Dual Case Study of SCI during Pregnancy
In 2017 approximately 285,000 individuals in the US were afflicted with Spinal Cord Injury (SCI) while the incidence of SCI is 17,500 cases per year. The average age at time of injury is 45 years, with gender breakdown 81% male compared to only 19% female.1 Although pregnancy rates among other chronic mobility disabilities are typically listed as quite similar to those of uninjured females, statistical findings on pregnancy with SCI vary between 2%2 to 14%.3 These numbers may seem low, but to a woman who has paraplegia (paralysis of legs) or tetraplegia, (paralysis of legs and arms) who wishes to start a family, they may be alarmingly high. What most patients do not recognize is that SCI itself does not significantly alter fertility (only 12% of SCI women report infertility or difficulty conceiving, however this may not be due to SCI). Although immediately post-injury most women (50-85% depending on level of injury) experience amenorrhea, this is most often only temporary.4 The purpose of this case study is to raise awareness in the neurologic Physical Therapy (neuro PT) community of both the probability and possibility of carrying a baby to full term, while additionally safely managing pregnancy with SCI. In turn, it serves to prepare the neuro PT community for safe rehabilitation management for this cohort of patients. The vastly different episodes of care of the two extraordinary women discussed in this article (1 incomplete SCI, meaning some sensory or motor control below level of injury, and 1 complete SCI, meaning no sensory or motor control below level of injury)5 support the fact that females who have sustained an SCI maintain their fertility6 and capability of birthing children if they remain active and are monitored by the proper high risk medical and rehabilitation teams.
The first patient is MT, an 18-year-old who sustained paraplegia with a diagnosis of T4 AIS A on the American Spinal Injury Association Impairment Scale two years prior from a gunshot wound. MT received rehabilitation at a local children’s hospital prior to pregnancy and presented to Kessler Institute for Rehabilitation (outpatient SCI therapy gym) in 2017 at five months pregnant, receiving PT three days per week. She conceived naturally and was being managed by a high risk OB-GYN who recommended PT due to increased difficulty with transfers and functional mobility, as well as increased caregiver dependence. Please note her objective measures taken during her first bout of PT in the chart below. She experienced a significant decline in independence in regards to her transfers as compared to prior to pregnancy, from an independent level to maximal assistance with a transfer board. This significant change was due to increase in girth, change in base of support, change in center of mass, decrease in body awareness, and patient report of being fearful of “hurting the baby”. MT scored a maximal reach score of 3 inches on The Modified Functional Reach scale (MFR- a fall risk assessment validated for SCI) indicating an elevated fall risk. Her PT goals included improving her upper extremity strength and sitting balance to assist in transfers and activities of daily living (ADL), posture, cardiovascular endurance, and maintaining flexibility while reducing swelling.
MT unexpectedly ceased PT services due to laboring naturally at nine months, although she had been scheduled for an induction at 9.5 months. She began suspecting contractions due to feeling symptoms of autonomic dysreflexia (AD) while at home, although she reportedly could not localize the sensation due to paralysis. MT stated that she had felt this sensation a few times prior and visited the emergency room with resulting diagnoses of contractions, however not active labor. MT delivered via uncomplicated cesarean section (C-section) and was able to breastfeed immediately, taking her baby home within days. She returned to therapy two days per week at six months post-birth to improve balance, transfers and functional mobility.
The second patient is SM, a 41-year-old female who was fifteen weeks pregnant (natural conception) with her second child when she was diagnosed with sensory incomplete paraplegia from Transverse Myelitis, with no motor function in her lower extremities. She began her therapy at five months pregnant due to her acute diagnosis and paralysis requiring comprehensive inpatient rehabilitation, and began her outpatient course at seven months pregnant. Her primary means of mobility was a power wheelchair and her transfers were at a moderate assistance level with a transfer board. She was unable to complete an MFR without losing her balance (max score of 0 inches) indicating a significant fall risk. Her outcome measures are detailed in a chart below. She was also receiving her medical management from a high risk OB-GYN, and was receiving additional PT services at a second facility (totaling five days per week) due to insurance allowance. Her goals aligned with MT’s, including strengthening, balance, posture, cardiovascular endurance and flexibility. However since her spinal paralysis was acute and from a potentially incomplete disease process, her therapy additionally included orthostatic tolerance training via tilt table/standing frame, passive cycling to lower extremities with and without electrical stimulation (cleared by her OB-GYN) to maintain muscle mass and circulation, and neuromuscular re-education below her level of injury via functional electrical stimulation and active assisted lower extremity exercises.
Similar to MT, SM unexpectedly ceased PT services due to laboring naturally at 8.5 months, displaying significant vaginal bleeding post- PT session, although she had also been scheduled for an induction at 9.5 months. SM was immediately rushed to a nearby hospital and had a complicated C-Section resulting in a short NICU stay. Two weeks later, a healthy and thriving breastfed baby was brought home. SM returned to PT at one month post-birth following clearance by her high-risk OB-GYN due to the immediacy precluding typical post-birth exercise recommendations (general recommendation is to hold vigorous exercise until six weeks after vaginal birth, or eight weeks after C-section, however the American College of Obstetricians and Gynecologists reports that you can begin with gentle exercises, like pelvic floor exercises, within a few days).
Although the two patients varied greatly in their injury types as well as birth experiences, their rehabilitation precautions remained the same, as should all females who are receiving PT while pregnant (aside from individual allowances determined by their high-risk doctors- which occurred for SM who was cleared to receive functional stimulation to her lower extremities only). The general contraindications to exercise during pregnancy are listed below7:
- Active heart and/or lung disease
- Cervical insufficiency or Cerclage
- Pregnant with multiple children with risk factors for preterm labor
- Placenta Previa after 26 weeks of pregnancy
- Preterm labor or ruptured membranes during this pregnancy
- Preeclampsia (pregnancy-induced High Blood Pressure)
- Severe Anemia
Relative Contraindications/ Precautions:
- Extreme morbid obesity
- Extremely underweight (BMI less than 12)
- Intrauterine growth restriction
- Poorly controlled Hypertension, seizure disorder, thyroid disease or Diabetes Mellitus
- Orthopedic limitation
- Maternal Cardiac Arrhythmia
- Heavy smoker
- Chronic Bronchitis
- History of extremely sedentary lifestyle
There are certain recommendations and warnings that should be followed by all pregnant SCI patients, and they are as follows:8
Physical Activity Recommendations:
- At least 150 minutes of moderate intensity aerobic exercise, weekly (walk, swim, recumbent bicycle, modified Yoga or Pilates)
- Light weightlifting at moderate repetitions
- Short exercise bouts in cool temperatures
- Assess changing wheelchair positioning and pressure relieving cushion if decreased sensation/ insensate
- Avoid during Physical Therapy or Exercise:
- Physical Modalities (electrical stimulation, diathermy, laser therapy, ultrasound, thermotherapy)
- Valsalva Maneuver
- Supine exercise after the first trimester (Gravid Uterus may obstruct Aorta and Inferior Vena Cava, causing decrease in Uteroplacental blood flow and venous return to the heart)
- Heavy lifting (specified by MD)
- Excessive abdominal strengthening post- Diastasis Recti (separation of abdominal muscles due to hormonal changes and tissue stretch)
- Plyometrics or overstretching
When treating the pregnant SCI woman it is important to consider the systemic and physiological changes that are occurring including (but not limited to) the following9: bladder/bowel incontinence, frequency to intrathecal catheterize, urinary tract infection, constipation, dyspnea, increased risk of pneumonia & aspiration from vomiting with weakened cough, increased risk of deep vein thrombosis, skin breakdown from pressure differences (more detail to follow due to importance of monitoring this change), spasticity (cease of medications), imbalance (altered center of gravity), posture, increased dependence for transfers and functional mobility, fatigue, autonomic dysreflexia (for persons at or above the level of T6) causing preeclampsia which can cause early labor, and orthostatic hypotension. As noted above, patients are at risk of skin breakdown and pressure injuries due to the changing weight, susceptibility to anemia and changing nutritional demands that can alter healing if a pressure injury were to occur. Additionally, it is of the utmost importance for the labor and delivery team to monitor the patient’s skin due to decreased sensation and prolonged positioning.10 Due to patients’ continued weight gain and change in weight distribution they will require adjustments made to their wheelchair including the pressure relieving cushion to prevent skin breakdown. Patients in manual wheelchairs may require adaptive power assist components to maintain independence due to limited pushing ability while pregnant.11
There are also some practical details to keep in mind which assist in maintaining a safe treating environment for pregnant patients who have had an SCI. These can include simple positional setups such as reclining on large wedges instead of supine, or pelvic positioning accommodations through strapping on the mat or wheelchair/cushion adjustments. While in a safe setup, patients can then do light weight lifting and/or work on seated balance without being at risk of abdominal trauma, thus risking patient and baby safety. Therapists may also employ adaptive equipment such as slide boards to increase ease and safety of transfers even if a patient wasn’t using equipment prior. Always monitor heart rate and rate of perceived exertion. In order to achieve cardiovascular activity, alternate forms should be encouraged including upper body ergometer, lower extremity passive cycling, or referrals to adapted yoga or aqua therapy can be made if available.
Pulmonary function can be compromised in all patients with high thoracic or cervical spine injuries and is particularly important to be aware of with the pregnant SCI population. Supine position, as noted above, may further impede pulmonary function.12 Due to the growing baby and limited space for lung expansion secondary to pressure from the diaphragm, pulmonary function can be compromised. For some patients with a spinal cord injury their ability to cough is weakened from limited muscle innervation and they are at an elevated risk for aspiration. Additionally, patients will need modified positioning for assisted cough, assisting above the baby as to not cause harm.7
Keeping the above mentioned recommendations and precautions in mind, MT and SM both returned to therapy after their births displaying some immediate and some gradual improvements in their objective measures as outlined in the charts below including the Modified Functional Reach Test, The Neuromuscular Recovery Scale (NRS- an SCI specific measure of recovery of functional task ability)13 and transfer/mobility functional status. MT’s rehabilitation focused on returning to her prior level of modified independence in transfers and wheelchair level mobility in addition to para-gait training and receiving custom knee ankle foot orthoses (KAFOs). Her focus was geared in this direction due to her SCI being chronic/ complete and addressing her compensatory bracing and training needs for at home weight bearing and exercise purposes. Comparatively, SM’s rehabilitation, was heavily concentrated on recovery utilizing various equipment, assistive devices and technology to stimulate neuromuscular re-education. She used standing frames, functional electrical stimulation to her legs and trunk during static and dynamic activities via the Xcite system, and robotic-assisted body weight supported gait training via the G-eo system. As outlined in the charts, within a few months, both patients returned to modified independence in transfers, improved in functional task ability, and decreased their fall risk. Due to the nature of her SCI being incomplete, SM began to display return in both sensation and volitional movement (at a 1 or 2-/5 score on the Manual Muscle Test) within weeks of returning to therapy.
In closing, the rare case of SCI during pregnancy should not be overlooked by the neurologic Physical Therapist due to the ongoing fertility of females who are child-bearing age. Hopefully, with the appropriate sexual health information, PT’s can educate patients with SCI of the ability to successfully conceive, birth and even breastfeed (although recent studies have mentioned decreased rates at or above T6 level of injury14) babies with high-risk OB-GYN monitoring. In turn, these patients can go on to be maximally independent and actively raise their children utilizing any adaptations that they may need.
|Initial Evaluation (following birth)
|Modified Functional Reach||3 inches||3 inches||0 inches||5.5 inches|
|Neuromuscular Recovery Scale (NRS)15||Sit: 1C
Reverse Sit Up: 1C
Sit Up: 1C
Trunk Extension: 1B
Sit To Stand: 1B
Reverse Sit Up: 2A
Sit Up: 1C
Trunk Extension: 1B:
Sit To Stand: 1B
Stand and Walking: not tested
Reverse Sit Up: 1C
Sit Up: 1C
Trunk Extension: 1A
Sit To Stand: 1B
Reverse Sit Up: 2A Sit Up: 2B
Trunk Extension: 1B
Sit To Stand: 1B Stand: 1C
|Transfers||Transfer with transfer board: maximal assistance||Transfer with transfer board: minimal assistance||Transfer with transfer board: minimal – moderate assistance||Lateral transfer without board: modified independence|
|Outcome||Initial Evaluation June 2018||Re-Evaluation July 2018||Initial Evaluation (following birth) September 2018||Re-Evaluation October 2018|
|Modified Functional Reach||0 inches||1.7 inches||2.3 inches||5 inches|
|Neuromuscular Recovery Scale (NRS)||Sit: 1B
Reverse Sit Up: 2A
Sit Up: not tested due to positioning
Trunk Extension in Sitting: 1B (modified positioning)
Sit To Stand/ Stand Walking: not tested
Reverse Sit Up: 2A
Sit Up: 1C (tested quickly due to positioning)
Trunk Extension in Sitting: 1B (modified positioning),
Sit To Stand/ Stand /Walking: not tested
Reverse Sit Up: 1C Sit Up: 1C
Trunk Extension in Sitting: 1B
Sit To Stand: 1B
Reverse Sit Up: 2A Sit Up: 2B
Trunk Extension in Sitting: 1C
Sit To Stand: 1B Stand: 1B Walking: 2A
|Transfers||Transfer with transfer board: contact guard at trunk, moderate assistance for lower extremity management||Transfer with transfer board: close supervision, minimal assistance for lower extremity management||Lateral transfer without board: minimal assistance||Lateral transfer without board: modified independence|
- National Spinal Cord Injury Statistical Center. (2016). Facts and Figures at a Glance. Birmingham, AL: University of Alabama at Birmingham. https://www.nscisc.uab.edu/Public/Facts%202016.pdf. Accessed April 20, 2017.
- Iezzoni LI, Chen Yuying, et al. Current Pregnancy Among Women with Spinal Cord Injury: Findings from the U.S. National Spinal Cord Injury Database. Spinal Cord. 2015; 53(11): 821–826.
- Jackson, A.B. and V.A. Wadley, A multicenter study of women’s self-reported reproductive health after spinal cord injury. Arch Phys Med Rehabil, 1999. 80: p. 1420-1428.
- Spinal Outreach Team (2017). The impact of a spinal cord injury on pregnancy, labour and delivery: What you need to know, Brisbane, Queensland: Queensland Health.
- Schuld C, Franz S, Brüggemann K, et al. International standards for neurological classification of spinal cord injury: impact of the revised worksheet (revision 02/13) on classification performance. J Spinal Cord Med. 2016;39(5):504-12.
- Pannek, J. and S. Bertschy, Mission impossible? Urological management of patients with spinal cord injury during pregnancy: a systematic review. Spinal Cord, 2011. 49(10): p. 1028-32.
- American Congress of Obstetrician and Gynecologists. (2018). Exercise during pregnancy. http://www.acog.org/Patients/FAQs/Exercise-During-Pregnancy. Accessed October 12, 2018.
- Garland, M.. Physical Activity During Pregnancy: A Prescription for Improved Perinatal Outcomes. The Journal for Nurse Practitioners. 2017; 13(1), 54-58.
- Spinal Outreach Team (2017). The Impact of Spinal Cord Injury on Pregnancy. Brisbane, Queensland: Queensland Health. https://www.health.qld.gov.au/__data/assets/pdf_file/0027/425772/pregnancy-sci.pdf
- Jackson A and Lindsey L. Pregnancy and Women with SCI. Birmingham: Medical RRTC; 1998:1-4. Available at: https://askus-resource-center.unitedspinal.org/?pg=kb.page&id=1586. Accessed November 5, 2018.
- Sexual Health Rehabilitation Service at Vancouver Coastal Health, Spinal Cord Injury BC, and BC Women’s Hospital. Pregnancy and Spinal Cord Injury. An Information Booklet for Women with SCI. Vancouver: Spinal Cord Injury Association of BC; 2015:1-16. Available at: https://scisexualhealth.ca/wp-content/uploads/2015/05/Pregnancy-and-SCI-booklet-V7.pdf. Accessed November 5, 2018.
- Obstetric Management of Patients with Spinal Cord Injuries. ACOG Committee Opinion No. 275. American College of Obstetricians and Gynecologists. Obstet Gynecol 2002;100:625–627.
- Velozo, Craig et al. Validity of the Neuromuscular Recovery Scale: A Measurement Model Approach Archives of Physical Medicine and Rehabilitation. 2015; 96(8):1385 – 1396.
- Holmgren T, Lee A, Hocaloski S, et al. The Influence of Spinal Cord Injury on Breastfeeding Ability and Behavior. Journal of Human Lactation. 2015; 34(3): 556-565.
- For further info on NRS scale refer to the NRS: A New Outcome Measure for Spinal Cord Injury Based on Pre – injury Function, Not Compensation: Neuromuscular Recovery Scale. Combined Sections Meeting 2013 San Diego, CA January 21 – 24, 2013.