LINEBURG


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Int. Anesthesiol. Clin. 1975; 13: 1“153. Int. J. Obstet. Anesth. 1993; 2: 49“52.
90. Baker, A. S., OJemann, R. G., Swartz, M. N. & Richardson, E. P., Jr. Spinal 116. Hunt, H. B., Schifrin, B. S. & Suzuki, K. Ruptured berry aneurysms and
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284: 1355“7. an obese parturient receiving enoxaparin therapy. Anesth. Analg. 2002; 95:
138. Messer, H. D., Forshan, V. R., Brust, J. C. & Hughes, J. E. Transient para- 441“3.
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144. Weatherby, S. J., Edwards, N. C., West, R. & Heafield, M. T. Good outcome of arterial pressure during spinal anaesthesia for Caesarean section.
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189
SPINAL CORD DISORDERS
10
Roanne Preston




Introduction with SCI. One approach is enforced bed rest with spinal immobi-
lization until the fetus is viable, followed by cesarean section
Patients with spinal cord injuries and spina bifida are not com-
(C/S) and spinal stabilization at one surgery. However, the risks
monly encountered in the obstetrical population, but their num-
of prolonged bed rest, including thromboembolism, and
bers will increase in the future as a result of improved surgical
acquired secondary neurological injury during this period, favor
techniques and rehabilitation therapy. Also, women with degen-
early surgical intervention. The risks of early intervention include
erative spinal cord diseases such as spinal muscular atrophy, and
a possible impact on the fetus of prolonged surgery in the prone
amyotrophic lateral sclerosis are surviving to child-bearing age
position, and hemodynamic instability secondary to spinal shock.
and choosing to become pregnant despite the risks. Unusual dis-
Due to the small number of cases reported, the actual risk of
eases of the spinal cord such as tethered cord, syringomyelia and
preterm labor is unknown.5,17,18 Unstable thoracolumbar frac-
postpolio syndrome are also known to occur in pregnant women.
tures invariably require early surgical stabilization as a body
brace may compromise the growing fetus.
The initial phase of acute SCI, lasting three to six weeks, is
Spinal cord injury
known as spinal shock and is due to the sudden interruption of
The incidence of spinal cord injury (SCI) is 25“30 per million of suprasegmental descending neurons, which normally keep spinal
population in North America, or 10 000 new cases per year in the motor neurons in a continuous state of readiness.19 Spinal shock
USA. Most victims are young, and in Canada 20% of them are is characterized by flaccid paralysis below the level of the lesion
female.1,2,3 Advances in both acute and rehabilitation care have and loss of all sensory modalities, temperature regulation, and
led to improved outcomes resulting in higher levels of indepen- spinal reflexes (tendon and autonomic). Cardiovascular effects
dent function after SCI. Rehabilitation emphasizes integration include hypotension (may be severe), bradycardia (with high
back into society and cord-injured patients are encouraged to thoracic lesions), and dysrhythmias. Fetal heart monitoring dur-
work, establish relationships, and have families. ing spinal shock provides information about the fetus and mater-
Pregnancy in SCI patients is no longer rare; a 1999 survey nal hemodynamic status.20 Due to loss of vasomotor tone, the
looked at 472 women with SCI, all at least one year post injury.4 extremities lose heat rapidly if exposed, and develop dependent
Fourteen percent became pregnant after their injury, and in 60% edema. There may be a prolonged period of paralytic ileus.
it was their first pregnancy. The average time to pregnancy fol- Cervical lesions at C2“4 usually mandate ventilatory support for
lowing SCI is 4 to 13 years, but the average age at pregnancy and a prolonged or permanent period, while lower cervical lesions
time interval since injury have decreased in the last few years.5,6,7 may only require initial ventilation until the thoracic cage mus-
The first successful pregnancy in a quadriplegic was reported in cles recover function. During the acute injury phase, patients with
1953.8 Most reports since then involve chronic SCI, although high thoracic lesions are highly susceptible to aspiration and
there are some reports on management of the pregnant patient pneumonia due to impaired ability to cough or to clear the airway
with acute SCI.9,10,11,12,13,14 of secretions. Treatment of spinal shock includes high doses of
steroids, surgical stabilization of fractures, and supportive care in
an intensive care unit setting. Following this stage of flaccid
The acute spinal cord-injured pregnant patient paralysis, SCI patients usually develop exaggerated reflexes with
muscle spasms, upper motor neuron-injury pattern tendon
Pregnant women constitute less than 1% of total acute admis-
sions to trauma centers.9 Acute SCI incurred during pregnancy reflexes, and autonomic hyperreflexia (AH).
is uncommon,9 and often is associated with a high incidence
of miscarriage, stillbirth, and fetal abnormalities (14/45 in a 1970
Medical complications in chronic spinal cord-injured
review).10,11 Second trimester pregnancies have the worst out-
women and the impact of pregnancy
comes, partly due to uterine trauma with placental abruption or
direct fetal trauma.10,11,12,13,14 The primary survey of the pregnant Following spinal shock, the situation stabilizes as chronic
trauma patient with a viable fetus (>24 weeks™ gestation), should SCI. Approximately 50% of patients will be an American Spinal
include fetal heart rate monitoring. This may provide useful data Injury Association ˜˜A™™ injury, which is functionally a complete
about maternal hemodynamic status.3,15,16 High dose steroid cord transection.21 The remainder are a mix of sensory
therapy is not contraindicated.3,16 If the fetus remains viable, sparing/motor nonfunctional/motor functional injuries.4 Most
there are two approaches to the management of the mother neurological improvement is made within the first year post


Obstetric Anesthesia and Uncommon Disorders, eds. David R. Gambling, M. Joanne Douglas and Robert S. F. McKay. Published by Cambridge University Press.
# Cambridge University Press 2008.
3 Nervous system disorders


injury, although some patients make slow progress over the sub- could not transfer independently at term, and 4.5% were unable
sequent years.19,22 Patients with cervical and high thoracic injury to propel their wheelchairs.4 Pregnancy predisposes to more
urinary stasis, resulting in increased UTI rates.6,28 Intermittent
levels typically have impaired pulmonary function with
decreased respiratory reserve, resulting in poor cough and recur- bladder catheterization results in less morbidity than indwelling
rent pulmonary infections. Renal function may deteriorate due to catheters, but the frequency of catheterization may have to
chronic or recurrent urinary tract infection (UTI) with calculi increase with gestation. Orthostatic BP changes may be augmen-
formation. Deep vein thrombosis (DVT) and decubitus ulcers ted by the pregnancy-induced decrease in systemic vascular
remain a persistent concern in the wheelchair-bound patient. resistance and become symptomatic.
Anemia of chronic disease is common, and iron supplementation
may cause deterioration in bowel function. Many SCI patients
Management of the chronic cord-injured parturient
have low blood pressure (BP) due to low blood volume as well as
impaired capacitance vessel function.23 Antepartum and medical management
Pregnancy may aggravate many of these conditions (see Patients with chronic SCI should be assessed prior to conception to
Table 10.1). Common problems encountered during pregnancy determine their ability to tolerate pregnancy. Many SCI patients
in SCI patients are UTI (45“80%), anemia (10“60%), pressure take medications for spasticity, such as baclofen and diazepam.
sores (6“26%), and increased spasticity.1,4 The respiratory Baclofen has been used during pregnancy, without untoward
effects; however, experience is limited.29,30 Diazepam was asso-
changes of pregnancy, including loss of functional residual capa-
city and expiratory reserve volume, further compromise cough ciated with an increased incidence of lip and palate malforma-
tions31 although other studies dispute this.32 However, a fetal
mechanics, while the expanding uterus limits diaphragmatic
excursion. This is important in the patient with cervical cord benzodiazepine syndrome has been described, which includes
injury who may be entirely dependent on her diaphragm for intrauterine growth restriction, dysmorphism, and central nervous
system (CNS) dysfunction.33 In view of this, benzodiazepines should
respiratory function due to loss of intercostal muscle function.
Labor normally puts an enormous demand on ventilation, and be stopped preconception. Evaluate pulmonary function early in
may actually cause acute diaphragm fatigue.24,25,26,27 Although pregnancy to identify women at risk of respiratory deterioration
during later stages of pregnancy and labor.34,35 Pulmonary function
this fatigue does not cause clinical deterioration in the healthy
parturient, labor may not be tolerated in the respiratory- tests are recommended and respiratory consultation should be
sought if there is significant compromise.1 Some patients require
compromised SCI patient. Much of the increased minute ventila-
tion in labor is precipitated by the pain of parturition, something ventilator assistance during late pregnancy, and negative pressure
which may not occur in parturients with high spinal cord lesions. ventilators are ideally suited to this task. Every effort should be made
As weight increases and ligaments become more lax, transfers to assist the SCI patient to cease smoking.
may become more difficult. In Jackson™s study, 11% of women
Obstetrical management
Preterm labor is more common in SCI parturients and unattended
Table 10.1 Medical complications of spinal cord injury delivery may occur in women with complete lesions above T10
aggravated by pregnancy because of difficulty in ascertaining when labor begins. There is an
increased need for assisted delivery because of the loss of abdom-
Pulmonary
inal musculature needed for expulsive efforts. 5,6,7,28,36,37,38,39,40
Decreased respiratory reserve
Earlier reports of a high incidence of fetal malformations have
Atelectasis and pneumonia
not been confirmed.39 One study found an increased risk of low
Impaired cough
birth-weight babies beyond the risk of prematurity.4
Hematological
Obstetrical management begins with the assessment of pelvic
Anemia
adequacy, especially in women who suffered the injury before
Thromboembolic phenomenon
puberty.1,34 If the pelvis is deemed adequate, vaginal delivery
Urogenital
should be anticipated as approximately 50% of SCI parturients
Chronic urinary tract infections
will have a spontaneous vaginal delivery, with 30% requiring
Proteinuria
assistance.4,41,42 Preterm labor, a known risk in SCI patients, is
Renal insufficiency
treated with beta-mimetic tocolytics and magnesium sulfate
Urinary tract calculi
(MgSO4),1,38,39 but due to its muscle relaxation effects MgSO4
Dermatological
may precipitate respiratory failure.43 Women with complete
Decubitus ulcers
lesions above T10 are at risk for unexpected and unattended
Cardiovascular
delivery, especially if labor begins while asleep. If awake, other
Hypotension
symptoms such as increased spasticity or symptoms of AH may
Autonomic hyperreflexia
alert the woman to the onset of labor.3 Some centers have routine
admission at 36“37 weeks to prevent unattended delivery,36,44,45
From Crosby, E. T., St. Jean, B., Reid, D. et al. Obstetrical anaesthesia
others use frequent tocodynamometry and cervical examina-
and analgesia in chronic spinal cord-injured women. Can. J. Anaesth.
tions as term gestation is approached.15 Home uterine activity
1992; 39 489.



192
Chapter 10


monitoring starting at 26“28 weeks™ gestation enables the woman increased skin temperature, facial flushing, and nasal conges-
to remain at home.41 There is consensus that C/S be reserved for tion.2,51 Morbidity from AH includes retinal hemorrhage, intra-
cranial hemorrhage,43,46,53,54 hypertensive encephalopathy,53
obstetric indications. During labor, continue specific nursing care
seizures,5 atrioventricular conduction abnormalities including
for SCI, such as frequent turning to prevent pressure sores, and
sinus arrest,45,52 fetal dysrhythmias, and uteroplacental insuffi-
optimal bladder care. Education about pregnancy and SCI is
ciency leading to fetal hypoxemia.1
important for the patient™s physical and mental well-being during
labor. Many patients at risk for AH will give a history of AH episodes
with visceral (bladder or rectal) overdistention. Pregnancy may
result in increased episodes of AH.4 Labor is a potent stimulus
Autonomic hyperreflexia
The most dangerous complication during labor and delivery is and AH may be precipitated for the first time during parturi-
tion.5,55,56 There are case reports detailing the manifestation of
AH. Failure to identify patients at risk and provide appropriate
prophylaxis and treatment for episodes of AH remains an import- AH as waxing/waning headaches with each contraction, with the
ant medical and legal issue.1,5,28 In a report of six quadriplegic headaches being used as an indicator of the efficacy of labor
epidural analgesia.57 Maximal noxious stimulation occurs in the
women who developed AH: one died of an intracerebral hemor-
rhage, one had significant brain damage, and one suffered an perineal region innervated by S2“4, and AH may not present until
intrauterine fetal death, all due to lack of recognition or poor perineal stretching occurs in the late first stage or early second
treatment of AH.46 The American College of Obstetricians and stage of labor.36,52 Other stimuli include vaginal examinations,
instrumentation, amniotomy, and oxytocin infusions.2 The dif-
Gynecologists guidelines published in 2002 recommend early
initiation of epidural block to prevent AH in patients at high ferential diagnosis of hypertension in SCI parturients is pre-
risk.1 If epidural block is not available immediately, the guidelines eclampsia. The two differ clinically with AH having a sudden
recommend vasodilator treatment. If labor induction is planned, onset and episodic hypertension, coinciding with contractions.
patients at high risk for AH should have an epidural initiated The lack of proteinuria, characteristic of preeclampsia, also helps
before induction.1,2,39 Avoid ergonovine in the third stage to confirm the diagnosis.58
because hypertension and dysrhythmias may mimic the diagno-
sis of AH.36 Of note, the incidence of preeclampsia is not Anesthetic management of labor and delivery
increased in this patient population.34,47 Problems in SCI patients of relevance to the anesthesiologist
Autonomic hyperreflexia, or the mass autonomic response, was include an increased incidence of premature labor and painless,
first reported in 1890 but not well described until 1947.5,48 It is a precipitous labors, the need for labor analgesia, the occurrence
life-threatening reflex caused by a mass sympathetic response to of muscle spasms in labor, the frequent requirement for assisted
noxious stimuli that is not modulated by the supraspinal influ- delivery, prophylaxis for AH, potential for hypotension, and
ences of the central nuclei.36,49 Commonly seen in patients with hyperkalemia with succinylcholine in those with subacute
spinal cord injuries at T5 or above (85“90%), it is less common in injury. Anesthesia during the spinal shock phase of SCI can be
patients with lesions between T5 and T8 (50“65%), and is rare very challenging. Unopposed vagal parasympathetic activity
with lesions below T8.50 Most patients at risk for AH have com- puts the woman at high risk for severe bradycardia during
plete lesions,5 as incomplete lesions allow for craniocaudad airway manipulation, including suctioning. Usually general
neural traffic, with the potential for supraspinal modulation of anesthesia (GA) is required for surgery during this period of
instability. 51
spinal reflexes. This syndrome requires an intact sympathetic
system below the level of the lesion, and is not seen in cases of Antepartum anesthesia consultation is encouraged and should
be routine for parturients with SCI.2,36 During this visit, the need
cord infarction.
The reflex is initiated by a noxious stimulus entering the dorsal for analgesia and the risks and benefits of the different methods
horn of the spinal cord and passing into sympathetic neurons in should be discussed. Concerns about worsening symptoms fol-
the intermediolateral columns of the lateral horns. These sympa- lowing regional anesthesia should be addressed, and the benefits
thetic neurons travel to the paraspinal sympathetic chain, allow- of regional anesthesia for those at risk of AH emphasized. Patients
ing propagation of these impulses in cephalad and caudad with complete injury levels above T5 have painless labors and are
directions and peripherally. A large sympathetic outpouring at high risk for developing AH, whereas those with complete
causes vasoconstriction and visceral spasm. The excessive sym- lesions between T5 and T10 are at reduced risk. Although,
pathetic response is in part due to the large, disorganized increase patients with an injury level below T10 generally experience nor-
in presynaptic terminal boutons that occurs post injury.51 Spinal mal labor pain, those with incomplete lesions between T6 and
levels above the lesion are influenced by supraspinal modulation T10 may not have typical labor pain, but may be subject to
leading to reflex compensatory vasodilation. However, if the extreme leg and abdominal spasms with contractions.
lesion is above the midthoracic level there is insufficient vasodi- There are several options for treating AH during labor. Initial
lator reserve to counteract the vasoconstriction, resulting in reports recommended the combined use of anxiolytics with anti-
hypertensives.28 Control of BP was not optimal, but there was no
severe systemic hypertension. Baroreceptor response to the
hypertension produces bradycardia and vasodilation above the reported morbidity attributable to the AH. Labor analgesia was
lesion level.50,52,53 Clinical signs and symptoms include severe not considered necessary in most SCI patients. Direct arterial
hypertension, headache, bradycardia, sweating, blurred vision, vasodilators such as sodium nitroprusside and hydralazine have



193
3 Nervous system disorders


been used with varying success, as have calcium channel, gang- Regional anesthesia may cause significant hypotension in
lionic (trimethaphan), and adrenergic (guanethidine, prazosin) women with borderline BP due to the combined effects of SCI
blocking agents.59,60 First-line agents include sublingual nifedi- and pregnancy.71 Although SCI patients are near-maximally vaso-
pine 10 mg, transdermal nitroglycerin, and phentolamine.51 dilated as a baseline state, the use of dilute local anesthetic solu-
Clonidine may be useful when significant spasticity is a prob- tions for labor analgesia negates the need for a mandatory
lem.51 There is one report on the use of MgSO4 to treat AH.61 preepidural fluid bolus. One should carefully titrate the analgesia
Because the hypertension may be episodic in labor-induced AH, level upward while montoring vital signs. Treatment of hypoten-
maternal BP may be very high during contractions despite anti- sion is with intravenous (i.v.) fluids and then, if needed, careful
hypertensive medication, then very low in the intervening period administration of vasopressors. Both i.v. ephedrine (2.5“5 mg
before the onset of the next contraction. Beta-blocking agents are bolus) and i.v. phenylephrine (20“50 mg bolus) are safe. If the
not recommended because of possible uterine vessel vasocon- woman has signs of AH and has been given antihypertensive
striction, although the combined alpha/beta-blocker labetalol agents, one needs to be careful of interactions with the subse-
has been used successfully.36,45 The literature overwhelmingly quent use of vasopressors. Ephedrine may have reduced efficacy
supports epidural analgesia as the method of choice for prophy- in the presence of beta-blockade, and an exaggerated effect if
laxis and treatment of AH in labor.1,2,6,34,36,44,51,62,63,64,65,66,67,68,69 ganglionic-blockers have been administered. High thoracic levels

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