Autonomic What? Care of the Pregnant Patient with New Paraplegia

Background:

Spinal cord injury resulting in paraplegia in pregnancy is rare.  SCI alters the function of multiple organ systems and chronic medical conditions are extremely common in this patient population. The obstetric management and nursing care of these women present specific challenges requiring a multidisciplinary approach for maternal and fetal health.

Case: A 24 year old G2P0 patient was transferred to our high risk antenatal unit at 29 weeks gestation from a rehabilitation facility. Her history is significant for a gunshot wound sustained at 15 weeks resulting in paraplegia at level T3 T4.  She had severe neuropathic pain control issues controlled with narcotics; neuropathic bowel  and neuropathic bladder complicated by urinary tract infections.  A foley catheter was in place with macrobid for suppression.  She was on DVT prophylaxis.  She had been started on Baclofen for increased muscle tone, as well as multiple medications for gastrointestinal prophylaxis.  She had a history of depression/anxiety and was  being assessed for PTSD. She was admitted for preterm labor monitoring and the potential for associated autonomic dysreflexia. (ADR).

A multidisciplinary team met multiple times to plan and manage her care. She challenged the OB nursing staff with unfamiliar rehabilitation regiments. Educational materials were compiled to provide  information on her multiple medications, as well as the pathophysiology, signs and symptoms and treatment for ADR. She was initially quite depressed over her transfer from rehab and refused Patient Care Assistant help. Several primary nurses were scheduled to facilitate her care. Fetal surveys showed a normally developing fetus.  She presented to L&D at 31.5 weeks with signs of PTL and concern for autonomic dysreflxia. Her blood pressure remained normotensive and she returned to antepartum . At 33.5 she returned to L&D for labor management.  She was given an epidural for prevention and management of ADR. She had a forcep assisted vaginal delivery. She was discharged to rehab on postpartum day four. Her infant remained in the NICU for prematurity and withdrawal.

Conclusion: There is little current literature on the care of the pregnant patient with spinal cord injury. Nurses serve a crucial role in the facilitation of a multidisciplinary approach in the care these complicated patients. Understanding the chronic medical conditions as well as the potentially life threatening complication of ADR, will allow OB nurses to provide optimal care to patients with SPI during pregnancy and delivery.

Keywords: Spinal cord injury, paraplegia, automomic dysreflexia, high risk pregnancy