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ABSTRACT INTRODUCTION Women of childbearing age make up around 5–10% of individuals with spinal cord injury (SCI) and may face unique medical and functional complications during pregnancy,

including prolonged hospitalization and increased risk of early rehospitalization due to falls. CASE PRESENTATION Here, we discuss a case of a young ambulatory woman with a lumbar motor

incomplete spinal cord injury who underwent successful delivery via cesarean section and the role of the physiatrist in the management of the patient’s antepartum, intrapartum, and

postpartum complications. The patient faced significant antepartum challenges secondary to her neurogenic bladder and pelvic floor weakness, resulting in increased use of her manual

wheelchair. The physiatry team assisted with the co-development of a multidisciplinary bladder plan for increased urinary frequency and urinary tract infection prevention with the patient’s

obstetrics physician (OB). In addition, the physiatry team assisted with the procurement of a new wheelchair suited for the patient’s pregnancy and childcare needs in anticipation of

decreased mobility during this time. Regarding intrapartum challenges, the physiatry team worked with the patient and her OB to develop a safe birth plan considering the method of delivery,

epidural usage, and the need for pelvic floor therapy before and after childbirth. DISCUSSION The patient had a successful cesarean section delivery, with return to independent mobility soon

after childbirth. In summary, this case demonstrates that there is a need for a multidisciplinary approach to patients with SCI during pregnancy and that the role of physiatry is critical

to optimizing medical and functional outcomes. You have full access to this article via your institution. Download PDF SIMILAR CONTENT BEING VIEWED BY OTHERS SLEEVE GASTRECTOMY AS A BRIDGE

TO MATERNITY IN A PATIENT WITH OBESITY, INFERTILITY AND TETRAPLEGIA. A CASE REPORT Article 20 January 2024 SUCCESSFUL PREGNANCY AND CESAREAN DELIVERY IN A TETRAPLEGIC,

HOME-INVASIVELY-MECHANICALLY-VENTILATED PATIENT – CASE REPORT Article 28 June 2022 SURGICAL TIMING IN TRAUMATIC SPINAL CORD INJURY: CURRENT PRACTICE AND OBSTACLES TO EARLY SURGERY IN LATIN

AMERICA Article 19 March 2022 INTRODUCTION Women of childbearing age make up around 5–10% of individuals with spinal cord injury (SCI) [1]. Individuals with SCI are at risk of a multitude of

medical complications including autonomic dysfunction, neurogenic bowel and bladder, pressure ulcers, venous thromboembolism, osteoporosis, and muscle spasticity [2]. Women with SCI

experience additional unique challenges regarding reproductive health. While women with SCI can safely achieve pregnancy, labor, and deliver vaginally, providers should be aware of

antepartum, intrapartum, and postpartum complications [2]. Common antepartum complications in women with SCI include urinary tract infections (UTI), pyelonephritis, deep vein thromboses

(DVTs), and worsening of spasticity [3,4,5]. Though pregnancy itself can exacerbate spasticity, an acute to subacute increase in tone should warrant investigation of other common triggers

including UTI, bladder distention, and constipation. UTIs have been reported in anywhere from 5 to 100% of pregnant patients with SCI, with higher percentages in individuals with indwelling

catheters [3, 5, 6]. Current US Preventative Service Task Force guidelines recommend screening for asymptomatic bacteriuria in all pregnant women at least once [7]. Prophylactic antibiotics

are recommended in pregnancy if a patient has a history of recurrent UTIs to prevent pyelonephritis [7, 8]. Guidelines do not exist for management of asymptomatic bacteriuria in pregnant

women with SCI and strong evidence does not exist for or against the use of antibiotic prophylaxis in these individuals [7, 9, 10]. One small study showed that weekly antibiotic prophylaxis

reduced UTI frequency in pregnant women with SCI [10]. Individuals with a history of chronic UTI, pyelonephritis, and SCI should have an informed discussion with providers regarding

prophylactic antibiotics. Several considerations should be made when planning for labor and delivery for women with SCI, due to increased risks in the intra and postpartum time periods [2,

6, 9]. The most common intrapartum complications in women with SCI are premature rupture of membranes and cesarean delivery [3]. Vaginal births are possible in individuals with SCI, barring

the presence of medical indications for cesarean section. Individuals with SCI should be considered for cesarean section if pelvic contractures or poorly controlled autonomic symptoms are

present [11, 12]. Though vaginal births are possible, cesarean deliveries are more common in individuals with SCI as compared to the general population. A Swedish population study of 109

pregnant women with SCI, revealed higher rates of planned and non-planned cesarean sections and labor induction as compared to the general population [5]. Increased rates of cesarean section

have been attributed to higher risk of fetal malposition, preterm labor, and autonomic dysfunction [11, 12]. There is no data evaluating the utility and safety of labor inductions in

individuals with SCI. Recent data has shown that planned induction of low-risk nulliparous women at 39 weeks gestation resulted in lower rates of cesarean section and no statistical

difference in intrapartum complications [13], but this study did not assess individuals with SCI. Additionally, women with SCI experience longer hospitalization stays and higher rates of

re-hospitalization in the year following delivery [3], suggesting they may benefit from close follow up with a care team familiar with SCI related complications. Rehospitalization in this

population was often due to trauma-related injury, such as falls [3], warranting continued assessment of the individual’s mobility needs. Postpartum complications also include higher rates

of postpartum mood disorders, particularly in individuals with cervical injuries [3, 14]. Regular screening for symptoms should occur at postpartum visits using a validated screening tool,

such as the Edinburgh Postnatal Depression Scale [3, 14, 15]. Additional functional complications of pregnancy should be addressed by the SCI trained specialist throughout pregnancy.

Significant weight gain and shift in center of gravity have many implications these individuals, including a higher risk of pressure ulcers. This may necessitate adjustments to the

individual’s wheelchair and their approach to activities of daily living [2, 11]. Here we discuss the case of a young ambulatory woman with a lumbar motor incomplete spinal cord injury who

underwent successful delivery via cesarean section. We describe unique challenges this patient faced during antepartum, intrapartum, and postpartum care and demonstrate a physiatrist’s

critical role in the co-management of these complications and their impact on an individual’s function. PATIENT INFORMATION The patient is a 31-year-old previously healthy female with a

history of an L3 ASIA impairment scale (AIS) C SCI (per the ASIA/ISCoS International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)), after sustaining a crush

injury that resulted in a L1 burst fracture. She underwent open reduction of the fracture with posterior spinal instrumentation and fusion from T12-L2, L1 corpectomy with spinal

decompression, and placement of anterior strut graft from T12-L2. She was discharged to acute rehabilitation and subsequently followed in the outpatient physiatry clinic. Her neurologic exam

remained stable with bilateral distal paraplegia, with decreased sensation below the L3 level. She remained active as a Paralympic swimmer and maintained a full-time job in the community.

Her primary concerns managed by our physiatry team included neurogenic bladder, which was stable and managed with self-straight catheterization, and hamstring tendinopathy, treated with

physical therapy (PT) and extracorporeal shockwave therapy. At seven years post-injury, she achieved pregnancy which was deemed low-risk by her obstetrician (OB). Several complications were

addressed in our physiatry clinic and co-managed with her OB. A timeline of her care can be seen in supplementary Table 1. CLINICAL FINDINGS Prior to conception, the patient had a stable

neurological examination, consistent with an L3 AIS C (per the ASIA/ISCoS International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)) paraplegia. The patient had

full strength and intact sensation of the bilateral upper extremities and bilateral proximal lower extremities, with the exception of 4/5 strength of the right gluteus medius. Bilateral

ankle plantarflexion strength was 1/5 and ankle dorsiflexion strength was absent. The patient had intact sensation to light touch at the L3 level, with decreased sensation bilaterally in the

lower leg and the foot, and preserved sensation over the medial arch of the left foot. The patient presented with bilateral ankle-foot-orthoses (AFOs). There was no evidence of lower

extremity edema at the time. ANTEPARTUM NEUROGENIC BLADDER Since the SCI, the patient managed her neurogenic bladder with intermittent straight catheterization every four to six hours,

complicated by one to two UTIs per year. Initial screening urine culture was negative. The patient developed UTI symptoms at 10 weeks gestation and was in direct contact with her

obstetrician. Urine culture was obtained and grew greater than 100,000 colony forming units per mL _Escheria Coli_. She was initiated on cefalexin, per the bacteria sensitivities. Of note,

she had been admitted to acute care for pyelonephritis as recently as 3 months prior to conception. On further discussion with her OB, the decision was made to maintain cefalexin 250 mg

daily as antibiotic prophylaxis throughout her pregnancy, given her frequent UTIs and hospitalization for pyelonephritis. Repeat urine cultures throughout the pregnancy remained negative and

she remained on prophylaxis until delivery. As her pregnancy progressed, the patient required significantly more frequent catheterization, up to every two hours, with continued intermittent

episodes of incontinence. She was not interested in an indwelling catheter at that time. At 34 weeks pregnant, the patient could not ambulate without experiencing urinary incontinence and

was dependent on briefs. At this time, her OB recommended a trial of a pessary, which was ineffective at relieving the incontinence. The decision was made to utilize her manual wheelchair

(MWC) as a primary mode of mobility, discussed below. Due to suspected ongoing and anticipated exacerbation of pelvic floor weakness by labor and delivery, the patient was referred to pelvic

floor PT for antepartum and post-partum rehabilitation. With increased use of her MWC and pelvic floor therapy, her incontinence decreased significantly over her third trimester. IMPAIRED

MOBILITY The patient’s functional status prior to her pregnancy was modified independent. She utilized multiple mobility aids including an MWC, bilateral AFOs, and left-sided Lofstrand

crutch. The patient’s AFOs and Lofstrand crutch did not require adjustment during her pregnancy. We continued to recommend compression stockings to manage lower extremity edema.

Pre-pregnancy, she used her MWC for extended community mobility and travel. Her MWC was more than 5 years old, with multiple broken components and issues with her front casters and brakes.

In anticipation of increased wheelchair requirements during pregnancy due to weight gain and increased challenges with mobility, a referral was made to an outpatient wheelchair clinic.

Prescribed adjustments to the MWC included low profile air cushion for pressure relief and pain management to increase seated tolerance, double-sided caster to reduce flutter, and ultralight

composition for propulsion efficiency. In addition, the patient was prescribed a wheelchair with an ultralight rigid frame for ease of lifting and transporting into her car and an anterior

frame for sit to stand, ease of mobility, and ease of childcare in the postpartum period. Despite this, the patient experienced delays in receiving her wheelchair from the manufacturer. Her

urinary leakage progressed, and she could no longer ambulate with her crutch without experiencing significant incontinence. She chose to use her MWC for mobility, as opposed to ambulating

with crutches. To ensure timely delivery of the MWC, our medical team coordinated with the physical therapists, communicated directly with the wheelchair manufacturer and supported the

patient’s self-advocacy with her wheelchair representative. INTRAPARTUM CREATING A BIRTH PLAN As mentioned previously, the patient’s initial SCI required spinal instrumentation and hardware

placement at T12-L2. It is recommended that women with SCI receive epidural pain management for labor and delivery to help manage potential autonomic complications during labor for those

with lesions above T6, but specific guidance for lower lesions does not exist [2]. Given her hardware placement, she was deemed high risk for difficult epidural placement and incomplete

coverage of anesthetic due to her SCI [16, 17]. Through a shared decision-making discussion with the patient, we recommended planned induction at 39 weeks to her OB, to allow for epidural

placement in a controlled setting. As her pregnancy progressed, however, the fetus remained in breech positioning, and she was scheduled for a cesarean section. Due to this change in her

birth plan, we discussed the need for rehabilitation immediately post-partum. Activity restrictions after open abdominal surgery typically consists of four to six weeks of reduced activity

and limited lifting, however, these are not standardized [18] and no recommendations exist for those with pre-existing disability. During antepartum visits, we discussed the anticipated need

for additional rehabilitation services including home therapies to address difficulty with transfers and straight catheterizations. We recommended PT and occupational therapy (OT) consults

while she was admitted for her delivery, which we communicated to her obstetrics team. In addition, we discussed with the obstetrics team the importance of placing the patient in a

disability accessible room during antepartum, intrapartum, and postpartum visits to reduce fall risk and facilitate return to regular activities of daily living. She underwent uncomplicated

cesarean section with epidural anesthesia and delivery of a healthy baby. Indwelling catheter remained in place on discharge until patient was able to transfer and perform straight

catheterization independently. PT was consulted and recommended home therapy on discharge. POSTPARTUM IMPAIRED MOBILITY At eight weeks postpartum, the patient reported little to no issues

with mobility in her new wheelchair but reported challenges balancing her own mobility and caring for her infant, such as transferring her infant carrier to the car. Her AFO’s facilitated

effective transfers but no longer fit appropriately, due to fluid shifts and weight changes. She was referred to orthotics clinic to resize her AFO for her mobility needs. NEUROGENIC BLADDER

The patient required indwelling urinary catheter during the cesarean delivery. This remained in place until she was able to transfer independently. Once removed, her urinary frequency

returned to pre-pregnancy baseline and she has returned to her typical catheterization regimen without incontinence. PELVIC FLOOR DYSFUNCTION In the weeks leading up to and following

childbirth, the patient participated in pelvic floor therapy. The patient stated that pelvic floor therapy had been going extremely well. Therapy notes stated that the patient had excellent

transverse abdominus activation with exercises and was continuing to work on lumbostabilization exercises to strengthen the core with a functional goal of returning to swimming. DISCUSSION

Women with SCI can safely achieve pregnancy, labor, and delivery with appropriate management of potential secondary medical complications. In 2020, the American College of Obstetricians and

Gynecologists (ACOG) published guidelines on obstetric care in individuals with spinal cord injury, which highlighted the need for a multidisciplinary team including rehabilitation medicine

physicians [19]. In line with these guidelines, we demonstrated the importance of physiatry co-management with obstetrics, anesthesiology, and rehabilitation therapists. These individuals

benefit from longitudinal care from physicians trained in SCI to manage the secondary medical complications. Unfortunately, studies have shown that women with SCI report difficulty accessing

specialized integrated care in SCI and pregnancy [20]. One Swiss study showed that women were less likely to utilize highly specialized SCI care as compared to their male counterparts [21].

This case demonstrates pregnancy-related complications unique to individuals with SCI and illustrates the need for physiatry’s co-management. In individuals with or without SCI, pregnancy

can increase urinary frequency and therefore increases the frequency of intermittent straight catheterization in those that use this method for bladder emptying. Pregnancy also increases

strain on the pelvic floor musculature [22], the strength of which may be compromised in individuals with SCI. In this case, the increase in pelvic floor pressure and urinary frequency

resulted in a significant change in the patient’s ambulatory status. Several multidisciplinary strategies were implemented to address these symptoms and their functional consequences. The

increased use of the wheelchair and the expected weight gain prompted urgent repairs to her MWC, requiring coordination of multiple providers and the wheelchair manufacturer to ensure

delivery of the MWC during the third trimester. To address pelvic floor strengthening and its impact on urinary frequency and ambulation, the patient was referred to pelvic floor PT,

resulting in subjective improvement that was carried into the postpartum period. Additionally, the obstetrician suggested a pessary to aid in reduction of urinary leakage. Though this did

not provide subjective benefit, this strategy may be useful to other individuals with compromised pelvic floor strength. This case also highlighted gaps in knowledge regarding the safety and

benefits of labor induction and post-partum activity for individuals with SCI. Though this patient’s pregnancy culminated in a cesarean delivery due to breech positioning, preliminary plans

were to pursue vaginal delivery via elective induction of labor. The patient’s hardware placement posed a risk to effective and timely epidural anesthesia [16, 17], necessitating the

discussion of a planned induction. There is an overall lack of data reporting on the efficacy of epidural anesthetic in individuals with a history of spinal cord injury in labor.

Additionally, there is little information in the literature regarding post-operative restrictions after abdominal surgery and no data specific to those with pre-existing disability. Given

the increased risk of prolonged hospitalization and high rate of readmission secondary to trauma for this patient population, it is critical that a physiatrist assesses the mobility needs

and fall risks in these individuals and plans appropriately. In this case, the patient required new mobility aids during the antepartum and postpartum visits and required referrals to both

physical and pelvic floor therapy. This case highlights the critical need for a multidisciplinary approach to patients with SCI during pregnancy and the lack of evidence driven practices for

these individuals. Though women of childbearing age make up a small proportion of individuals with SCI, they require highly specialized care in the setting of pregnancy and more research

should be geared towards this population. This patient relied on a team of providers from physiatry, obstetrics, rehabilitation therapies, and anesthesiology to optimize her care.

Communication between the specialties facilitated the appropriate management of this patient’s pregnancy, ultimately culminating in the birth of a healthy infant. Physiatry played a critical

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https://doi.org/10.1002/ijgo.12513. Article  Google Scholar  Download references AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Spaulding Rehabilitation Hospital, Boston, MA, USA Lauren Hall,

 Connie Hsu, Chloe Slocum & John Lowry * Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA Lauren Hall, Connie Hsu, Chloe Slocum & John

Lowry Authors * Lauren Hall View author publications You can also search for this author inPubMed Google Scholar * Connie Hsu View author publications You can also search for this author

inPubMed Google Scholar * Chloe Slocum View author publications You can also search for this author inPubMed Google Scholar * John Lowry View author publications You can also search for this

author inPubMed Google Scholar CONTRIBUTIONS LH was responsible for outlining the case report, writing the case report, conducting the literature review, and arranging the report for

publication. CH was responsible for writing the case report and arranging the report for publication. CS and JL provided feedback on the report. CORRESPONDING AUTHOR Correspondence to Lauren

Hall. ETHICS DECLARATIONS COMPETING INTERESTS The authors declare no competing interests. ETHICAL APPROVAL The research did not involve human subjects, human material, or human data and is

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unique challenges in pregnancy and delivery in a patient with incomplete lumbar SCI: a case report. _Spinal Cord Ser Cases_ 10, 40 (2024). https://doi.org/10.1038/s41394-024-00652-3 Download

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