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Autonomic Dsyreflexia: Management in the Laboring Patient
Abstract Number: S-09
Abstract Type: Case Report/Case Series
Around 2,000 women with spinal cord injuries (SCI) may become pregnant each year in the United States (1). Anesthesia providers must become familiar with the proper management of SCI patients, should any of its associated complications occur during delivery, namely that of Autonomic Dysreflexia (AD).
Our patient is a 37 year old G1P0 at 36w5d with a medical history significant for C6 paraplegia following a gunshot wound to her neck in 1992. She presented in active labor, with signs and symptoms evident of autonomic hyperreflexia, including diaphoresis and vasoconstriction. A labor epidural was placed, after which the diaphoresis greatly subsided. At the time of delivery, the patient became extremely hypertensive. She responded promptly to a small bolus of nicardipine and an arterial line was placed for hemodynamic monitoring. After delivery, with the noxious stimulus resolved, the patient became profoundly hypotensive. The LEA was stopped and fluid resuscitation began, to which she responded well.
When spinal cord injuries occur at a level of T6 or higher, the spinal cord loses its ability to maintain proper autonomic control of the abdominal viscera and organs, leading to sympathetic overactivity in response to noxious stimuli caudal to the level of SCI (2). Intact sensory nerves below the SCI sense noxious stimuli and activate a sympathetic response, causing an increased blood pressure. Baroreceptors sense the increased BP and counter this with parasympathetic input. However, such input is impeded by the SCI, leading to the key presentation of AD, that of sympathetic input below the level of the SCI, and parasympathetic input above the SCI.
Typical presentation of AD includes systolic BP elevation by 20-40 mmHg above baseline, headache, bradycardia, flushing of the face, and profuse sweating above the level of the lesion with pale, cold skin below the lesion (3). Bowel or bladder distension are common causes of AD, however uterine contractions can also lead to this.
AD is best avoided in the laboring patient with early initiation of LEA (1). If this fails to control the blood pressure, it is recommended that BP be pharmacologically lowered (3). Noxious stimuli should be removed quickly, as untreated AD can lead to devastating outcomes such as stroke, myocardial infarction, coma, and death (2).
Prompt recognition and treatment are integral management strategies of Autonomic Dysreflexia, because left untreated, it can lead to deleterious sequelae.
Camune, Barbara. “Challenges in the Management of the Pregnant Woman with Spinal Cord Injury.”
Journal of Perinatal and Neonatal Nursing 27. 3 (2013): 225-230.
Furlan, Julio. “Autonomic Dysreflexia: A Clinical Emergency.” Journal of Trauma and Acute Care Surgery
75.3 (2013): 496-500.
Milligan, James et al. “Autonomic Dsyreflexia.” Canadian Family Physician 58.8 (2012): 831-