Wednesday, November 28, 2007

Nursing Strategies in the Pregnant Client With Spinal Cord Injuries

Spinal cord injuries (SCI) and pregnancy can be a potentially fatal combination for both the mother and fetus; nurses must be alert to signs and symptoms of complications and be prepared to use interventions including pharmacologic and nonpharmacologic measures along with preventative plans of care. It is the nurse’s responsibility to educate the pregnant, spinal cord-injured client about potential complications of this high-risk situation as most women in this position wonder if pregnancy should be avoided.

Autonomic Dysreflexia (also known as hyperreflexia), is an exaggerated sympathetic response in clients with spinal cord injuries. The pathophysiology of autonomic dysreflexia begins with a noxious or painful stimulus below the level of the lesion on the spinal cord. There are many precipitants that may trigger this dangerous hypertensive cycle with most common to include: a distended bowel or bladder, a pressure sore, restrictive clothing, an ingrown toenail, or labor (Blackmer, 2003). This noxious stimulus will trigger an afferent motor nerve that sends the message toward the brain about the potential tissue harm, pain, or damage. However, in the client with a spinal cord injury the message is blocked in its path at the level of the lesion and detoured to the autonomic nervous system. Once the autonomic nervous system receives this pain message, it begins to release neurotransmitters which cause vasoconstriction with a sudden and dangerous elevation in blood pressure (20 to 40 mm Hg above baseline). According to Essat (2003) the pressure receptors in the aortic arch of the heart sense the increase in blood pressure and attempt to correct the problem by sending another message asking the brainstem to slow the heart rate via vagal stimulation. In addition to slowing the heart rate, the brainstem also sends an efferent sympathetic message to correct the issue, although the message pathway encounters the same block. Hypertension and bradycardia continue until the noxious stimulus is eliminated.
It is important for the nurse to differentiate between the elevated blood pressure associated with autonomic dysreflexia and preeclampsia. In 2005 Bycroft, Shergill, Choong, Arya, and Shah reported that both autonomic dysreflexia (32%) and preeclampsia (38%) were found at relatively high rates among women with spinal cord injuries. Hypertension with preeclampsia will rise and fall with contractions and will disappear after delivery; a hypertensive crisis associated with autonomic dysreflexia will continue to rise until the noxious stimulus is removed regardless of uterine contractions. Nurses should include the common signs and symptoms of autonomic dysreflexia in the education care plan, because often times this sympathetic nervous system response may be their only sign of the onset of labor. Bycroft et al. (2005) reported that the presentation of this disorder makes the definition of autonomic dysreflexia a difficult syndrome to detect. Diagnostic clinical criteria have been suggested for autonomic dysreflexia; however it has been compromised by the increase in systolic blood pressure by at least 20%, and the following: sweating, chills, cutis anserine ("goose flesh"), headache, or flushing.
Pregnant clients with spinal cord injuries are at great risk for developing deep vein thrombosis (DVT) due to the immobility associated with spinal cord injuries. In consideration of Virchow’s triad (hypercoaguability, stasis, and endothelial injury) it is important to keep the legs moving to promote lower extremity circulation. According to Ethans (n.d.) nurses should recruit assistance from outside departments (such as physical therapy) to educate the pregnant client on active and passive exercises to promote blood flow. Lower extremity edema is common in both pregnancy and spinal cord injuries, so it is important for the nurse to stress the importance of using pressure stockings and leg elevation as much as possible.
Pregnant clients with SCI may have “silent labor” meaning they may have painless contractions and painless cervical dilation. Often too, the signs of labor may go unnoticed because the contractions may be interpreted as a dull ache, and the rupture-of-membranes may be mistaken for urinary incontinence. Obstetric nurses should instruct their pregnant clients on how to use uterine palpation techniques and how to identify other signs of labor, including feelings of anxiety, changes in spasticity or breathing, pelvic pressure, and autonomic dysreflexia (Morantz and Torrey 2002, p. 1781).
Every woman, pregnancy, and spinal cord injury are different and therefore it is a very individualized choice weather or not to consider pregnancy. Women of this population must be made aware of signs, symptoms, complications, and management of autonomic dysreflexia. Nurses in this field must have a detailed plan-of-care prepared to review with these clients including safety precautions, preventative measures, and signs of labor onset. Due to the risk of added blood volume and immobility, it is important to take extra precautions in preventing thromosis and emboli during pregnancy by wearing pressure stockings, active and passive range of motion, and leg elevation. Women with spinal cord injuries may be considered to have high-risk pregnancies. However, it does not mean that pregnancy should be avoided all together. This situation gives the nurse another opportunity to educate on prevention and treatment of complications.

Intervention 1: Client Education
Pregnant clients with spinal cord injuries are considered high-risk cases. They must be educated on their unique pregnancy risks in comparison to pregnant clients without spinal cord injuries.

Disadvantage 1: Knowledge Deficit
Spinal cord injured clients present with the possibility of developing Autonomic Dysreflexia (AD) which can lead to a dangerous rise in blood pressure and can be potentially fatal to both the mother and fetus. Morantz and Torrey (2002) state, “Autonomic Dysreflexia is the most significant medical complication seen in women with SCIs, and precautions should be taken to avoid stimuli that can lead to this potentially fatal syndrome.” These unique obstetric clients should be educated on the signs & symptoms of AD because this autonomic nervous system response may be their only sign of the onset of labor. Uterine contractions, speculum examinations, bladder distension, bladder infections, catheterization, constipation, and cesarean delivery can trigger this syndrome (Demasio and Magriples 1999, p. 225). Symptoms include severe hypertension, headaches, anxiety, diaphoresis with piloerection, and cardiac arrhythmias.

Disadvantage 2: Information Misrepresentation
It is important to differentiate between the elevated blood pressure associated with AD and preeclampsia. This risk for preeclampsia will increase with gestation; however AD can occur at any time during pregnancy. Demasio and Magriples (1999) state, “Autonomic Dysreflexia complicates pregnancy in 85% of SCI women…hypertension is the most common medical complication in pregnancy and complicates 10% of all pregnancies, preeclampsia does not occur more frequently in the SCI woman.” Hypertension with preeclampsia will rise and fall with contractions and will disappear after delivery; a hypertensive crisis associated with AD will continue to rise until the noxious stimulus is removed regardless of uterine contractions.

Intervention 2: Prevention of Avoidable Complications
Due to the fact that SCI clients are non-ambulatory and self-limiting, the pregnant client must take necessary precautions to prevent avoidable complications.

Disadvantage 1: Immobility and Peripheral Complications
This unique population of pregnant women is especially at risk for developing deep vein thrombosis (DVT) due to immobility associated with spinal cord injuries. Morantz and Torrey (2002) state, “For all patients, elevation of the legs and range-of-motion exercises may be implemented as pregnancy advances.” It is also important to note the high possibility of pressure ulcers related to transfer difficulties due to increasing weight, and immobilization in the advancing pregnancy.

Disadvantage 2: Bowel and Bladder ConsiderationsUrinary tract and bowel management are essential for pregnant spinal cord-injured clients. In consideration that many SCI clients have neurogenic bladder, as the fetus increases in size, it can push on the bladder causing incontinence. In addition, toward the end of the pregnancy the client feels the need to increase the frequency of self-catherization to avoid incontinence. This creates a higher risk for developing a urinary tract infection. Ethans (n.d.) states, “Urine infections may be more common, and it’s important to get these treated, as infected urine is more likely to go backwards to infect the kidneys, when there is pressure on the bladder from the baby.” Constipation and fecal incontinence can result from decreased sphincter tone and slowed gastrointestinal mobility as a result from increased progesterone levels. Severe constipation requiring bowel evacuation can cause AD and therefore should be avoided and prevented (Demasio and Magriples 1999, p. 223).

References

Blackmer, J. (2003). Rehabilitation medicine: 1. Autonomic dysreflexia. Canadian Medical Association Journal, 169, 931-935. Retrieved on February 5, 2007 from ProQuest database.
Bycroft, J., Shergill, I.S., Choong, E.A.L., Arya, N., & Shah, J.R. (2005). Autonomic dysreflexia: a medical emergency. [Electronic version]. Postgraduate Medical Journal, (81), 232-235. Retrieved on May 17, 2007 from http://pmj.bmj.com/cgi/content/full/81/954/232
Essat, Z. (2003). Management of autonomic dysreflexia. Nursing Standard, 17(32), 42-44. Retrieved on May 19, 2007, from Expanded Academic database.
Ethans MD, K. (n.d.). Pregnancy in Women with Spinal Cord Injury. Retrieved on May 5, 2007, from www.spinalcord-injury.com/newpregpage.html
Morantz, C. and Torrey, B. (2003). Obstetric Management of Patients with spinal Cord Injuries. American Family Physician, 66(9), 1781-1782. Retrieved on May 7, 2007 from ProQuest database.
Popov, I., Ngambu, F., Mantel, G., Rout, C., & Moodley, J. (2003). Acute Spinal Cord Injury in Pregnancy: An Illustrative Case and Literature Review. Journal of Obstetric and Gynecology, 23(6), 596-598.
Carrie Morantz, Brian Torrey. (2002). Obstetric management of patients with spinal cord injuries. American Family Physician, 66(9), 1781-1782. Retrieved November 2, 2007, from Platinum Full Text Periodicals database. (Document ID: 243996711).
Kafui Demasio, Urania Magriples. (1999). Pregnancy Complicated by Maternal Paraplegia or Tetraplegia as a Result of Spinal Cord Injury and Spina Bifida. Sexuality and Disability, 17(3), 223-232. Retrieved November 2, 2007, from Research Library database. (Document ID: 943918391).
Ethans MD, K. (n.d.). Pregnancy in Women with Spinal Cord Injury. Retrieved on October 29, 2007, from www.spinalcord-injury.com/newpregpage.html


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