Labor and Disability: A Nation-Wide Analysis of Pregnancy Outcomes after Spinal Cord Injury

Spinal cord injury (SCI) is a challenging clinical entity necessitating multidisciplinary management. While the impact of SCI on male fertility is relatively well-understood, its impact on prepartum, peripartum, and fetal outcomes remains understudied. This study seeks to elucidate prepartum and delivery-related outcomes associated with a history of SCI in pregnant patients. We identified all pregnant patients admitted to United States hospitals with and without a history of SCI in the National Inpatient Sample from 2016 to 2019. For all patients, five outcomes were analyzed: in-hospital death, discharge disposition, prepartum complications, length of stay (LOS), and cost. For patients undergoing delivery during admissions, five additional outcomes were studied: preterm labor, epidural anesthesia administration, performance of cesarean section (CS), delivery-related complications, and fetal outcome. Unadjusted outcomes were summarized using survey-weighted estimates. Adjusted associations between SCI and maternal outcomes were estimated using stabilized inverse probability of treatment weighting (IPTW) with doubly robust models. We identified 367 unweighted SCI admissions, corresponding to a survey-weighted national estimate of 1,835 SCI admissions (0.01%) among 15,073,815 pregnancy admissions. 91.6% of admissions were for delivery, with 32.5% undergoing CS. Pregnant patients with SCI had an average age of 30.3 years, and a plurality of injuries was lumbosacral (20.7%). Among all pregnant admissions, patients with a history of SCI had higher odds of inpatient mortality (OR = 45.54 [95% CI: 8.45-245.40], p < 0.001), lower rates of routine discharge disposition (OR = 0.17, p < 0.001), greater LOS (+50%, p < 0.001), and elevated costs (+49%, p < 0.001). SCI patients were more likely to have prepartum complications of venous thromboembolism (VTE) (OR = 4.01, p = 0.041) and genitourinary infections (OR = 4.26, p < 0.001). SCI patients were significantly less likely to be admitted electively (39.5% vs. 47.9%, p < 0.001) or for delivery (OR = 0.38, p < 0.001). Among admissions for delivery, there were no differences in preterm labor or epidural anesthesia administration, but patients with SCI were less likely to experience delivery-related complications (OR = 0.56, p = 0.017) and stillbirth (OR = 0.05, p = 0.003). SCI patients had significantly higher odds of undergoing CS (OR = 1.88, p = 0.006). These findings suggest that SCI confers substantial excess maternal risk, particularly for mortality, as well as VTE, urinary tract infection, CS, and overall resource utilization. Future work using SCI-specific registries with detailed neurological characterization and longitudinal follow-up is needed to refine risk stratification and inform multidisciplinary guidelines for pregnancy management in this population.