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© Borgis - Postępy Nauk Medycznych 7/2016, s. 494-498
*Monika Łukasiewicz
Pregnancy and delivery in patients with spinal cord injury
Ciąża i poród u pacjentek po uszkodzeniu rdzenia kręgowego
2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Father Jerzy Popiełuszko “Bielański” Hospital, Independent Public Health Care Institution in Warsaw
Head of Department: Associate Professor Romuald Dębski, MD, PhD
Streszczenie
Ciąża u pacjentek po uszkodzeniu rdzenia kręgowego nie jest przeciwwskazana. Nasila jednak problemy zdrowotne charakterystyczne dla tej grupy pacjentek: zwiększa ryzyko powikłań zakrzepowo-zatorowych, często w trakcie jej trwania pojawiają się problemy z układem moczowym (nietrzymanie moczu, zakażenia), nasilają się problemy z oddychaniem oraz odleżyny. Częściej również niż przed ciążą kobieta z uszkodzeniem rdzenia narażona jest na zagrażające życiu autonomiczne dysrefleksje (AD). Również poród siłami natury nie jest przeciwwskazany, wymaga jednak wczesnego założenia znieczulenia zewnątrzoponowego i właściwego monitorowania porodu (kobiety z uszkodzeniem poniżej Th10 nie odczuwają skurczów, narażone też są na autonomiczne dysrefleksje). Prowadzenie ciąży i porodu u pacjentki z uszkodzeniem rdzenia wymaga dużej wiedzy i doświadczenia. Karmienie piersią po porodzie przebiega zazwyczaj prawidłowo. Tylko u pacjentek z całkowitym uszkodzeniem rdzenia powyżej T4 obserwujemy opóźnienie laktacji. Wskazana jest wtedy dodatkowa wizualna stymulacja albo donosowa oksytocyna. Tylko 11% kobiet z uszkodzeniem rdzenia karmi po porodzie. Płodność kobiet po URK jest prawidłowa. Wskazane jest zatem zastosownie właściwej antykoncepcji. Doustne hormonalne tabletki antykoncepcyjne są przeciwskazane w tej grupie pacjentek. Rekomenowane są minitabletki gestagenne, implanty gestagenne i iniekcje z progestagenem.
Summary
Pregnancy after SCI (spinal cord injury) is not contraindicated. However, it exacerbates most problems associated with SCI by increasing the risk of thromboembolic complications, urinary conditions (urinary incontinence, infections) as well as respiratory symptoms and decubitus ulcers. Furthermore, pregnant SCI women are at higher risk of life-threatening autonomic dysreflexia (AD) compared to before pregnancy. Also, natural delivery is not contraindicated in SCI patients, however, early epidural anaesthesia as well as appropriate monitoring during labour are needed (females with injury below the level of Th10 do not feel contractions and are at risk of autonomic dysreflexia). Antenatal management in a patient with spinal cord injury requires extensive knowledge and experience. Breastfeeding is normal after delivery, however in women with complete SCI above T4 breastfeeding is delayed and additional stimulation is required (nasal oxytocin or visual stimulation). Minority of patients with SCI breastfeed (about 11%). Fertility is not affected in women with SCI. Contraception after delivery is recommended. Combined oral contraception containing estrogen is contraindicated. Progestogen only pills, progestogen injection, implants are more appropriate in this group of patients.
“People with disabilities are not a race that should live in isolation. This is not a group of people whose simple diagnosis of disability renders them abnormal or worthless. We could be disabled if a disaster had happened yesterday..., or if it happens tomorrow...”
Hamilton, 1978
Introduction
“Becoming a parent has significantly improved the quality of my life” – this answer was provided by 96% of respondents with SCI who have given birth (1). Approximately 10,000 new SCI cases are reported in the USA each year. This is an average of 28 to 55 people per one million inhabitants (2). Currently, there are over 40,000 SCI patients in the UK. Most of them are young people of reproductive age, including 26% of women (3). The number of SCI women is growing each year. The most common SCI causes include car accidents (36-48%), violence (5-29%), falls from height (17-21%) and sport (7-16%) (2, 3).
Reproductive health in women with SCI
A study in 472 women with SCI showed that most of these patients reported the same gynaecological problems as the majority of population. SCI women with statistically more common urinary tract infections and vaginal fungal infections compared to non-SCI women are an exception. Some of SCI patients develop secondary amenorrhea, which resolves spontaneously within 3 to 6 months in more than 50% of women. SCI patients are much less likely to undergo routine mammography. A total of 87% of patients reported having sexual intercourse prior to SCI, whereas the rate was 67% after injury. Autonomic dysreflexia (AD) and urinary incontinence are the most common problems preventing sexual intercourse. The percentage of women who experienced orgasm before injury, i.e. 79.1%, decreased significantly after the injury (37.3%). In the USA, 70.3% of SCI women use contraception (4). Kalpakijan et al. specified a relationship between menopause and its signs in SCI and non-SCI women (5). The study showed no significant differences in the age of onset of menopause between the groups. However, somatic symptoms, such as urinary bladder infections and decreased libido, were statistically significantly more common in SCI patients. Vasomotor symptoms and vaginal dryness were much more commonly reported by non-SCI patients. SCI women who do not undergo regular gynaecological examinations report difficulty using gynaecological chair, difficulty finding an appropriate doctor or problems with transport as the reasons (2, 4).
The author of this article performed an assessment of patients with physical disability who participated in a questionnaire. The study included 22 physically disabled women aged between 21 and 43 years. Higher education was declared by 7, secondary education by 11 and primary education by 4 respondents. Spinal cord injury was reported by 12 women (complete injury by 4 and partial injury by 8 patients), 4 women had cerebral palsy, myelomeningocele was reported by 5 patients and arthrogryposis by 1 woman. One of the SCI patients became pregnant. Seventeen SCI respondents had their first gynaecological visit between the ages of 17 and 27 years, including 10 women who attended a gynaecologist only once in their life. Regular menstrual cycles were reported by 18 respondents. Sporadic dysmenorrhoea was reported by 9 respondents, and regular dysmenorrhoea by 9 patients. Five respondents had never used contraception; previous or current use of contraception was declard by 16 patients. Condom was the most popular method of birth control. Only three respondents used oral contraceptives. Five patients were virgins. Ten respondents had regular sexual intercourse, with the classic position being the most common choice. Nine patients had a permanent life partner, while 5 respondents had never had one. Urinary incontinence and reduced genital sensitivity were the most commonly reported problems in sexually active patients. Nine women experienced typical discomfort during speculum insertion. Thirteen respondents had never had a smear test. All patients had normally developed internal and external genitals. Gynaecological examination revealed vaginal inflammation in 4 patients; anti-inflammatory treatment was implemented. Ultrasound revealed cysts with a diameter of more than 3 cm in two patients. Polycystic ovaries were detected in one patient. All smear test results were normal. During the program, one of SCI patients became pregnant and stayed under the care of the university outpatient clinic. Among the remaining 21 respondents, only two women had previously been pregnant. One of respondents had three childbirths by vaginal delivery; the other patient underwent a caesarean section (6).
Pregnancy and spinal cord injury
Spinal cord injury is not a contraindication for pregnancy. However, patients should be appropriately educated and the pregnancy should be thoroughly planned once physical and emotional rehabilitation is completed. Jackson and Wadley showed that approximately 14% of women had at least one conception after spinal cord injury. Furthermore, no increase in stillbirth rates or congenital malformations in the foetus were observed in these patients (4). However, prenatal management should be implemented with proper care and knowledge on the measures to be taken in the case of potential complications. Guidelines for antenatal care, delivery and postpartum care in patients with SCI presented in this paper are based on literature data and author’s own experience (7-10).
Antenatal care in SCI patients
The general care of pregnant SCI patients should be conducted in accordance with the recommendations of the Polish Gynaecological Society. Pregnancy-related problems typical for this group of patients should be treated individually and taken into consideration in the course of pregnancy. The most common complications in pregnant SCI patients are shown in table 1 (7-10).
Tab. 1. The most common complications in pregnant SCI patients
Autonomic dysreflexia
Cardiovascular:
– bradycardia
– hypotension
Urinary:
– infections
– increased risk of stones in the urinary tract
– urinary incontinence
Gastrointestinal:
– constipation
Respiratory:
– hypoxaemia
– increased retention of respiratory secretions
– increased susceptibility to pneumonia
Skin:
– decubitus ulcers
Osteoporosis
Anaemia
Increased risk of thromboembolism
Thermoregulation:
– injury above the level of T6 – lack of perspiration
Autonomic dysreflexia (AD)

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Piśmiennictwo
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otrzymano: 2016-06-03
zaakceptowano do druku: 2016-06-24

Adres do korespondencji:
*Monika Łukasiewicz
2nd Department of Obstetrics and Gynecology Centre of Postgraduate Medical Education Father Jerzy Popiełuszko “Bielański” Hospital, Independent Public Health Care Institution in Warsaw
ul. Cegłowska 80, 01-809 Warszawa
tel. +48 (22) 569-02-74
mlukas7@wp.pl

Postępy Nauk Medycznych 7/2016
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