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Obstetric management following traumatic tetraplegia: case series and literature review

Australian and New Zealand Journal of Obstetrics and Gynaecology 2008; 48: 485– 491
Obstetric management following traumatic tetraplegia: Case series and literature review Emma SKOWRONSKI1 and Keith HARTMAN21Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, and 2Royal North Shore Hospital, Pacific Highway, St Leonards, New South Wales, Australia Objective: Pregnancy in tetraplegia is a rare event, with only sporadic cases reported. This case series describes seven
pregnancies in five tetraplegic women, all with spinal cord injuries in the region of C6.
Design: Retrospective case series.
Setting: Sydney, Australia.
Population: All tetraplegic women presenting to the obstetric service of a university teaching hospital, which also provides a
regional spinal injury service, between 1981 and 2006.
Methods: Hospital records of all patients were examined and information extracted regarding demographics, pregnancies and
their complications, labour and delivery and neonatal data.
Main outcome measures: Course, complications, management and outcomes of pregnancy in tetraplegic women.
Results: Mean age at the time of injury was 22 years, and, at the time of pregnancy, 33 years. All patients suffered recurrent,
and sometimes severe, urinary tract infections and episodes of autonomic dysreflexia during pregnancy. Frequent and
sometimes lengthy hospital admissions were required for these and other reasons. Only two pregnancies required caesarean
section and all entered labour spontaneously, at a mean of 37.9 weeks of gestation. Episodes of autonomic dysreflexia were
aggressively managed using pre-emptive epidural anaesthesia and sublingual nifedipine. All pregnancies resulted in normal,
near-term babies with no serious perinatal problems.
Conclusions: Pregnancy and childbirth in tetraplegic women can be undertaken safely, usually with spontaneous onset of
labour and vaginal delivery. However, hospitalisation for intercurrent problems is common. Management requires a
multidisciplinary approach and is best undertaken in major centres with both obstetric and spinal cord injuries medical expertise.
Key words: autonomic dysreflexia, childbirth, labour, pregnancy, quadriplegia, tetraplegia.
urinary tract infections (UTI), autonomic dysreflexia and Introduction
increased risk of preterm labour and delivery.
Pregnancy in tetraplegic patients is a rare event. The Tetraplegia in this paper is defined as a SCI above the population of tetraplegic women of child-bearing age is small neurological level of T1. Although patients with lesions and the potential non-obstetric complications of their below C5 may have some upper limb function and therefore condition are numerous. The literature worldwide reports could be strictly defined as tetraparetic rather than tetraplegic, only single cases and a few very small case series of injuries above T1 are associated with increased risks pregnancy and delivery in spinal cord injuries at various compared with lower spinal cord injuries. Almost all such spinal levels,1 the most recent series published in 19942 and patients experience autonomic dysreflexia. They have significantly decreased mobility compared with patients with Obstetric management of tetraplegic patients is influenced lower lesions. They have decreased respiratory reserve by the level and completeness of spinal cord injury (SCI) which is further compromised as pregnancy advances. The and individual psychological issues in addition to obstetric increased severity of their disability further impacts on their and fetal problems. Previously published series list the major psychosocial and physical situation, requiring increasing complications in these pregnancies as recurrent and severe support as their pregnancy advances, during theirhospitalisation and at discharge.
Autonomic dysreflexia (sometimes called autonomic Correspondence: Dr Emma Skowronski, resident, Canberra hyperreflexia) is a syndrome of massive, unbalanced reflex Hospital, Yamba Drive, Garran, ACT 2605, Australia. sympathetic discharge occurring in patients with SCI above the splanchnic sympathetic outflow (T5–T6). Below the injury, Received 4 February 2008; accepted 20 March 2008. sensory nerves transmit impulses that stimulate sympathetic Journal compilation 2008 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists Table 1 Maternal characteristics
neurones located in the spinal cord. The large, unopposed labour, anaesthesia used, perineal tears and episodes of sympathetic outflow causes sudden elevation in blood autonomic dysreflexia, including the maximum blood pressure pressure, piloerection, skin pallor, and severe vasoconstriction reached. Outcome assessment included the general health of the mother postnatally and any long-term sequelae of The inhibitory response to this, from cerebral vasomotor pregnancy, as well as the general health of the babies. We centres, causes vasodilation above the level of injury, with also assessed breastfeeding and any complications. Baby pounding headache, flushing, blotching of skin, nasal follow-up data included growth parameters, Apgar scores congestion, nausea, anxiety, malaise, prickling sensation in the skull. Signs include sweating, blushing, piloerection,tremor and nasal obstruction. There may be twitching and increased spasticity in all limbs. Cardiac rhythm disturbancesare possible, including extrasystoles, bigeminy, prolonged PR There were five patients and seven pregnancies. One patient interval and AV block. Cardiac arrest,4 retinal haemorrhage, acquired her SCI during pregnancy. Five of seven babies subarachnoid and other forms of intracranial haemorrhage were delivered vaginally. Four male and three female infants Table 1 lists the characteristics of the mothers. All had SCI at C6. Mean age at the time of injury was 22 years (range 13–32). Mean age at the time of pregnancy was 33 years Royal North Shore Hospital, Sydney (RNSH) provides both (range 26–38). Admissions ranged from one to three per a statewide SCI service and a large obstetric service. A single pregnancy. DVT prophylaxis was only used in the two most obstetrician (KH) was referred all obstetric patients linked to the SCI unit between 1981 and 2006. This paper reports his Table 2 lists complications that arose during the seven experience with pregnant tetraplegic patients and constitutes pregnancies. All the tetraplegic mothers developed UTI.
the first such case series reported.
Autonomic dysreflexia and increased spasticity occurred in All cases of tetraplegic pregnancy at RNSH were managed most. The patients required hospital admission from one to by one of the authors (KH) between 1981 and 2006. Medical three times per pregnancy. Problems arising during records were analysed retrospectively both from his private pregnancy, labour and the puerperium resulted in protracted files and the public hospital records. All correspondence, periods of inpatient care. Patients spent a mean of 59.4 days medical and nursing records were assessed. All files were in hospital (range 17–166) per pregnancy.
reviewed by the same investigator (ES).
Table 3 lists labour-related data. Only two pregnancies Information collected included details of the spinal cord required caesarean section. Mean onset of labour was at 37.9 injuries as well as the pregnancies. Data collected regarding weeks gestation (range 35–39). For vaginally delivered the spinal cord injuries included the neurological level, pregnancies, mean duration of first stage of labour was 4.7 h mechanism of injury and duration of tetraplegia. We also (range 3.2–7.8), second stage 27.8 min (range 11–30), and assessed continence and fertility status. We looked at the third stage six minutes (range three to 13).
course and complications of the pregnancies, deliveries Blood pressure data were not available for three and postnatal period. Other data collected regarding the pregnancies. For those where data were available, marked pregnancies included maternal age, number of pregnancies, hypertension was apparent, reflecting episodes of autonomic gestation, fetal presentation and gestation on admission to dysreflexia. Mean maximum systolic pressure was 192 mmHg hospital. Pregnancy complications sought included UTI, (range 160–215), mean maximum diastolic pressure was autonomic dysreflexia and muscle spasms, deep-vein thrombosis (DVT), skin breakdown and uterine prolapse. Delivery data Table 4 lists basic neonatal data. Despite their complex included method of delivery, the duration of each stage of pregnancies and deliveries, all babies were born in good Journal compilation 2008 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 48: 485– 491
Obstetric management following traumatic tetraplegia Table 2 Complications during pregnancy
One precipitated preterm labour at 33 weeks One required a surgical flap months after delivery DVT, deep-vein thrombosis; MRSA, methicillin-resistant Staphylococcus aureus; UTI, urinary tract infection. condition. Mean neonatal weight was 3139 g (range following general surgery.16 In a 2004 case report, an 2680–3710). Mean body length was 50 cm (range 48–53) epidural infusion of local anaesthetic was maintained for four and mean head circumference was 34 cm (range 32–35.5).
days after a general surgical procedure. Since tetraplegic There was a high rate of difficulties with breastfeeding.
patients have been reported to have autonomic dysreflexia Contributing factors included convenience, little milk flow for up to five days post-partum,1 epidural anaesthesia might and dysreflexia during breastfeeding.
be considered in patients who have been more susceptible todysreflexia during pregnancy and may therefore be moresusceptible in the postpartum period. In 2006, a case report Discussion
by Osgood et al.17 suggested that spinal anaesthesia may besuperior to epidural anaesthesia in providing haemodynamic Preterm birth
stability against autonomic dysreflexia during caesarean Obstetric management of tetraplegic patients is an area in section. Neither spinal nor prolonged epidural anaesthesia which there is little experience or knowledge. The largest case series of spinal cord-injured patients was published in In our case series, autonomic dysreflexia was managed 1972 and pooled retrospective observations of clinicians pre-emptively by insertion of an epidural either before or from 24 countries of 175 cases.3 This series suggested that in the early stages of labour. Generally, autonomic there was a risk of preterm labour, as five preterm babies, dysreflexia was well controlled. Although there were peaks less than 2500 g, and another three less than 3000 g were that were dangerously high these were quickly managed born out of 33 pregnancies that proceeded past six months.
by prompt identification of the stimulus and, during labour, A review by Pereira6 in 2003 synthesised the more complete by the administration of either sublingual nifedipine or data available from the four more recent case series7–10 (1986–1993) and found that preterm birth rates ranged from In some parts of the world sublingual nifedipine is no 6–13%, which is similar to the published rates of preterm longer available. The capsule form was withdrawn from the labour in the USA (in 1998) of 11% before 37 weeks Australian market in 1997 due to concerns about adverse gestation. However, this issue remains uncertain, with the effects of long-term treatment in patients with heart disease, three series using differing definitions for ‘pre-term’ and the although nifedipine and hydralazine had been endorsed for series sizes ranging from only 13 to 49, including spinal cord use for severe hypertension in pregnancy by the Australasian injuries at all levels. In our series, one infant was born at Society for the Study of Hypertension in Pregnancy.18,19 35 + 0 weeks as a direct result of maternal septicaemia Although clonidine is not approved for use in pregnancy, no associated with UTI, which could be directly attributed to adverse effects were experienced in our case. Glyceryl her SCI. The remainder were born at or near term.
trinitrate is now commonly used by our spinal injury serviceto treat autonomic dysreflexia in non-pregnant patients.
Labetalol and mini-bolus diazoxide have both been recently Epidural anaesthesia and autonomic
advocated as safe and effective alternatives to hydralazine for dysreflexia
acute hypertension in pregnancy.20,21 All these medications Several authors have recommended the use of prolonged have the potential to cause acute hypotension that could epidural anaesthesia to control autonomic dysreflexia in the postpartum period.11–15 Epidural anaesthesia has been shown Figure 1 demonstrates the typical pattern of autonomic to control autonomic dysreflexia in a tetraplegic patient dysreflexia in patient D. The graph also suggests a beneficial Journal compilation 2008 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 48: 485– 491
Labour da
3
Journal compilation 2008 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 48: 485– 491
Obstetric management following traumatic tetraplegia Table 4 Neonatal data
Figure 1 Mother D’s blood pressure
during the peripartum period. Sublingual
nifedipine was also given sometime between
delivery of the baby and placenta but we
were unable to accurately record the timing
of this.
effect in reducing blood pressure of delivery of the baby and born mildly premature at 35 weeks gestation. Because of then the placenta. Given our favourable experience and the decreased or absent sensation, labour may go undetected by known potential for serious adverse outcomes from autonomic the patient, so regular monitoring of uterine tone and dysreflexia, we recommend close monitoring and early, cervical dilation and effacement is important. As pregnancy aggressive treatment of hypertensive episodes.
continues, the frequency of episodes of dysreflexia increases.
Monitoring of blood pressure and prompt managementprevents adverse sequelae. Autonomic dysreflexia may also Urinary tract infection
affect the uteroplacental blood flow, so careful clinical and All seven pregnancies in this series were complicated by electronic monitoring of the fetus is also recommended when multiple and severe UTIs. For three of the pregnancies this resulted in hospital admission for the remainder of the As with the care of other complex patients, the involvement pregnancy. One UTI, complicated by septicaemia, precipitated of many different medical and allied health subspecialties is threatened preterm labour at 33 weeks and was almost important. Experts involved in the care of our patients certainly responsible for the premature birth at 35 + 0 weeks.
included obstetricians, spinal rehabilitation physicians, Several infected patients experienced multiple blockages of anaesthetists, nurses, physiotherapists, occupational therapists, their suprapubic catheters due to excessive urinary sediment.
lactation consultants, paediatricians and neonatologists as All were treated with intravenous antibiotics, usually well as many others. Cohesive multidisciplinary team function ceftriaxone. One patient had recurrent UTIs caused by is essential, and we recommend that these patients be various organisms. She was placed on rotating antibiotics for managed, where possible, in centres where expertise in spinal the remainder of her first pregnancy and the entirety of the cord injuries and obstetrics coexists.
next one. Cephalexin, amoxycillin and sulfamethoxazole Careful pregnancy planning is also recommended. All were rotated weekly. This patient was never admitted for tetraplegic patients have complex medical problems prepregnancy. Management of medications is a potentialdifficulty, with so many of the less-commonly used drugsuntested for possible teratogenicity and other adverse effects.
Coordination of care
The goal of optimising the medical management of the A low threshold for hospital admission is generally advisable.
mother while minimising the potential risks to the fetus can As discussed above, tetraplegic women may be susceptible to be a difficult juggling act, requiring much research and premature labour3,10 and one infant in this series of 7 was Journal compilation 2008 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 48: 485– 491
Other issues
Acknowledgements
In 1991, a case series of 16 spinal cord-injured patients was Many thanks to those who advised and assisted us during the published,1 ‘about half tetraplegia’. These authors identified writing of this paper. These include Associate Professor G.A.
an increased risk of complications such as abnormal Skowronski, Dr Lianne Hunt, Dr Sue Rutkowski and presentation and failure to progress. These features were not members of the Neurology Department at Canberra Hospital.
Other significant observations have included autonomic Ethics approval
dysreflexia as a sign of uterine contractions in pretermlabour,22 the importance of using non-absorbable sutures in This study was approved by the Ethics Committee of the episiotomy closure in denervated areas due to an increased Northern Sydney Central Coast Area Health Service risk of sterile abscess and wound dehiscence,23 as well as noting that caesarean section in the presence of a permanentsuprapubic catheter may dictate a classical surgical incision.1 References
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Journal compilation 2008 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 48: 485– 491

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