Obstetrical anaesthesia and analgesia in chronic spinal cord-injured women

Abstract

Improved acuteand rehabilitativecareand emphasis on integrating patients into society after spinal cord injury is likely to result in increasing numbers of cord-injured women presenting for obstetrical care. Anaesthetists providing care to these women should be familiar with the complications resulting from chronic cord injury and aware that many may be aggravated by the physiological changes of normal pregnancy. These complications include reduced respiratory volumes and reserve, decreased blood pressure and an increased incidence of thromboembolic phenomena, anaemia and recurrent urinary tract infections. Patients with cord lesions above the T5 spinal level are at risk for the life-threatening complication of autonomic hyperreflexia (AH) which results from the loss of central regulation of the sympathetic nervous system below the level of the lesion. Sympathetic hyperactivity and hypertension result in response to noxious stimuli entering the cord below the level of the lesion. Labour appears to be a particularly noxious stimulus and patients with injuries above T5 are at risk for AH during labour even if they have not had previous AH episodes. Morbidity is related to the degree of hypertension and intracranial haemorrhage has been reported during labour and attributed to AH. We report our experience in providing care to three parturients with spinal cord injuries. Two patients had high cervical lesions, one of whom experienced AH during labour and was treated with an epidural block. The second was at risk for AH having had episodes in the past and received an epidural block to provide prophylaxis for AH. In both cases epidural blockade provided effective treatment and prophylaxis for AH. The third patient had alow thoracic cord lesion, a comfortable labour but required an urgent Caesarean section performed under general anaesthesia for placental abruption and antepartum haemorrhage. The outcome of all three maternal-neonatal pairs was excellent. We recommend antepartum anaesthesia consultation for all cordinjured mothers and an epidural block as prophylaxis against AH in all parturients with cord lesions at T5 or above. © 1992 Canadian Anesthesiologists.