SPINAL CORD INJURY

Irfan Sugiyanto
RSUD dr. Chasbullah Abdul Majid
Kota Bekasi
2017
Definition
• Spinal cord injury (SCI) is diagnosed neurologically. It can occur following
trauma to the spinal cord and also because of a variety of pathologies (e.g.,
neural tube defect, congenital, transverse myelitis, etc.).

Epidemiology
• About 12,000 new spinal cord injuries per year occur in women of
childbearing age in the United States, and each year, about 2000 women
with SCI will become pregnant [1]. SCI diagnosed during pregnancy is rare.
SCI preexisting pregnancy is relatively more common.

(1) National Spinal Cord Injury Statistics Center. UAB

Vincenzo B. Maternal – Fetal Evidence
Spinal Based
Cord Injury Guidelines.
Info Sheet #15.3th USA. 2017AL:
Birmingham,
University of Alabama; 2009. Updated 2012.
[Epidemiologic study]
 Pregnancy Management (Preconception)
• Should be made aware of
Women with
the increased risk of spinal
congenital spinal
cord lesions to their
lesions, such as
offspring and placed on 4
meningomyelocele
mg/day of folic acid (6)
• Are at risk for epidural or
Women with Klippel– subdural hemangiomas and
Trenaunay or von should undergo MRI to
Hippel–Lindau determine the safety of
syndromes neuraxial anesthesia (7)
Pregnancy Management (Prenatal)
• This typically presents with hypotension,
bradycardia, and hypothermia because of
Acutely, SCI results in parasympathetic effects
neurogenic shock or “spinal • Adequate volume resuscitation and pressor
shock” because of the loss of support should be administered
sympathetic innervation

• In those cases, embolization or

In rare cases, acute SCI may decompressive surgery may be
result from acute necessary during pregnancy (7,12)
hemorrhage, malignancy, or
aggressive hemangiomas
Antenatal Management of Preexisting SCI
• Recurrent UTIs and or sepsis are common complications of SCI
• Frequent urinary cultures or antibiotic
Urinary • Intermittent catheterization every four to six hours may be preferable

• Stool softeners and a high-fiber diet to prevent constipation

Gastro
intestinal

• Routine skin exams for any evidence of decubitus ulcers at each

visit and frequent position changes
Dermatology • Supplemental Vitamin D (2000 IU daily) is recommended
Antenatal Management of Preexisting SCI

• possible need for ventilatory assistance in labor are recommended

Pulmonary

• Screen for and treat anemia aggressively

Hematology

• ADR is the most serious complication impacting obstetric management, affecting

about 90% of patients with lesions at or above the level of T6
• The most common sign of ADR is systemic hypertension
Autonomic • ADR may be mistaken for preeclampsia, but several findings may help differentiate
dysreflexia the two conditions
 Preventive Management of ADR
1. Routine bladder catheterization with topical anesthetic
2. Pelvic exams : consider pudendal block or topical anesthetic
(lidocaine) prior to exams. Avoid cold stirrups or
speculums if possible
3. Prophylactic antihypertensive therapy (as necessary to
prevent recurrent ADR) with oral nifedipine (10–20 mg),
terazosin (1–10 mg), or clonidine
4. Epidural anesthesia at the onset of labor
 Treatment of ADR
1. Remove offending stimulus. Expedite delivery if in second
stage with forceps or vacuum or perform cesarean
delivery (discuss this with patient prior to labor)
2. Antihypertensive therapy—rapid onset :
• Nitroprusside (0.5 ug/kg/min intravenously, titrate
to BP) or sublingual sodium nitroglycerin (0.3–0.6 mL)
• Amyl nitrate (one capsule crushed for inhalation)
• Ganglionic blocking agent: trimethaphan (Arfonad),
1 ampule in 500 mL D5 at 3 to 4 mg/min continuous
intravenously
• Prazosin, α–adrenergic blocker: 0.5–1.0 mg PO
• Direct vasodilator: hydralazine, 10 mg orally, or
nifedipine bite and swallow tablet 10 to 20 mg
4. Anesthesia—regional (preferred) or general anesthesia
 DELIVERY
Labor is the period during which ADR is most likely to
arise. Therefore, there should be a plan for delivery in a unit
capable of invasive hemodynamic monitoring
Appropriate antihypertensive therapy should be available at the patient’s
bedside during labor
Continuous hemodynamic monitoring during labor by maternal
electrocardiogram, pulse oximetry, and arterial line should be performed
in patients with baseline pulmonary insufficiency
The rate of spontaneous vaginal delivery and need for
assisted vaginal delivery depends on the level of the spinal
cord lesion. Approximately 30% of SCI patients will be delivered
by cesarean [12,14,23]
 In the postpartum period, bladder distension
and constipation should be avoided. The use
of thromboprophylaxis of SCI patients during
the puerperium is controversial

Post Partum Care

And Breast-feeding should be encouraged

Breast Feeding
Oral contraceptive pills appear to be safe.
Progesterone-only pills, transdermal patches,
intramuscular medroxyprogesterone
injections, condoms and spermicide, and
intrauterine devices are all acceptable.
 GUILLAIN–BARRÉ SYNDROME

Pregnant women with

Guillain–Barré syndrome The use of general anesthesia
The safety and effectiveness can be particularly dangerous in
(GBS) face similar GBS patients,
of plasmaphoresis to treat
challenges. The risk of
GBS in pregnancy have A multidisciplinary team
extreme muscle weakness
been established approach is highly
can lead to paralysis and the recommended.
need for ventilatory support