A spinal cord injury (SCI) involves damage to the spinal cord, resulting in a change in motor, sensory, or autonomic function. A growing number of women with SCI are choosing to become mothers, and with specialized medical care, successful maternal and infant outcomes are common. However, the reproductive journey for a woman with SCI is considered high-risk and requires a multidisciplinary approach involving obstetricians, physiatrists, and anesthesiologists to manage unique physiological challenges.
Fertility and the Ability to Conceive
A spinal cord injury does not typically compromise a woman’s long-term ability to conceive a child. The reproductive organs and the endocrine system, which controls ovulation and hormone production, generally remain functional following the injury. Fertility rates for women with SCI are comparable to those of the non-injured population.
A common initial effect of SCI is temporary cessation of the menstrual cycle, known as amenorrhea. This interruption is attributed to the physical and emotional shock of the trauma. For most women, the menstrual cycle spontaneously returns to pre-injury regularity within three to nine months, confirming that ovulation has resumed.
Since fertility is largely unaffected, women with SCI who are sexually active must use reliable contraception. Preconception counseling is important to ensure existing health issues are managed and medications are reviewed for safety during pregnancy. Assisted reproductive technology is generally unnecessary unless other pre-existing factors require it.
Unique Health Considerations During Gestation
The physiological changes of pregnancy significantly increase the risk of complications unique to spinal cord injury. As the fetus grows, the physical and circulatory demands on the mother’s body are increased, necessitating attentive medical management throughout gestation. This requires focused management to prevent conditions that could threaten the health of both mother and baby.
Autonomic Dysreflexia (AD) is among the most serious complications, posing a life-threatening risk for women with injuries at or above the sixth thoracic vertebra (T6). AD is an uncontrolled, exaggerated reflex response of the sympathetic nervous system to a painful or irritating stimulus below the level of injury. This response causes a sudden, severe spike in blood pressure that can lead to stroke, seizures, or even death if left untreated.
During pregnancy, the most common triggers for AD include a distended bladder, bowel impaction, and later, the uterine contractions themselves. Signs of AD can include a pounding headache, flushed skin above the injury level, sweating, and nasal congestion, which require immediate intervention. Prompt identification and removal of the irritating stimulus, often through bladder or bowel management, is the first line of treatment.
The weight gain and changes in posture associated with pregnancy significantly increase the risk of developing pressure ulcers. Altered circulation, limited mobility, and changes in the center of gravity place greater pressure on bony prominences. A physiatrist and physical therapist should evaluate seating and positioning to ensure specialized cushions or devices are used to redistribute pressure effectively.
Women with high cervical or thoracic injuries (T4 or above) may experience reduced respiratory function due to partial paralysis of breathing muscles. As the growing uterus pushes upward on the diaphragm, lung capacity can be further compromised. This can lead to increased shortness of breath and a greater susceptibility to respiratory infections, sometimes requiring specialized respiratory support.
Urinary Tract Infections (UTIs) are a frequent concern for women with SCI and the risk is dramatically increased during gestation. The growing uterus puts pressure on the ureters, which can cause urine to back up and increase the risk of infection. If left untreated, a UTI can quickly escalate to a kidney infection (pyelonephritis) or sepsis, which can trigger premature labor or an episode of Autonomic Dysreflexia.
Navigating Labor and Delivery
The process of labor and delivery presents a unique set of challenges, particularly in recognizing the onset of contractions and managing pain. Women with sensory loss at or above the tenth thoracic vertebra (T10) are unlikely to feel the typical pain of uterine contractions. This sensory deficit makes detecting the start of labor difficult and increases the risk of an unassisted delivery.
Instead of pain, women with sensory loss must be educated to look for alternative signs that labor has begun, such as:
- Increased spasticity.
- Abdominal or leg spasms.
- A general feeling of abdominal pressure.
- The tell-tale signs of an Autonomic Dysreflexia episode.
Some women with upper extremity sensation can be taught to palpate their abdomen to detect the hardening of the uterus during a contraction.
Vaginal delivery is generally possible and often preferred, as SCI itself does not automatically necessitate a Cesarean section. The level of injury does not typically affect the ability of the cervix to dilate or the uterus to contract effectively. However, a C-section may be required for standard obstetric reasons, such as a baby in breech position or a history of pelvic injury that limits the size of the birth canal.
Managing pain and preventing AD during labor is a primary concern. Continuous epidural anesthesia is typically recommended for women with injuries above T6 to block the noxious stimuli from the contracting uterus, which can otherwise trigger a severe AD response. An epidural provides long-lasting pain relief and is the most effective way to prevent AD during the active phase of labor.
Even after delivery, the risk of Autonomic Dysreflexia remains elevated, particularly immediately postpartum. Sudden changes in bladder or bowel fullness, or even the process of breastfeeding, can act as a trigger. Therefore, close monitoring of blood pressure and vital signs is required in the immediate hours following birth to prevent and manage any postpartum AD episodes.