Safe prescribing in pregnancy: Medication considerations for people with spinal cord injury

Pregnancy among individuals with spinal cord injury (SCI) occurs at rates similar to the general population, yet reproductive care for this population remains underexamined. Pregnant individuals with SCI experience secondary complications including neurogenic bladder and bowel, spasticity, pain, venous thromboembolism (VTE), and autonomic dysreflexia that often require pharmacologic management. However, limited evidence exists regarding the safety of commonly prescribed medications during pregnancy, contributing to clinical uncertainty and disparities in maternal and fetal outcomes.

Synthesize literature on the safety of frequently used medications during pregnancy for individuals with SCI to develop a pragmatic tool to facilitate initial identification and discussion of medications that may be considered during pregnancy.

A multidisciplinary team identified medications commonly prescribed for secondary complications of SCI. A literature review was conducted using PubMed, UpToDate, Briggs' Pregnancy and Lactation Guide, and the NatMed Pro Database. Medications were categorized by indication, evaluated for safety during pregnancy, and assigned a consensus recommendation based on available evidence through iterative discussion among the authors.

Several medications for SCI-related conditions appear generally safe during pregnancy, including polyethylene glycol, acetaminophen, selective serotonin reuptake inhibitors, low-molecular-weight heparin, insulin, and vitamin supplementation. Other medications, including anticholinergics, gabapentinoids, and some spasticity agents, have limited or mixed safety data.

Pharmacologic management of secondary complications during pregnancy in individuals with SCI requires shared decision-making with patients due to limited safety data, emphasizing the need for nonpharmacologic management when possible. This review provides a reference for clinicians and highlights the need for prospective research and disability-inclusive guidelines.