CASE REPORT
A 25-year-old nulliparous woman gravida 1, para 0 with paraplegia from an injury to T4-T6 in a motor vehicle crash 8 years ago was admitted to our hospital at gestation of more than 36 weeks suffering from intrahepatic cholestasis of pregnancy.Physical examinations: body temperature was 36.4℃, blood pressure 90/60 mm Hg; pulse rate 86 beats per min; respiratory rate, 20 times per min. In gestation of more than 37 weeks, manifestations of AH as a result of uterine contractions, include palpitation, dizziness, sweating, and increase of blood pressure (120/80 mm Hg).External electronic monitoring showed fetal heart rate 180 beats per min.An emergency cesarean section (CS) was carried out because of fetal distress at 16:30 on August 20, 2001.During surgery, a hypertensive crisis (155/95 mm Hg) developed.After epidural administration of 5 ml lidocaine, following a slow intravenous injection of 0.2 mg perdipine, blood pressure dropped immediately to 120/60 mm Hg.This symptom appeared three times during CS.Two min later, a 2722-g baby boy was delivered with Apgar scores of 9 and 10 at 1 and 5 min, respectively.Blood pressure appeared normal at 20:00 after surgery.The mother and her baby were discharged 11 days later.
DISCUSSION
Spinal cord injury (SCI) by no means contraindicates pregnancy, but it can present a challenge to the patient and her physicians.The most significant medical complication to which SCI patients are susceptible is undoubtedly AH.[2] In 85%-90% of patients with lesions above T6, symptoms of AH may occur.[3] AH is a life-threatening complication characterized by severe hypertension and bradycardia associated with facial flushing, sweating and pilomotor erection.It may cause convulsions, cerebral hemorrhage and even death.[4] These symptoms result from sympathetic hyperactivity and spinal cord reflex below the level of spinal cord injury and are not under hypothalamic control.They occur in response to centripetal stimuli such as skin irritation, organ traction, and uterine contraction.Any SCI woman whose level is at T6 or higher is at risk for acute AH as a result of uterine contractions.If induction is with Pitocin/Oxytocin, the risk is even greater.[1] AH may occur in the antepartum, intrapartum, and postpartum periods.Epidural and spinal anaesthesia are effective in producing prompt cessation of AH by interrupting the reflex arc extending from the contracting uterus to the cardiovascular system via the spinal cord.But the most common technique used has been continuous epidural anesthesia.[5] Epidural anesthesia would make it easier to control the onset of sympathetic block and thus minimize cardiovascular instability.At the same time, it can be used to repeat epidural administration.For these reasons, we prefer Epidural anesthesia.One case reported a woman had symptoms of AH for 5 days postpartum which were treated with continued epidural anesthesia.[6] After failure of epidural anesthesia related to technical difficulties, general anesthesia can be provided.[2] During surgical procedures, AH also can be treated with intravenous antihypertensive agents such as hydralazine.[2] This report showed perdipine can also be useful.Of course, noxious stimulis should be removal in order to control AH.
