Example 1: A 33-year-old lady (2011) who had polio is pregnant for the first time. She describes her acute illness and recovery and requests advice:
"I had polio when I was 7 months old and was paralyzed throughout my whole body. My parents told me that they fed me using a spoon and a dropper. I could not sit up by myself when I was 4-5 years old, so they put pillows around me. I had surgery on my Achilles heel by physicians from the San Diego Children’s Hospital who came to my home in Tijuana. They also gave me braces on both of my legs.
By the time I was 6-7 years old, I was able to sit by myself, and my father would put a towel behind my arms and take me ‘to a walk.' He always said, 'You have to try, and you will be able to do it.'
I just keep practicing my walking but eventually the braces did not fit anymore, so I begin to walk by holding my left knee. A neighbor told us about Shriners Hospital in Los Angeles and after almost 2 years of wearing casts and with braces on both legs, I walked. I wore a long leg brace on the left and had a brace from toe to knee on the right. Eventually I only wore a brace on my left leg. Shriners Hospital stopped my care when I turned 21.
When I was 16 I began to work in a grocery store against my mother’s wishes. At 20 I decided to drive and bought a car. At first, I lied to my parents and told them it was my friend’s car.
At 24, I meet my husband and we decided to have a child. That was my dream, and now I can say I am complete as a human being.
I need advice about what to be concerned about during my pregnancy and delivery."
Antonio Toniolo, MD, virology, (Italy): I am working as a virologist. We have searched for poliovirus remnants in nearly 80 polio patients and their family members (including more than 25 sons/daughters). I can say that we never found any trace of polioviruses in the children of polio patients.
Lauro S. Halstead, M.D., internist, (USA): A major concern from a medical perspective is the size of the birth canal. Frequently women who had polio at a very young age in one or both legs will not have normal development of the pelvic bones. This leads to a compromise of the birth canal that can often make delivery of a normal size fetus difficult or impossible. The dimensions of the birth canal are typically assessed with an x-ray although there may be other methods that are preferable now. I would think an x-ray would be safe toward the end of the third trimester, but that decision needs to be made by the attending physician. Knowing the size of the birth canal and possibly even the fetus before labor is critical for planning a possible caesarean section.
Lise Kay, M.D, (Denmark): As a doctor and a polio survivor now aged 59, I can tell you that I had two pregnancies in my twenties that went well. My considerations are whether it would be a good idea to wear a corset to support the abdominal muscles to prevent them from being overstretched. Besides the size of the birth canal (which an experienced obstetrician, to some extent, can judge by palpation), lack of sufficient muscle strength in the abdominal wall may become a problem during the birth. It is important to give birth at a place where it is possible to have a caesarean section, and of course, someplace where there is knowledge of following polio patients through an operation.
Oscar Schwartz, MD, pulmonology, (USA): When acute polio affects the whole body, women are at high risk for respiratory complications and should be screened. If a significant residual restrictive defect is present, this can be a problem. The enlarging abdomen causes increasing diaphragmatic restriction and increases hypoventilation risks. I have seen worsening respiratory restriction with hypoventilation during pregnancy. I used an iron lung for the third trimester in one patient many years ago. Now it is possible to use nasal/oral positive pressure
Selma Calmes, MD, anesthesiology, (USA): A 2010 (August) article,Kyphoscoliosis complicating pregnancy: Maternal and Neonatal outcome by Chopra S. et al. in Arch Gynecol Obstet is from an OB unit in India. (Seven of the 22 patients had polio as cause of scoliosis.) Only three women had vaginal delivery. The rest needed lower segment C-section. Fifteen of the 26 C-sections were emergency. There were two failures to place spinal anesthesia (the usual C-section anesthesia), so they changed to all general anesthesia. Also, only one patient had had a spinal fusion.
Rhoda Olkin, PhD, psychology, (USA): I had polio as an infant and had two babies in my 30s. The first (at age 34) was vaginal delivery but lasted 40 hours because the baby got stuck on a bone. Every muscle in my body got overused and gave out. The epidural resulted in paralysis in my weak leg for about 10 days, and recovery was very slow. My second child was a planned caesarean section with general anesthesia (due to concerns about epidural). It went much more smoothly and recovery was much faster, despite my older age (37).
Generally there are not issues for the baby, but the health and well-being of the mother should be carefully considered. If I knew then what I know now, I would either have two caesarean sections, or try a vaginal delivery in water so that the water supports the body.
The Disabled Woman's Guide to Pregnancy and Birth by Judi Rogers and Molleen Matsumura is very good. It contains the experiences of 36 women.
Frederick Maynard, MD, physiatrist, (USA): I agree that the concerns are with the birth canal size for vaginal delivery and her high likelihood of needing a caesarean section. The major concern is that she has a competent obstetrician and hospital nearby who will give her the special professional care she will need. After the birth, it will be a matter of sufficient material supports.
Marny Eulberg, MD, Family practice, (USA): I have seen 800 plus women who have had polio with varying degrees of paralysis and some with more severe paralysis than this lady describes. Most of them have born children and without any more problems than other pregnant women except that they may have needed a caesarean section somewhat more often.
Example 2: “I have recently turned 40 years old and I am 9 weeks pregnant for the very first time. I contracted polio at age 3 and for the first year or so was paralyzed from the waist down. After a long recovery I began to walk again with severe atrophy to my right leg. At age 5, I came to the United States and received medical attention at the Children’s Orthopedic Hospital in Los Angeles. At age 12, I had surgery on my left knee which consisted in stopping the growth on the left leg to allow my right leg to somewhat catch up. Up until the age 13, I used a metal brace that covered my whole right leg (from my thigh down to my toes) and at age 14 I made the decision to stop using the brace and never have since then. I have been married for nearly 9 years and I have lived somewhat of a normal life. Now that I am 40, I have learned of this pregnancy that I did not expect at this stage in my life. I know that the fetus will not be affected by the polio. However, I do have great concern of what the pregnancy and birth would do to my body. I have done a little bit of research and some of my findings such as paralysis are a major concern. I have also come across articles that talked about possible damage to the abdominal muscles and pelvic bone due to the excessive weight. I am in need of professional opinion on my case and would appreciate some feedback.”
Carol Vandenakker Albanese, MD, physiatrist, (USA): I have had a number of patients go through pregnancy and childbirth without problem. Mobility can become an issue as pregnancy progresses and a wheelchair or a scooter should be available. C-section may be necessary, but a high-risk obstetrician should be able to judge size of birth canal, etc. Consideration should be given to diet during pregnancy and not gain excessive weight.
Lauro S. Halstead, M.D., internist, (USA): Falls. As the fetus grows, the center of gravity shifts forward . If someone is already a little unsteady on their feet, the risk for falls increases. Going back to a leg brace and using a cane or crutches would be helpful interventions. In the later stages of pregnancy, it would be worth considering using a manual wheelchair for ultimate safety.
Labor and delivery. When there is severe involvement of one leg with polio as a child and the leg fails to develop normally, there is a concomitant failure of the pelvic bones to develop normally as well. This typically results in an asymmetric and compromised birth canal. This can make a vaginal delivery problematic. Most obstetricians would pick this up in the course of routine prenatal care. However, it’s important for the mother to be aware of this in the event she goes into labor with an unfamiliar obstetrician in charge.
Selma Calmes, MD, anesthesiologist (USA): In my experience, the main problem in these patients is that ventilation can become compromised as the growing fetus pushes up the diaphragm. She should have a pulmonary consult early in pregnancy and get basic PFTs, at least a VC and FEV1. The pulmonologist should follow her during pregnancy to be sure that ventilation is adequate as the pregnancy progresses. Regarding the anesthesia care for delivery: Many of the patients I’ve been involved with needed a C-section for obstetric reasons, so there should be a just-in-case plan for that. Labor pain is nearly always handled with an epidural nowadays. Epidural placement is now facilitated by use of ultrasound in patients with scoliosis, even severe scoliosis. Published reports of regional anesthesia, both in OB and other patients, was without complication, including follow up for possible worsening of muscle weakness. It is recommended that care be provided by a team (includes anesthesia and a high-risk perinatologist) that focuses on high-risk pregnancies.
William DeMayo, MD, physiatrist, (USA): As always, it is hard to give solid advice with limited information, at the same time, one of the concerns that stands out is injury to the sacroiliac (SI) joint - common after polio due to not only weakness but to gait deviations . It is also very common in pregnancy. Hormonal changes will loosen the ligaments holding SI together. This is a common cause of severe low back pain in pregnancy and there is no way around that part of the risk. One factor that is something to potentially modify is the risk due to gait deviation. Although it sound like "getting rid" of brace did not cause any major functional loss (or at least none was noted), one can assume that it would not have been prescribed in the first place had it not provided some biomechanical advantage. That advantage could potentially be a big issue with risk of SI injury during pregnancy. It is recommended that a physiatrist is seen who can give some good practical advice in this area - potentially a brace that helps yet is lighter and lower profile.
Marny Eulberg, MD, Family Physician, (USA): It may mean more difficulty walking as the pregnancy proceeds and the "big belly" throws off balance and the position of back but that should resolve after delivery. The major complication that women polio survivors who became pregnant in the past have had is that some required a C-section to deliver because of bony deformity of the pelvis. The other risks are being of "advanced maternal age" (which would be true if she hadn't had polio and was 40 years old) is the increased risk of the child having Down Syndrome and the increased risk of pre-eclampsia.
Tagged as: childcare , family , health , hypoventilation , muscles , pregnancy