Henderson et al. (2009) documented that women with cerebral palsy have a higher incidence of obesity, gastroesophageal reflux, urinary tract infections, dysphagia and osteoporosis. Skin ulcerations, respiratory compromise, interpersonal abuse, substance abuse and mood disorders are more common among this population as well (Signore et al., 2011). Women with cerebral palsy often have poor dental health due, in part, to difficulty finding dentists skilled in treating patients with spasticity (Henderson et al., 2009). Adults with disabilities have a depression rate three to four times higher than the population in general. Additionally, many adults with cerebral palsy and other disabilities are less likely to engage in community activities and may lack social support (NINDS, 2011). Because women with cerebral palsy may be mentally challenged or sensory impaired, communication and health education can be challenging. These patients may also take a number of medications, which further complicates the pregnancy and adds increased risk.
Pain and Fatigue
Although cerebral palsy is not a progressive disorder, its manifestations are not static, and aging often results in increased loss of function, especially mobility (Lipak, 2008). Pain, fatigue and muscle weakness result from bone deformities, muscle abnormalities, arthritis and “overuse syndrome,” or repetitive motion injury (Lipak, 2008). Pain may be acute or chronic, with back and leg pain being the most commonly reported (Lipak, 2008, NINDS, 2011). Malone and Vogtle (2010) found that pain and fatigue were consistently reported by adults with cerebral palsy and resulted in decreased ability to participate in daily life. People with cerebral palsy expend three to five times more energy than able-bodied individuals when performing activities of daily living (NINDS, 2011).
Pain and fatigue were consistently reported by adults with cerebral palsy and resulted in decreased ability to participate in daily life
Pain and fatigue are common concerns of many women having an uncomplicated pregnancy and birth. Anemia, hormone fluctuations, sleep disruption and adjustment to parenting roles all contribute to fatigue. The “discomforts” of pregnancy are many and include constipation, heartburn, muscle aches and backache, to name a few. When one considers the added stress of pregnancy for a woman with cerebral palsy, pain and fatigue become significant issues.
Pregnancy-related complications reported in the literature for women with cerebral palsy include preeclampsia, preterm birth and an increased rate of cesarean delivery (Signore et al., 2011). Further, women with upper motor neuron disorders such as cerebral palsy may have an increase in spasticity during pregnancy. Gastrointestinal comorbidities, such as dysphagia and reflux, can limit healthy food choices and lead to nutrient deficiencies. Women with limited mobility may experience more problems with constipation; this can result in lowered compliance with prenatal vitamin and iron supplements, increasing the risk for anemia (Signore et. al., 2011). Many women with cerebral palsy have osteoporosis and may need vitamin D supplementation.
Deep Vein Thrombosis
Women who develop deep vein thrombosis (DVT) during pregnancy often have multiple risk factors, including impaired mobility, obesity, surgical delivery, hemorrhage and sepsis. Women with inherited and acquired thrombophilias, such as Factor V Leiden, have a significantly higher risk for DVT in pregnancy and the postpartum. It's interesting to note that Factor V Leiden mutation and other thrombophilias are associated with an increased risk for cerebral palsy (Gibson et. al., 2003).
The risk for DVT is four to six times greater in pregnant women when compared to nonpregnant women of the same age group. The true incidence may be even higher (Stone & Morris, 2005). Women in late pregnancy may experience shortness of breath, tachypnea, edema of the lower extremities and leg pain. Common signs and symptoms of DVT and pulmonary embolism may be vague, or are often attributed to physiologic changes of pregnancy, thereby increasing the chances for undiagnosed DVT. Even asymptomatic patients are at risk for pulmonary embolism. Pulmonary embolism is life threatening and has emerged as one of the leading causes of maternal mortality and morbidity, largely due to the rise in cesarean births (Stone & Morris, 2005).
Hypercoagulability is a physiologic change in pregnancy resulting from venous stasis, altered levels of clotting factors and hormonal influences during pregnancy. Blood flow is normally slower in the venous system, where the primary clotting mechanism occurs with activation of the thrombin system and the production of fibrin. Strands of fibrin trap red blood cells with platelets to form a clot. Left-sided DVT is more commonly seen because venous stasis is more pronounced on the left side, partly due to compression of the left common iliac vein (Stone & Morris, 2005).
Women who require anticoagulation during pregnancy will also need to be fully anticoagulated after delivery (see Box 2). Heparin is the drug of choice for treating a DVT and pulmonary embolism surrounding delivery. Intravenous heparin allows for rapid anticoagulation and it has a short half life. More importantly, it does not cross the placenta, and therefore cannot be teratogenic and will not cause fetal hemorrhage. Heparin and warfarin are also safe for breastfeeding mothers, as heparin is not found in breast milk and amounts of warfarin secreted in human milk are insignificant (Duhl et al., 2007).
Box 2. Considerations for Heparin Anticoagulation
Heparin anticoagulation is not without risks. According to Duhl and colleagues (2007), patients may develop thrombophilias that can be either heparin-associated or heparin-induced. Heparin-induced throbophilia is immune-mediated and more severe. Anticoagulation should be discontinued if the platelet count drops below 150,000 (Duhl et al.). Heparin-induced thrombophilia is uncommon during pregnancy. Allergic reaction and heparin-induced osteopenia are additional risks.
A disadvantage of heparin is difficulty maintaining a therapeutic response. Pregnant women may require higher doses of heparin due to increased levels of heparin binding proteins, increased plasma volume, increased glomerular filtration rate, and increased degradation of the drug by the placenta (Stone & Morris, 2005). Physicians commonly utilize the activated partial thromboplastin time (aPTT) lab value for monitoring and dosing heparin. This value has poor correlation with blood heparin concentration. Use of the antifactor Xa or functional heparin assay has been proposed in the literature to achieve therapeutic heparin dosing (Smith & Wheeler, 2010).
Bleeding is a significant risk, especially during the postpartum and postoperative recovery. Postpartum hemorrhage can be life threatening. Other potentially fatal bleeds are retroperitoneal, ovarian (corpus luteum) and intracranial. Bleeding risk is dosage- and age-related, with patients receiving higher doses and those over age 70 at greatest risk.
Wound hematoma is a common complication with anticoagulation, especially those with a transverse incision. Collections of blood in or around the wound may not cause symptoms, or symptoms may be attributed to incisional pain, or “gas pain.” Increased abdominal pain, swelling and/or drainage occurring several days after surgery should be investigated. If the hematoma is infected, there may be fever, erythema, wound induration and leukocytosis. Diagnosis can be made by ultrasound. Large hematomas are treated by opening up the wound and negative pressure wound therapy. It's important to note that people with diabetes often experience poor wound healing. Wound healing can also be hindered by anemia secondary to blood loss after delivery.
Patients with DVT may initially benefit from bed rest with elevation of the affected leg to promote venous return; however, there is no evidence that bed rest prevents detachment of the clot.