F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
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Reflex effects of uterine contractions on other autonomic mechanisms (the
autonomic stress syndrome)
As one would expect, strong contractions of the uterus during labour, like other excessive
visceral activity, elicit profound reflex responses in the cardio-vascular system and other
autonomic mechanisms in cord lesions above T5/6. We first observed this in 1963 in a
tetraplegic woman below C6 following fracture-dislocation of 04/5. During labour,
when the head of the baby was deep in the pelvis, the first sign of autonomic hyperreflexia
was an outburst of sweating on the left side of the face, associated with dilatation of the
left pupil. Blood pressure rose steadily from 90/55 and the pulse fell, and about 10 min
before delivery the BP reading was 180/100. Both pupils were dilated and there were
outbursts of sweating on both sides of face and neck. The patient complained of frontal
and occipital headaches of throbbing type, which coincided with each uterine contraction.
Forceps were applied and during delivery the blood pressure rose to 190/100 and the
pulse rate fell to 48/50. No irregularities of the heart rate were discovered by auscultation.
After delivery of the baby and placenta, the exaggerated autonomic reflex responses
ceased.
Since that publication (Guttmann, 1963), several more paraplegic women with
complete and incomplete cord lesions were studied in detail during labour, amongst
them two with complete lesions below T5 and T6. They confirmed the previous findings,
that uterine contractions in advanced labour set up profound reflex responses in auto
nomic mechanisms, the most important being intermittent hypertension combined with
bradycardia coinciding with the uterine contractions. One young woman with a complete
lesion below the 5th dorsal segment, following fracture-dislocation of the spine, developed,
in addition to the usual changes of the vascular system described above, profound
cardiac irregularities at the end of labour. These were studied in detail electro-cardio-
graphically and published elsewhere (Guttmann, Frankel & Paeslack, 1965).
Case report.
Miss J.W. then aged 18, who had previously enjoyed good health, was a
pillion passenger on a motor-cycle involved in a road accident on n May 1958. She
suffered from:
1
Fractured skull, remained unconscious for 6 weeks.
2
Fracture-dislocation T3/4 (two weeks after injury had a laminectomy and spinal
fusion) leaving a transverse spinal cord syndrome complete below T5.
3
Fracture of shaft right femur.
On 8 August 1958 admitted to National Spinal Injuries Centre, Stoke Mandeville
Hospital, when her mental condition was good, she, however, remained rather talkative
and excitable. She had a right abducens paresis which recovered and complete anosmia
which had persisted. She had a complete spastic paraplegia below T5 segment.
She was treated and rehabilitated and was discharged home on 13 December 1958.
Although the paraplegia remained complete below T5, she was independent, able to
dress herself and get into and out of her wheelchair. Her urine was sterile and an intra
venous pyelogram was normal. She had about i min warning of automatic bladder
emptying; this warning consisted of tingling and sweating on her forehead; bowel action
produced similar sensations.
