🤰 Pregnancy and Spina Bifida: Challenges, Risks, and Management
Spina bifida, a neural tube defect, has significant implications for pregnancy. The level of spinal cord involvement, associated neurological impairments, and the unique physiological changes during pregnancy determine the risks, complications, and management strategies. Here's an exhaustive look at pregnancy in women with spina bifida.
🧠 Levels of Spinal Cord Involvement
🩺 Cervical Spine (C1–C8)
- Rarely linked to spina bifida but can severely affect:
- Breathing and respiratory function.
- Upper limb and body strength.
🩺 Thoracic Spine (T1–T12)
- Lesions above T6 carry a high risk of autonomic dysreflexia (AD), a potentially life-threatening condition during pregnancy.
- Reduced trunk control and respiratory capacity are common.
🩺 Lumbosacral Spine (L1–S5)
- Most commonly affected in spina bifida.
- Impacts:
- Lower limb function and mobility.
- Bladder and bowel control.
🤰 Maternal Risks During Pregnancy
🦽 Mobility and Postural Issues
- Worsening of pre-existing mobility limitations during pregnancy.
- Increased risk of pressure sores due to weight gain and immobility.
- Requires frequent physiotherapy and adaptive equipment to maintain comfort.
🧴 Urinary Tract Infections (UTIs)
- Neurogenic bladder leads to incomplete bladder emptying or incontinence.
- Recurrent UTIs increase the risk of triggering AD.
🚨 Autonomic Dysreflexia (AD)
- Occurs in lesions above T6 and can be triggered by:
- Bladder distension.
- Uterine contractions.
- Constipation or pressure sores.
- Symptoms include:
- Severe headache, flushing, bradycardia, and hypertension.
- Potential for cardiac complications if untreated.
- AD is a medical emergency requiring immediate intervention.
😮💨 Respiratory Complications
- Lesions above T4 may impair respiratory muscles, reducing lung capacity.
- Breathing difficulties worsen in late pregnancy due to the growing uterus.
🩸 Venous Thromboembolism (VTE)
- Immobility combined with pregnancy significantly increases the risk of deep vein thrombosis (DVT) and pulmonary embolism.
💩 Bowel Dysfunction
- Pregnancy hormones exacerbate constipation in women with neurogenic bowel dysfunction.
- Unmanaged constipation can trigger AD.
🩺 Delivery Challenges
- Vaginal delivery is generally preferred but may be complicated by:
- Pelvic contractures.
- Spasticity.
- Fetal malposition (e.g., breech or transverse lie).
- Cesarean section may be necessary for obstetric indications.
🩹 Anemia
- Chronic illness and nutritional challenges often increase the risk of anemia during pregnancy.
👶 Fetal Risks
🧬 Congenital Anomalies
- Women with spina bifida have an increased risk of passing on neural tube defects to their babies.
- Maternal folic acid deficiency is a significant contributing factor.
🕒 Preterm Birth
- Common due to:
- Uterine overdistension.
- Infections.
- Complications such as AD.
🚼 Malpresentation
- Breech or transverse lie is more frequent in pregnancies complicated by spina bifida.
- Reduced abdominal muscle tone in higher lesions contributes to this issue.
📉 Intrauterine Growth Restriction (IUGR)
- Impaired uterine blood flow can lead to restricted fetal growth.
💔 Fetal Distress
- Maternal hypertensive episodes caused by AD can reduce placental perfusion, leading to fetal hypoxia.
🩺 Management Strategies
🩹 Pre-Conception Care
- Folic Acid Supplementation:
- High-dose folic acid (4–5 mg/day) at least 3 months before conception to reduce the risk of neural tube defects in the fetus.
- Multidisciplinary Assessment:
- Pre-pregnancy evaluation by neurologists, urologists, and obstetricians to optimize health.
- Medication Review:
- Adjust or discontinue teratogenic medications.
🩺 Antenatal Care🤰
📝 General Antenatal Care
- Follow NICE antenatal guidelines for general care.
- Individualized management of pregnancy complications caused by SCI.
- Early assessment by a dedicated consultant obstetrician in the first trimester.
- Multidisciplinary team (MDT) involvement, including:
- Obstetric anesthetist.
- Spinal nurse.
- Specialist midwife and nurse.
- Physiotherapist and occupational therapist.
- Named spinal consultant involvement only if required.
- For women living far from a specialist center, concurrent care is provided by a local obstetrician and community midwife.
🛏️ Admission Late in Pregnancy
- Recommended in the third trimester to prevent unattended delivery.
- Women receive contact numbers for the spinal ward and delivery suite.
🚼 Antenatal Problems in Lesions Above T10
- Perception of fetal movements:
- Normal in lesions below T10.
- Altered in lesions above T10. Movements may trigger minor episodes of autonomic dysreflexia (AD).
- Uterine contractions:
- Altered perception in lesions above T10.
- Women are taught abdominal palpation to detect contractions.
- Fetal malpresentation:
- Breech or transverse lie more frequent in lesions above T10, possibly due to reduced abdominal muscle tone.
- External cephalic version (ECV) offered for uncomplicated breech presentations.
🩸 Thromboprophylaxis
- Increased risk of thromboembolism in the first 6 months post-SCI.
- After 6 months, the risk is similar to the general population due to vessel remodeling.
- Local practice follows RCOG guidelines for thromboprophylaxis:
- Score of ‘1’ for immobility in chronic SCI.
- Low-molecular-weight heparin (LMWH) is often used.
😮💨 Respiratory System
- Lesions above T4 may cause partial or complete paralysis of ventilation muscles, leading to:
- Difficulty breathing as pregnancy advances.
- Respiratory function assessment:
- Recommended at booking for lesions above T6.
- Chest physiotherapy, CPAP, or mechanical ventilation advised if needed.
- Mechanical ventilation considered if vital capacity drops below 12–15 mL/kg.
❤️ Cardiac Considerations
- Baseline blood pressure and pulse recorded at booking and every antenatal visit.
- Tetraplegic women may experience:
- Bradycardia (40–50 bpm).
- Hypotension (80/50 mmHg).
- Rise in systolic BP (20–40 mmHg above baseline) is a sign of AD.
- Bradycardia may resolve over time but can recur with respiratory suctioning, hypoxia, or AD episodes.
🩺 Renal and Bladder Function
- Pregnancy exacerbates urinary incontinence due to:
- Neurogenic bladder.
- Incomplete bladder emptying.
- Increased risk of urinary tract infections (UTIs).
- Local practice treats asymptomatic bacteriuria only if:
- Symptomatic with cloudy urine, fever, frequent spasms, or AD.
- Catheter management:
- Indwelling or suprapubic catheters may be needed due to incontinence or mobility limitations.
- Catheter changes recommended within 24 hours post-surgery to prevent infection.
💩 Bowel Management
- Pregnancy and SCI are independent risk factors for constipation.
- In susceptible women, unmanaged constipation can trigger AD.
- A good bowel care routine includes:
- Increased fiber intake.
- Timed bowel movements using the gastrocolic reflex.
- Laxatives or digital evacuation if necessary.
🩹 Skin Care
- Pregnancy increases the risk of decubitus ulcers due to:
- Weight gain.
- Tissue edema.
- Immobility.
- Local practice includes:
- Waterlow score for pressure ulcer risk assessment.
- Regular skin examinations and meticulous care.
- Use of pressure-relieving devices.
💉 Analgesia in Labour
- Lesions above T6:
- Early epidural or combined spinal-epidural is recommended for AD prevention.
- Block height of T8–T10 is adequate.
- Continuous spinal anesthesia may be required if scar tissue prevents proper epidural spread.
- Lesions below T6:
- Women can choose their preferred analgesia, including epidural.
- Lesions above T10 may not require analgesia as sensory nerves enter at T11–L1.
👶 Preterm Delivery
- Historically thought to be high in SCI pregnancies, but recent data show:
- Preterm birth rate reduced with frequent surveillance and proper management of UTIs and pressure ulcers.
- Rate of 15% late preterm births reported in some studies.
🏥 Labour and Delivery
📋 General Considerations
- Pain Perception:
- Lesions above T10 may result in unperceived labour or sympathetic symptoms (e.g., scalp tingling, increased spasms).
- Lesions below T10 cause painful contractions.
- Hospital Admission:
- From 36+6 weeks for daily CTG and 4-hourly uterine activity monitoring.
- Educate on signs of labour and abdominal palpation.
🚑 First Stage of Labour
- Early admission to the delivery suite for familiarity.
- Pain management:
- Early epidural for high-risk AD cases.
- Application of topical anesthetics for vaginal examinations or catheter insertion.
- Bladder management:
- Indwelling catheter to prevent AD due to bladder distension.
🚼 Second Stage of Labour
- Address spasms with optimal positioning.
- Avoid forced flexion during spasms.
- Instrumental delivery (e.g., forceps) may be required for uncontrolled AD.
🩹 Third Stage of Labour
- Active or physiological management based on individual needs.
- Avoid ergometrine if at risk of AD.
✂️ Cesarean Section
- Indicated only for obstetric reasons.
- Post-surgical care includes:
- Early physiotherapy.
- Regular repositioning to prevent pressure sores.
🌸 Postnatal Care
🤱 Breastfeeding
- Breastfeeding is generally possible but may require additional stimulation (e.g., oxytocin nasal spray) for lesions above T4.
- Baclofen is safe for breastfeeding mothers.
⚕️ Contraception
- Fertility is unaffected in chronic spina bifida.
- Combined oral contraceptives are avoided due to thrombosis risk.
- Progestogen-only methods or sterilization are preferred.
- IUD use requires caution due to the risk of AD and limited mobility for thread checks.
🌟 Long-Term Considerations
- Parenting adaptations, such as wheelchair-accessible cribs, ensure better postpartum care.
- Psychological support is essential, as the physical and emotional challenges of pregnancy and parenting can increase the risk of depression in women with spina bifida.
With comprehensive and multidisciplinary care, women with spina bifida can successfully navigate the challenges of pregnancy, ensuring a healthy outcome for both mother and baby. Proper planning and monitoring are key to addressing complications and promoting well-being.
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