to respiratory compromise. Women with spinal cord injury at and above T-10 are at risk of atelectasis and pneumonia. Patients with cervical and high thoracic lesions also may require increased ventilatory support due to decreased respiratory reserve and vital capacity. Patients in their third trimester are also at risk of thrombophlebitis and bilateral lower extremity edema as the growing uterus compresses the pelvic veins.
Labor and delivery
Recent studies have shown that between 30 and 40 percent of women with SCI enter labor during the 37th week. Signs and symptoms of labor may present differently in women with SCI, and can include pain above the level of injury, increased spasticity, increased autonomic dysreflexia, change in breathing and anxiety. Because the risk of autonomic dysreflexia increases during labor in patients with injuries at and above T-6, unattended labor should be avoided as much as possible. Autonomic dysreflexia symptoms peak during contractions and abate after the contraction ends. Use of epidural or spinal anesthesia can block afferent impulses, reducing autonomic dysreflexia episodes. Use of antihypertensives must be monitored to avoid rebound hypotension, which can cause a reduction in placental perfusion.
Because orthostatic hypotension is common during the postpartum period, slow acclimation to sitting with compression stockings and an abdominal binder may be necessary. Continued use of pain medications or epidural should be considered to help avoid autonomic dysreflexia triggered by pain during breast-feeding or other postpartum pain. Proper positioning, decreased nipple sensation and decreased milk production also can be challenging for patients attempting breast-feeding.
Other postpartum problems include bowel and bladder difficulties, thrombophlebitis, fatigue, spasticity and headaches. Postural changes that may have occurred during pregnancy also can lead to difficulty in seating and functional activities.
The Spinal Cord Injury Rehabilitation Program at Mayo Clinic in Minnesota offers a collaborative team approach with obstetricians to assist women with spinal cord injury through safe and successful pregnancies.
Answering questions about SCI, pregnancy and parenting
A team of Mayo Clinic physical medicine and rehabilitation staff and patients recently worked together to draft a new patient education booklet entitled "Pregnancy and Parenting: Spinal Cord Injury." Written for a patient audience, the new booklet addresses:
- How issues related to spinal cord injury can affect pregnancy, labor and delivery
- The possible effects of pregnancy, labor and delivery on the body
- Parenting issues and concerns
In addition to project leaders Lisa Beck, R.N., C.N.S., and Tamara L. Vos-Draper, O.T., ATP, three new mothers who were followed by Mayo's spinal cord injury rehabilitation team throughout their pregnancies played valuable roles in developing the informational booklet. "These advisers did a great job of helping to keep the content and organization focused and useful for a patient audience," says Beck. "We think that this booklet pulls together a lot of valuable information into a concise read, and we are pleased to make this available to our patients considering pregnancy."
Points to remember
- Special care needs to be taken during pregnancy to keep women with spinal cord injury from experiencing complications such as autonomic dysreflexia, urinary tract infections, pressure ulcers, deep vein thrombosis or respiratory difficulty.
- Before and throughout pregnancy, each patient's individual need for medications should be weighed against their possible risk(s) to the fetus.
- Body changes and fatigue that occur during pregnancy in women with SCI can also cause difficulty with activities of daily living, driving, transfers and their ability to propel a wheelchair. Outpatient therapy can help patients increase endurance and strength and learn new techniques to compensate for changes in function.