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Peripartum Anesthetic Management in Patients With Chronic Spinal Cord Injury
Abstract Number: F 59
Abstract Type: Case Report/Case Series
Introduction: Chronic spinal cord injury impacts multiple organ systems and complicates peripartum obstetric anesthetic management. The current literature describing anesthetic management of this patient population during pregnancy is limited (1).
Methods: The records of all women admitted for delivery at Mayo Clinic, Rochester, Minnesota between January 2001 and May 2012 were searched using ICD-9 codes or free-text query for terms relating to spinal cord injury. Only patients with upper motor neuron symptoms at the time of delivery were included. Data pertaining to labor, delivery, and post-partum management were abstracted from each patient’s medical record.
Results: Nine deliveries occurred in 8 patients with chronic spinal cord injury. Median time from cord injury to delivery was 13 years (range = 2-19 years). Six women underwent trial of labor. All patients who had successful vaginal delivery had epidural analgesia. Cesarean delivery (CS) was performed in the remaining 3 women because of fetal distress (n=1) or arrest of dilation (n=2). In these patients, surgical anesthesia was provided with epidural (n=1), spinal (n=1), and general (n=1) anesthesia (GA). Three women underwent elective CS under epidural (n=1), spinal (n=1), and GAl (n=1)a. Of these, 2 were performed for obstetric reasons and one was performed to avoid complications of severe autonomic hyperreflexia (AH). In this latter patient, epidural placement failed and the CS was performed via GA.
Four subjects had a history of AH prior to pregnancy and collectively had 5 deliveries. 1 patient had 2 vaginal deliveries both via epidural anesthesia and 3 patients had CS: 2 with epidural analgesia and 1 with GA. Three of the 5 deliveries were performed with invasive arterial pressure monitoring. Three of 4 patients experienced symptoms of AH in the peri-delivery period. One patient had symptoms only during second stage of labor (ie, headache and hypertension) that was treated with an epidural bolus and intravenous hydralazine. Two patients with AH who underwent CS had postsurgical symptoms in their postpartum room remote from delivery. These episodes were self-limited and did not require treatment. No other adverse maternal peripartum or neonatal events were noted.
Discussion: Spinal cord injury complicates peripartum anesthetic management. Sixty-seven percent of the pregnancies in this study resulted in a CS. This is higher than the national average of 32.3 percent reported by the Centers for Disease Control in 2009 (2). Epidural analgesia may be useful to attenuate AH but does not eliminate the risk of AH, especially during the second stage of labor. Further, AH episodes are common after delivery.
1. Cross LL. Paraplegia. 1992;30:890-902.