Cross et al. 1992; USA
Downs & Black = 4
Case Series
N=22

Population: 22 woman with SCI, 11 with cervical and 11 with thoracic injuries; 10 with incomplete and 12 with complete injuries.
Treatment: epidural anesthesia
Outcome Measures: presence of autonomic hyperreflexia, type of anesthesia, type of delivery, complications

1. AD was experienced in 9/16 > T6.
2. One patient had two grand mal seizures during labour, which may have been triggered by her severe AD and the subsequent intravenous administration of diazepam. 
3. Six patients had epidural anesthesia, which was effective for the control of AD.

Skowronski & Hartman 2008; Australia
Downs & Black = 10
Case Series
N = 5

Population: 5 females with tetraplegia who gave birth a total of 7 times (two subjects gave birth twice).
Treatment: N/A
Outcome Measures: Complication, management, and outcomes of pregnancy; hospital records

1. AD occurred in 6 of 7 pregnancies
2. AD was managed pre-emptively by insertion of an epidural either before or in the early stages of labour, with generally good results
3. Dangerously high peaks were managed by the administration of either sublingual nifedipine or intramuscular clonidine
4. Other major complications include urinary tract infection (present in all pregnancies) and muscle spasms (4 of 7 pregnancies)

Hughes et al. 1991; UK
Downs & Black = 5
Observational
N=15

Population: 17 pregnancies in 15 women with SCI, level of injury: T4-L3
Treatment: management and outcome of pregnancies in women with SCI.
Outcome Measures: antenatal care and problems, labour diagnosis and outcome

1. Labour tended to be diagnosed by dysreflexic symptoms or membrane rupture with confirmation by palpation of contractions and vaginal examination. 
2. Initial management of AD included elevation of head of the bed, nifedipine and nitrates. 
3. The most effective measure for controlling AD was to identify and interrupt the triggering afferent input to the spinal cord.

Cross et al. 1991; USA
Downs & Black = 4
Observational
N=16

Population: 7 subjects with cervical and 9 with thoracic injuries.
Treatment: questionnaire (in person or telephone) and hospital records review.
Outcome Measures: outcomes of pregnancies

1. Of the 16 women, 25 pregnancies occurred, resulting in 22 babies & 3 abortions.
2. 2/15 vaginal deliveries and 5/7 caesarian section had AD during delivery with 4 of these receiving epidural anesthesia for the control of AD.
3. 1 patient required epidural catheter 5 days postpartum to control AD.

Ravindran et al. 1981; USA
Downs & Black =6
Case report
N=1

Population: 19 yr-old female with C5 complete tetraplegia admitted to the obstetrical intensive care unit for intra-amniotic prostaglandin F2-alpha injection for uterine evacuation of a dead fetus of 20 wks gestation.
Treatment: Sodium nitroprusside (100 mg/min to 700 mg/min)
Outcome measures: BP and AD symptoms

1. 100 mg/min of sodium nitroprusside decreased SBP from 170 mmHg to 120 mmHg caused by vaginal speculum introduction.
2. Prostaglandin induced uterine contraction further elevated BP to 200/70 mmHg; headache and sweating.
3. Administration of 700 mg/min of sodium nitroprusside decreased SBP and alleviated AD.
4. Following cessation of uterine contraction, the patient developed hypotension (70/30 mmHg) requiring vasopressor therapy.
5. Sodium nitropruside was stopped and epidural analgesia was initiated for further management of AD.