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Module 1 - Physical Disabilities Spinal cord injury Cerebral palsy Spina bifida Multiple sclerosis
ObjectivesSpinal Cord Injury - SCI Upon completion of this module, the participant will be able to: • Recognize the specific interaction of menses, sexuality and menopause in women with spinal cord injury. • Describe the onset, symptoms and management of autonomic dysreflexia (ADR) • Describe considerations involving pregnancy, labor, delivery and postpartum for women with SCI • Identify specific resources available for the patient with SCI and her provider.
About Autonomic Dysreflexia • Autonomic dysreflexia (ADR) is the most important ob/gyn concern for women with spinal cord lesions • Spinal cord lesions at or above T6 segment – 50% incidence of ADR • Causes severe hypertension • Potentially lethal medical emergency
Precipitating Factors of ADR • Bladder or bowel distention or irritation • Cutaneous lesions • Menstruation • Sexual activity • Pelvic and rectal exams • Labor
Hypertension Baseline BP in SCI 90/60 120/80 may be abnormally high BP can reach 300/220 Piloerection Flushing Pounding headache Sweating Nasal congestion Malaise Skin tingling Nausea Blurred vision Cardiac dysrhythmia Signs and Symptoms of ADR
Menstruation after SCI • Usually stop menstruation up to 6 months following injury, most return to cycling • Increased incidence of prolonged amenorrhea • Increased autonomic symptoms during menses • Premenstrual dysphoric disorder (PMDD) symptoms continued after SCI
Sexual Activity • Women with SCI can have active and enjoyable sex lives post injury. • Lubrication is dependent on level and completeness of injury. • Orgasm may be independent of the level of injury LINK Part 1 Module 2
Data on Pregnancy and Spinal Cord Injury (SCI) • No studies investigating fertility and pregnancy after SCI • Case-reports and expert opinion inform obstetric management of pregnancy
Pregnancy Complications for Women with SCI Urinary tract infections Decubitus ulcers Deep vein thrombosis Alterations in pulmonary function Constipation Increased spasticity
Prevention of Pregnancy Complications • Monitor ability to transfer and ambulate • Monitor weight gain closely • Leg elevation • Range of motion exercises • Monitor need for increased services
ADR and Pregnancy/Labor Prevention • Avoid distended bladder • Avoid constipation/fecal impaction • Discuss past episodes of ADR and triggers • Discuss measures to relieve ADR Link to ADR section (slides 8-11)
ADR v. Preeclampsia Source: Pereira 2003
Labor and Delivery • Instruct patient in uterine palpation and unique symptoms of labor • Judicious use of early labor regional anesthesia for sympathetic blockade • Monitor closely for ADR symptoms • Increased incidence of operative vaginal delivery
Postpartum CareSpinal Cord Injury • Inspect perineum for signs of infection. Use ice packs with care. • Watch closely for postural hypotension • Assist with breast feeding, particularly if low nipple sensation (link to Part III- Mod 3 breastfeeding) • Monitor for breast health
Osteoporosis and SCI • Rapid bone loss of 25-50% in lower extremities occurs immediately post-injury. • Spasticity with consequent bone tension leads to additional bone loss. • Over90% of postmenopausal women have osteoporosis on screening exams • Treatment should be used, but the safety of bisphophonates in women with reproductive potential is still unclear. Link Part 3 – Module 7
Case Study • Considerations when prescribing contraception • Precautions during pelvic examination • Other components of well woman care
Summary SCI • The most important OB/GYN concern of SCI is ADR • Temporary amenorhea is common after acute SCI • Intrapartum care with SCI should be managed by a multidiciplinary team. • Early regional anesthesia is usually advised for labor management • Low bone density is common
References – Spinal Cord Injury • DeForge D, Blackmer J, Moher D, et al. Sexuality and Reproductive Health Following Spinal Cord Injury. Summary. Evidence Report/Technology Assessment: Number 109. AHRQ Publication No 05-E003-1, December 2004. Agency for Healthcare Research and Quality. Rockville MD. Downloaded from http://www.ahrq.gov/clinci/epcsums/sexlspsum.htm. on 8/8/08. • American Spinal Cord Injury Association. Standard Neurological Classification Of Spinal Cord Injury. 2006. Downloaded from http://www.asia-spinalinjury.org/publications/2006_Classif_worksheet.pdf on 12/5/08 • Wikipedia – Spinal cord injury,. Downloaded from http://en.wikipedia.org/wiki/Spinal_cord_injury on 12/17/08 • Campagnolo DI. Autonomic dysreflexia in spinal cord injury. 2006. Downloaded from http://emedicine.medscape.com/article/322809 on 12/17/08 • Jackson AB, Wadley V. A multicenter study of women’s “self-reported reproductive health after spinal cord injury. Arch Phys Med and Rehab 1999;80:1420-8. • Jackson AB. Medical management of women with spinal cord injury: A review. Topics in Spinal Cord Inj Rehabil 1995;1:11-26. • Research Review, Fall 2000 Published by UAB-RRTC on Secondary Condition of SCI, Birmingham, AL. Sownloaded from http://www.spinalcord.uab.edu/show.asp?durki=3237 on 8/7/08 • Whiple B. Sexual response in women with complete spinal cord injury.. Symposium at INABIS ’98. McMaster University. Downloaded from http://www.mcmaster.ca/inabis98/komisaruk/whipple0437/tow.html. On 8/11/08 • Sipski ML. Sildenafil effects on sexual and cardiovascular responses in women with spinal cord injury. Urology 2000;55(6):812-815 • Jackson A, Lindsey L, Llebine P, Poczatek R. Reproductive health for women with spinal cord injury. SCI Nursing 2004;21:88-91. • American College of Obstetrics and Gynecology. Committee Opinion #275 – Obstetric Management of Patients with Spinal Cord Injuries 2002;ACOG, Washingto n DC.
References SCI • Pope CS, Markenson GR, Bayer-Zwirello LA, Maissel GS. Pregnancy complicated by chronic spinal cord injury and history of autonomic hyperreflexia. Obstet. & Gyne. 2002;97:802-3 • Pereira L. Obstetric management of the patient with spinal cord injury. Obstetrical and Gynecological Survey 2003;58:678-86 • Estores IM, Sipski ML. Women’s issues after SCI. Topics in Spinal Cord Injury Rehabilitation 2004;10:107-25 • Pentland W, Walker J, Minnes P, Tremblay M, Brouwer B, Gould M. Women with spinal cord injury and the impact of aging. Spinal Cord 2002;40:374-387 • Weiss D. Osteoporosis and spinal cord injury. eMedicine Specialties2008.downloaded from www.emedicine.com/pmr/topic96.htm. on 8/1/08 • Jiang SD, Jiang LS, Dai LY. Management of osteoporosis in spinal cord injury. Clinical Endocrinology 2006;65:555-65. • Vestergaard P, Krogh K, Rejnmark L, Mosekilde L. Fracture rates and risk factors for fractures in patients with spinal cord injury. Spinal Cord 1998;36:790-6. • Smeltzer, S Zimmerman,V, and Capriotti,T. 2005 Arch Phys Med Rehab 86 (3); 582-6. • Physicians Desk reference (Bisphosphates) • Ornoy A. Wajnberg R. Diav-Citrin O. The outcome of pregnancy following pre-pregnancy or early pregnancy alendronate treatment. Reproductive Toxicology. 2006;22:578-9 • Cowley KC. Psychogenic and pharmacologic induction of the let-down reflex can facilitate breastfeeding by tetraplegic women: A report of 3 cases. Archives Of Physical Medicine And Rehabilitation 2005;86:1261-4. • Massagli TL, Reyes MR. Hypercalcemia and spinal cord injury. 2008. Downloaded from http://emedicine.medscape.com/article/322109 on 12/18/09 • Moonka R, Stiens SA, Resnick WJ, McDonald JM, Eubank WB, Dominitz, JA, Steizner, MG. The prevalence and natural history of gallstones in spinal cord injured patients. J AM Coll Surg. 1999;189:274-81
Spina Bifida Sub-Module 2 Spina Bifida
ObjectivesSpina Bifida • Recognize the specific interaction of menses, sexuality and menopause in women with spina bifida • Describe considerations involving pregnancy, labor, delivery and postpartum. • Identify specific resources available for the woman with spina bifida and her provider.
Spina Bifida – Case Study • Desires pregnancy • Spina bifida lesion at T8 • VP Shunt • Ileal conduit
Medical Concerns in Women With Spina Bifida Neurologic GI Orthopedic Urologic Dermatologic Source: Suzawa, 2006
Neurologic Complications • Hydrocephalus – VP Shunt • Most have normal intelligence • Most individuals with SB have strong verbal skills but have difficulties with attention and executive functioning.
Urologic and GI Complications Urologic • Neurogenic bladder GI • Constipation • Fecal incontinence • Obesity
Dermatologic • Severe latex allergy in 75% • Unknown etiology • Latex in many medical, clothing and household items • Pressure ulcers • Frequent skin examination (link to Part 2-Mod 2 skin) • Encourage frequent weight shifts
Pregnancy Preparation • Fertility is not impaired • Genetic Counseling • Risk of neural tube defect in offspring • Depends on frequency of occurrence within the family. • Small risk of affected pregnancy despite folic acid prophylaxis
Pregnancy Considerations • Bladder and urinary tract • Special care after urinary diversion surgery • Increased frequency of UTI • VP Shunt failure • Increased risk of back pain due to spinal abnormalities (Link -– Mod 1)
Aging and Osteoporosis • Kyphosis and scoliosis increase with age • Compromise respiratory status • Complicate positioning for exams and the interpretation of bone densitometry. • Osteoporosis can occur in childhood and persist into adult years.
Summary • Impaired executive functioning • Bladder and bowel incontinence • VP shunt may affect pregnancy, delivery and GYN surgery. • Genetic counseling and folic acid • Increased risk of osteoporosis due to onset of immobility at birth
Case Study – Spina Bifida What more information do you need from Jennifer regarding her history? What considerations are important for Jennifer prior to her pregnancy? What are 3 issues related to her spina bifida that may be of concern during Jennifer’s pregnancy? What considerations are necessary to prepare for Jennifer’s delivery?
Resources • Spina Bifida Association – Information and publications for providers and public. This includes the books featured below. Access at www.spinabifidaassociation.org
References • Hochber L and Stone J. Etiology, prenatal diagnosis, and prevention of neural tube defects. Up to Date. 2006 • American College of Obstetricians and Gynecologists. Neural tube defects. Practice Bulletin #44 ACOG 2003. Washington DC • Bowman RM, McLone DG, Grant JA, Tomita T, Ito JA. Spina bifida outcome: a 25-year prospective. Pediatric Neurosurg 2001;34:144-20. • Velde SV, Biervliet SV, Renterghem KV, Laecke EV, Hoebeke P, Winckel MV. Achieving Fecal Continence in Patients With Spina Bifida: A Descriptive Cohort Study. Journal of Urology. 2007 • Suzawa, H. Spina Bifida (powerpoint presentation. 2006. Downloaded from http://www.bcm.edu/medpeds/powerpoints/Spina%20Bifida.pps#257,3,Epidemiology on 8/13/08 • Rose BM, Holmbeck GN. Attention and executive functions in adolescents with spina bifida. J of Ped Psych 2007;32:983-94. • Liptak GSEvidence –based practice in spina bifida: Developing a research agenda. Presentation at the conference May 2003. Washington DC. Downloaded from http://www.spinabifidaassociation.org on 8/13/2008. • Klingbeil H, Baer HR, Wilson PE. Aging with a disability. Arch Phys Med Rehabil 2004;85(Suppl 3) S68-73 • Singhal B, Mathew KM. Factors affecting mortality and morbidity in adults spina bifida. Eur J Pediatric Surg. 1999:9(Suppl 1):31-2. • Levy E. Addressing sexuality in spina bifida. Pediatric News in Entrepreneur.com. Downloaded from http://www.entrepreneur.com/tradejournals/article/print/168434757.html on 8/14/08 • Vogel LC, Krajci KA, Anderson CJ. Adults with pediatric-onset spinal cord injury: part 2: musculoskeletal and neurological complications. J Spinal Cord Med 2002;25:117-23 • Arata M, Grover S, Dunne K, Bryan D. Pregnancy outcome and complications in women with spina bifida. J Reprod Med 2000; 45:743-748.
Objectives - Multiple Sclerosis • Recognize the specific interaction of menses, sexuality and menopause for women with MS • Describe considerations involving pregnancy, labor, delivery and postpartum. • Identify specific resources available for the woman with MS and their provider.
Case Study – Multiple Sclerosis (MS) • 38 years old • Decreased libido • Fatigue • Lack of lubrication • Decreased sensation
Presenting Symptoms of MS • Optic neuritis • Extreme fatigue • Paresthesias • Spasticity • Lower extremity weakness • Loss of coordination • Pain • Acute onset of bowel and bladder dysfunction
GYN Considerations • Possible worsening of neurologic symptoms with menses (self-report) • 40-80% of women report sexual dysfunction • Fatigue commonly contributes to sexual dysfunction • Depression may be associated with CNS changes. • Smoking may increase disease progression
The Effect of Pregnancy on MS • No change in fertility • Symptoms of MS may stabilize or remit during pregnancy with 20-40% of patients having relapse within 3 months after delivery. • No evidence suggests that pregnancy affects long-term course of MS • Increased risk for child having MS (2.5X)
MS – Labor and Delivery • Patient may not recognize labor onset • Epidural anesthesia does not increase relapse rate and is effective for treating labor-induced spasticity • Weakened maternal expulsive effort may be indication for operative vaginal delivery