Disclosures: Maya S. Newman, MD: Nothing to disclose

Case Description: A 42-year-old multiparous woman with amyotrophic lateral sclerosis (ALS) at 33 weeks gestation presented with spasticity during labor. Physical Medicine and Rehabilitation (PM&R) was consulted to help with positioning and tone management to optimize the patient for a vaginal forceps-assisted delivery.

Setting: Level I Trauma Hospital, Labor and Delivery.

Patient: The patient was diagnosed with ALS in 2/2016 and by 02/2019 her disease had progressed to tetraplegia, anarthria, dysphagia, and difficulty managing her secretions. Physical exam notable for ptosis and 3+ bilateral lower extremity pitting edema. She was on room air but positioned upright at 30° to enhance respiration. She was nonverbal, but able to consistently communicate yes/no responses with head movement. Motor exam demonstrated shoulder abduction 1/5 bilaterally, left finger flexion 1/5, otherwise 0/5 throughout remaining limbs. Reflexes 0/4 throughout, Babinski and Hoffman negative bilaterally, with mild left wrist and bilateral ankle clonus. No spasticity was appreciated, but she displayed an extensor pattern in her lower extremities during labor contractions.

Assessment/Results: Experts in spasticity, ALS, and pediatrics were contacted. Concern was elicited for any medication that might worsen respiratory status or cross into the placenta and breastmilk. Hypothesized that tone would improve acutely with an epidural and subsequently with removal of the noxious stimulus at delivery. PM&R demonstrated positioning techniques to break extensor synergy patterns. Ultimately, the fetus moved to a transverse position and a viable infant was delivered by cesarean section. Tone improved after delivery.

Discussion: Spasticity recommendations of the epidural, no oral tone medications, antigravity positioning and finally removal of the noxious stimulus itself were new to the obstetrics team.

Conclusion: PM&R assisted by recommending an epidural, no oral medications, demonstrating antigravity positioning techniques, and educating on the removal of the noxious stimulus. This is the first known report of acute spasticity management consultation in an ALS patient during labor and delivery.

Level of Evidence: Level V

« Back to AAPM&R Annual Assembly 2019

PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/spasticity-management-in-pregnancy-during-active-labor-and-delivery-in-a-patient-with-amyotrophic-lateral-sclerosis/