Multiple sclerosis in pregnancy: prevalence, sociodemographic features, and obstetrical outcomes

Children born preterm or small for gestational age to mothers with multiple sclerosis: Do these children have an increased risk of infections in early life?

BACKGROUND

Mothers with multiple sclerosis are at increased risk of preterm birth and small for gestational age infants. Both conditions pose a risk of morbidity, including early-life infections.

OBJECTIVE

This study aimed to assess the risk of infections in the first 3 years of life among children born preterm or small for gestational age to mothers with multiple sclerosis.

METHODS

We used Danish national health registers to establish the study cohort of all births by women with MS born from 1995 to 2023. In Cox regression models, we estimated hazard ratios (HRs) of infections in preterm or small for gestational age children.

RESULTS

Preterm children had an adjusted HR of 1.49 (95% confidence interval (95% CI) 1.15-1.93) for hospital-diagnosed infection and 0.88 (95% CI 0.72-1.06) for antibiotic prescriptions. Small for gestational age children had an adjusted HR of 0.81 (95% CI 0.54-1.22) for hospital-diagnosed infection and 1.07 (95% CI 0.82-1.38) for antibiotic prescriptions.

CONCLUSION

Children born preterm to mothers with multiple sclerosis had an increased risk of hospital-diagnosed infections in the first 3 years of life, but not of mild-to-moderate infections evaluated on prescriptions. Children born small for gestational age did not have an increased risk of infections.

Maternal and neonatal outcomes in pregnant women with multiple sclerosis disease: A systematic review and meta-analysis

OBJECTIVES

Little is known regarding the impact of multiple sclerosis (MS) on maternal and neonatal outcomes. Consequently, this systematic review and meta-analysis aimed to study the impacts of MS on maternal and neonatal outcomes in pregnant women with a history of MS.

METHODS

This review was designed in line with the PRISMA guidelines. Two researchers conducted independent reviews of the literature without time restrictions until January 2023 using international databases, including PubMed, Web of Science, CINAHL Plus, Embase, Scopus, Science Direct, and Google Scholar. A random-effect meta-analysis, using the db metan command in Stata 17.2, was used to calculate the pooled measure of association.

RESULTS

The meta-analysis identified 15 studies involving 33,174,541 pregnant women (32,191 with MS and 33,142,350 as controls). The findings indicate that women with a history of MS are at an increased risk of cesarean delivery (OR=1.28, 95% Confidence Intervals [CI]: 1.14-1.45, p-value: 0.042). Also, these women are at higher risk of neonatal outcomes, such as preterm birth (OR= 1.39, 95% CI: 1.08-1.78, p-value: 0.02), congenital malformations (OR=1.32, 95%CI: 1.16-1.50, p-value: 0.031), Apgar score <7 (OR=2.13, 95% CI: 1.19-3.79, p-value: 0.03), and small for gestational age (OR=1.27, 95% CI: 1.08-1.51, p-value: 0.040).

CONCLUSION

Pregnant women with MS have a greater chance of adverse pregnancy results than pregnant women without MS. Consequently, pregnant women with MS should create detailed before and after pregnancy plans, in consultation with their doctors, spouses, families, and friends, regarding the necessary care and supplements. Future studies applying a prospective cohort design that control for potential confounders are needed to further validate the findings.

Asthma and chronic obstructive pulmonary disease (COPD) in people with multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Studies have found that multiple sclerosis (MS) has an impact on the initiation or the course of asthma and chronic obstructive pulmonary disease (COPD). This review amied to investigate the prevalence and odds of asthma and COPD among people with MS (pwMS).

METHOD

PubMed, Embase, Scopus, and Web of Science were systemically searched from inception to May 2023. R version 4.3.2 and random-effect model were used to calculate the pooled prevalence and odds ratio (OR), with their 95 % confidence interval (CI), in pwMS.

RESULTS

A total of 40 studies consisting of 287,702 pwMS were included. 37 studies indicated that the pooled prevalences of asthma and COPD among pwMS were 5.97 % (95 % CI: 4.62 %-7.69 %, I2=99 %) and 3.03 % (95 % CI: 1.82 %-5.00 %, I2=99 %), respectively. 24 studies on 236,469 pwMS and 85,328,673 healthy controls revealed that the overall odds of asthma and COPD in MS were 1.14 (95 % CI: 0.76-1.71, p-value=0.53, I2=97 %) and 1.28 (95 % CI: 1.11-1.47, p-value<0.01, I2=70 %), respectively.

CONCLUSION

MS can increased the risk of developing COPD, while asthma does not exhibit a significant relationship with MS. Our study highlights the importance of identifying pwMS who face greater risks of respiratory issues to monitor efficiently and initiate suitable preventative actions.

Neonatal outcomes in women with Multiple Sclerosis - Influence of disease activity: A Danish nationwide cohort study

BACKGROUND

Maternal Multiple Sclerosis (MS) has been associated with an increased risk of adverse birth outcomes. We hypothesized that active disease during conception and pregnancy plays an important role in this context, which this study aims to address.

METHODS

We used the Danish registers to conduct a nationwide cohort study. Information on maternal disease activity during pregnancy was retrieved using proxies from the linked registers (hospitalization, magnetic resonance imaging of the brain, and use of systemic corticosteroids during pregnancy). Neonates, exposed in utero to maternal disease activity constituted the exposed cohort and the unexposed cohort constituted neonates without in utero exposure to maternal disease activity. The examined outcomes were preterm birth, small for gestational age, low 5-minute Apgar score, and major congenital anomalies. In logistic regression models we estimated the odds ratios (OR) with adjustment for confounders such as maternal age, comorbidities, parity, smoking, calendar year of birth, and disease-modifying treatment.

RESULTS

Among the study population of 2492 children of mothers with MS we identified 273 (11 %) neonates exposed to maternal disease activity during pregnancy, and 2219 (89 %) neonates without exposure to disease activity. The adjusted odds ratios (aOR) for preterm birth, small for gestational age, low 5-minute Apgar score, and major congenital anomalies among children born to women with disease activity during pregnancy were 0.92 (95 % confidence interval (95 % CI) 0.53-1.60), aOR 1.19 (95 % CI 0.62-2.26), aOR 2.57 (95 % CI 0.93-7.15) and aOR 0.93 (95 % CI 0.48-1.83), respectively.

CONCLUSIONS

Women with MS having disease activity during pregnancy did not have a statistically significantly increased risk of adverse neonatal outcomes compared to women with MS without disease activity, which is overall reassuring results. We believe, that this will be useful knowledge for patients and clinicians in planning a pregnancy and preparing a birth plan.

Unraveling the complex relationship: Multiple sclerosis, urinary tract infections, and infertility

BACKGROUND

Multiple sclerosis (MS) is an immune system disorder that affects the central nervous system (CNS) and progressively damages nerve fibers and protective myelin. People with MS often experience a wide range of complications, including lower urinary tract dysfunction, urinary tract infections (UTIs) and sexual dysfunction. MS is common in young people and can lead to sexual dysfunction (SD) and infertility, which becomes more pronounced as the disease progresses.

RESULTS

Over the past two decades, significant advances have been made in the management of MS, which may slow the progression of the disease and alter its course. However, UTI and SD remain significant challenges for these patients. Awareness of the underlying complications of MS, such as UTIs and infertility, is crucial for prevention, early detection and appropriate treatment, as there is a causal relationship between UTIs and the use of corticosteroids during an attack.

CONCLUSION

This article provides an overview of potential microbial pathogens that contribute to the development of MS, as well as an assessment of people with MS who report UTIs and infertility.

Pregnancy prevalence and outcomes after optic neuritis in South Korea

To compare pregnancy rates and complications in women with and without a history of optic neuritis (ON). A nationwide, population-based, retrospective study using data from the Korean National Health Claims from January 2011, to December 2017 was done. ON cohort (ON group) consisting of women aged 18 to 50 with a history of ON and 1:3 age-matched controls (control group) were compared for pregnancy and delivery rates using logistic regression after adjusting for possible confounders. Pregnancy-ON cohort (pregnancy-ON group), women aged 18 to 55 with a history of ON and pregnancy, and 1:3 age at pregnancy matched controls (pregnancy-control group) were analyzed for pregnancy complications using logistic regression after adjusting for covariates. ON group (n = 2516) showed decreased odds ratio (OR) for pregnancy [Adjusted OR2: 0.716, 95% confidence interval (CI): 0.626-0.820] and delivery (adjusted OR2: 0.647, 95% CI: 0.554-0.756) compared to controls (n = 7548). Pregnancy-ON group (n = 550) showed increased risk of delayed fetal growth (adjusted OR2: 9.867, 95% CI: 1.224-79.564), pre-eclampsia (adjusted OR2: 8.327, 95% CI: 2.911-23.819), preterm delivery (adjusted OR2: 3.914, 95% CI: 2.667-5.742), pregnancy and postpartum infection (adjusted OR1: 1.671, 95% CI: 1.296-2.154), diabetes in pregnancy (adjusted OR2: 1.365, 95% CI: 1.062-1.754) compared to pregnancy-control group (n = 1650). Our population-based cohort study suggests that history of ON is associated with decreased pregnancy and delivery rates. It may be a risk factor for various pregnancy complications.

Maternal Multiple Sclerosis and Health Outcomes Among the Children: A Systematic Review

Objective

To summarize the available literature and provide an overview of in utero exposure to maternal multiple sclerosis (MS) and the influence on offspring health outcomes.

Methods

We conducted a systematic review by searching Embase, Medline and PubMed.gov databases, and we used covidence.org to conduct a thorough sorting of the articles into three groups; 1) women with MS and the influence on birth outcomes; 2) women with MS treated with disease-modifying therapy (DMT) during pregnancy and the influence on birth outcomes; and 3) women with MS and the influence on long-term health outcomes in the children.

Results

In total, 22 cohort studies were identified. Ten studies reported on MS without DMT and compared with a control group without MS, and nine studies on women with MS and DMT prior to or during pregnancy met the criteria. We found only four studies reporting on long-term child health outcomes. One study had results belonging to more than one group.

Conclusion

The studies pointed towards an increased risk of preterm birth and small for gestational age among women with MS. In terms of women with MS treated with DMT prior to or during pregnancy, no clear conclusions could be reached. The few studies on long-term child outcomes all had different outcomes within the areas of neurodevelopment and psychiatric impairment. In this systematic review, we have highlighted the research gaps on the impact of maternal MS on offspring health.

Pregnancy and multiple sclerosis: 2022 recommendations from the French multiple sclerosis society

OBJECTIVE

The objective of this study was to develop evidence-based recommendations on pregnancy management for persons with multiple sclerosis (MS).

BACKGROUND

MS typically affects young women in their childbearing years. Increasing evidence is available to inform questions raised by MS patients and health professionals about pregnancy issues.

METHODS

The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and university databases (January 1975 through June 2021). The RAND/UCLA appropriateness method was developed to synthesise the scientific literature and expert opinions on healthcare topics; it was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence.

RESULTS

A strong agreement was reached for all 104 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, locoregional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses and disease-modifying treatments.

CONCLUSION

The 2022 recommendations of the French MS society should be helpful to harmonise counselling and treatment practice for pregnancy in persons with MS, allowing for better and individualised choices.

In Vivo Assessment of the Ameliorative Impact of Some Medicinal Plant Extracts on Lipopolysaccharide-Induced Multiple Sclerosis in Wistar Rats

Multiple sclerosis is a chronic autoimmune disorder that leads to the demyelination of nerve fibers, which is the major cause of non-traumatic disability all around the world. Herbal plants Nepeta hindustana L., Vitex negundo L., and Argemone albiflora L., in addition to anti-inflammatory and anti-oxidative effects, have shown great potential as neuroprotective agents. The study was aimed to develop a neuroprotective model to study the effectiveness of herbal plants (N. hindustana, V. negundo, and A. albiflora) against multiple sclerosis. The in vivo neuroprotective effects of ethanolic extracts isolated from N. hindustana, V. negundo, and A. albiflora were evaluated in lipopolysaccharides (LPS) induced multiple sclerosis Wistar rat model. The rat models were categorized into seven groups including group A as normal, B as LPS induced diseased group, while C, D, E, F, and G were designed as treatment groups. Histopathological evaluation and biochemical markers including stress and inflammatory (MMP-6, MDA, TNF-α, AOPPs, AGEs, NO, IL-17 and IL-2), antioxidant (SOD, GSH, CAT, GPx), DNA damage (Isop-2α, 8OHdG) as well as molecular biomarkers (RAGE, Caspase-8, p38) along with glutamate, homocysteine, acetylcholinesterase, and myelin binding protein (MBP) were investigated. The obtained data were analyzed using SPSS version 21 and GraphPad Prism 8.0. The different extract treated groups (C, D, E, F, G) displayed a substantial neuroprotective effect regarding remyelination of axonal terminals and oligodendrocytes migration, reduced lymphocytic infiltrations, and reduced necrosis of Purkinje cells. The levels of stress, inflammatory, and DNA damage markers were observed high in the diseased group B, which were reduced after treatments with plant extracts. The antioxidant activity was significantly reduced in diseased induced group B, however, their levels were raised after treatment with plant extract. Group F (a mélange of all the extracts) showed the most significant change among all other treatment groups (C, D, E, G). The communal dose of selected plant extracts regulates neurodegeneration at the cellular level resulting in restoration and remyelination of axonal neurons. Moreover, 400 mg/kg dose of three plants in conjugation (Group F) were found to be more effective in restoring the normal activities of all measured parameters than independent doses (Group C, D, E) and is comparable with standard drug nimodipine (Group G) clinically used for the treatment of multiple sclerosis. The present study, for the first time, reported the clinical evidence of N. hindustana, V. negundo, and A. albiflora against multiple sclerosis and concludes that all three plants showed remyelination as well neuroprotective effects which may be used as a potential natural neurotherapeutic agent against multiple sclerosis.

Pregnancy-Related and Perinatal Outcomes in Women With Multiple Sclerosis: A Nationwide Danish Cross-sectional Study

OBJECTIVE

To investigate differences in pregnancy-related and perinatal outcomes in women with multiple sclerosis (MS) compared with the general population.

METHODS

We conducted a cross-sectional study including pregnancies from January 1, 1997, to December 31, 2016, to women registered in the Danish Multiple Sclerosis Registry (the study cohort). Pregnancy-related and perinatal outcomes were compared with a randomly selected subcohort of pregnancies from the general population (the comparison cohort) using logistic regression adjusted for possible confounders.

RESULTS

In total, 2,930 pregnancies were included in the study cohort and 56,958 pregnancies in the comparison cohort. No differences were found in pregnancy-related complications (preeclampsia/gestational diabetes or placenta complications), emergency caesarean section (c-section), instrumental delivery, low Apgar score, stillbirth, preterm birth, or congenital malformations. Elective c-section (odds ratio [OR] 1.89 [95% confidence interval (CI) 1.65-2.16]), induced delivery (OR 1.15 [95% CI 1.01-1.31]), and being born small for gestational age (SGA) (OR 1.29 [95 %CI 1.04-1.60]) had a higher prevalence in the study cohort, whereas the prevalence of signs indicating asphyxia was lower in the study cohort (OR 0.87 [95% CI 0.78-0.97]) relative to the comparison cohort.

CONCLUSION

We found a higher prevalence of elective c-sections, induced delivery, and infants being SGA among newborns to women with MS, whereas the prevalence of asphyxia was lower in the study cohort. There were no significant differences in severe adverse perinatal outcomes when comparing women with MS and their newborns with those of the general population.

Does multiple sclerosis increase the risk of preeclampsia? A systematic review and meta-analysis

Objective: We investigated, via systematic review and meta-analysis, whether multiple sclerosis (MS) is associated with the risk of preeclampsia (PE).Methods: From the eligible studies, we pooled odds ratios (ORs) and confidence intervals (CIs) of PE for pregnant women with MS compared with pregnant women without it using the fixed-effects model. The I² measured heterogeneity between studies.Results: Eight eligible studies (9 cohorts) were included. Pregnant women with MS had no excess risk of PE compared with pregnant women without MS (pooled OR = 0.99, 95% CI: 0.89, 1.09; I² = 0.00%).Conclusion: MS is not associated with PE.

The effects of pregnancy on relapse rates, disability and peripartum outcomes in women with multiple sclerosis: a systematic review and meta-analysis

Background: Although previous cohort studies of women with multiple sclerosis (MS) yielded a reduction in relapse rate during pregnancy, the effect size has not been quantified in a comprehensive manner. In addition, the effects on disability progression and peripartum outcomes have been controversial. The purpose of this work is to assess the effect of pregnancy on disease activity, and to assess the effects of MS on pregnancy as well. Materials & methods: We searched in PubMed, Cochrane Library and EMBASE for cohort studies dealing with the effects of pregnancy on relapse rates, disability progression and peripartum outcomes in women with MS. The evaluated outcomes were: changes in the annualized relapse rate (ARR) in pregnancy and puerperium, disability worsening compared with the year before pregnancy, and peripartum outcomes, which were compared with the ones of non-MS women. In the majority of cohorts included here, the women were not under disease modifying therapies during pregnancy. Results: We found 23 cohort studies measuring changes in the ARR during pregnancy and puerperium; 12 were prospective and 11 retrospective. In 17 cohorts there was significant reduction in the ARR during pregnancy compared with prepregnancy period. The pooled mean reduction in the ARR was -0.5 (95% CI: 0.67-0.38), p < 0.001, from 15 cohorts included in meta-analysis. In 18 cohorts the ARR increased in the 3-month puerperium relative to prepregnancy year period; the pooled mean increase in the ARR was 0.22 (95% CI: 0.11-0.33), p < 0.001, from 14 cohorts included in meta-analysis. Disability worsening was addressed in 18 cohorts, and in 14 of them there were no significant changes. Peripartum complications and obstetrical outcomes were assessed in 16 cohorts, of whom 13 were retrospective, without finding significant differences. Conclusion: Pregnancy is associated with lower disease activity, and puerperium with higher disease activity. Disability does not change significantly after pregnancy. The obstetrical outcomes are not very different from those of non-MS women in most cohorts.

The Intersection of Disability and Pregnancy: Risks for Maternal Morbidity and Mortality

It is estimated that 1 in 4 women in the United States live with a disability, and using population-based estimates, 10-12% of women of childbearing age have a disability. There are limited data to suggest that women with disabilities experience higher rates of or risks for adverse outcomes related to pregnancy, delivery, and access to appropriate postpartum care. Research on specific disabling conditions demonstrates variable risk for syndromes that threaten the health of the mother, such as preeclampsia, infection, and coagulation disorders. Much of the literature suggests that normal, healthy pregnancy is possible but points to the need for tailored information for patients and providers about the intersection of their condition with pregnancy and specific care needs. Given the lack of systematic evidence in this area across conditions and functional impairments, more research is needed to clarify the interaction of specific disabilities with pregnancy and provide evidence-based information to the field to decrease the risks to mothers and their infants. This article will provide an overview of conditions that contribute to maternal morbidity and mortality as they relate to pregnancy in women with disabilities and provide resources to the field to further the investigation of this area.

Pregnancy outcomes in women with Multiple Sclerosis

INTRODUCTION

Women represent two-thirds of the MS population and are usually diagnosed during childbearing age. Collection of local information about pregnancy outcomes is fundamental to support individual decision-making.

OBJECTIVE

To explore the trends in pregnancy decision making and pregnancy outcomes before (PreMS) and after (PostMS) MS diagnosis.

METHODS

We developed a questionnaire for retrospective assessment of pregnancy outcomes in PreMS and PostMS patients under regular care at the Programa de Esclerosis Multiple UC in Chile.

RESULTS

From the 218 women who responded to the questionnaire, 67 women did not have pregnancies. The total number of pregnancies registered was 299, 223 were PreMS (97 women, mean 2.5 ± 1.3 per/woman), and 76 PostMS (59 women, mean 1.9 ± 1.1 per/woman, p = 0.003). Mean age at first pregnancy was 27.6 ± 6.2 in PreMS, and 32.6 ± 4.6 years in PostMS women (p < 0.001). Significant differences between PreMS and PostMS pregnancy outcomes were cesarean section (37% vs. 66%; OR 2.74 95%CI(1.5-52), p=0.002), suspected relapse during 6 months after birth (7% vs. 18%, p<0.001), and breastfeeding (83% vs 67%, p=0.005). Gestational age, weight/size at birth, were not different between groups. Major malformations were observed similarly in both groups.

CONCLUSIONS

Changes in pregnancy decision-making after MS diagnosis occur, having fewer children and at an older age. It also changes obstetrician decisions for cesarean sections, with a 3 fold increase. Regarding newborn outcomes, there were no differences between groups.

Prevalence of autoimmune disease among pregnant women and women of reproductive age in New South Wales, Australia: a population-based study

BACKGROUND

Autoimmune diseases disproportionately affect women and have been linked to increased risk of maternal and perinatal mortality and morbidity. Our aim was to determine the prevalence of autoimmune disease among pregnant women and women of reproductive age (WRA), which is not well described.

MATERIALS AND METHODS

A population-based study was conducted using data from a survey of general practitioner (GP) encounters and state-wide hospital admissions in New South Wales (NSW). A list of 29 conditions and relevant diagnosis codes was used to identify autoimmune disease. Prevalence estimates and trends were calculated using population denominators for GP encounters for WRA in 2011-2015 and hospital admissions for WRA and pregnant women in 2013-2017.

RESULTS

A total 31,065 GP encounters for WRA were identified and 607 (2.0%) reported an autoimmune disease, equivalent to 1.1 GP encounters per 10 WRA each year when extrapolating to NSW population figures. For WRA admitted to hospital, 2.6% had an autoimmune diagnosis recorded each year equivalent to a population prevalence of 0.5%. A total 477,243 births were identified, of which 4230 mothers (0.9%) had at least one autoimmune disease recorded during a 1-year pregnancy lookback period. Autoimmune disease prevalence among both pregnant women and WRA either attending GP or hospital increased, on average, 2-4% per year over the study period.

CONCLUSIONS

A small, but potentially growing proportion of reproductive age and pregnant women have a diagnosed autoimmune disease, and this may impact their health outcomes.

Pharmacotherapeutic considerations in women with multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is a chronically progressive disease of the central nervous system. The relapsing form of the disease predominantly affects women with onset between the ages 20 to 40 years. Therefore, timing, choice, and treatment options should take pregnancy planning into consideration to accommodate both the needs and safety of the mother and health of the fetus.

AREAS COVERED

In this review, the authors discuss and summarize the recent evidence of different pharmacotherapeutic possibilities in the treatment of women with MS.

EXPERT OPINION

There is evidence that disease modifying therapy reduces the risk of relapses and diminishes disability progression in people with relapsing MS. The disease is often diagnosed in the childbearing years, and thus pregnancy planning can possibly be a part of the pharmacotherapeutic considerations. The management of women planning pregnancy requires a balancing of risks. The clinician must consider the risks related to treatment discontinuation versus the risk of exposing the developing fetus to drugs that are potential fetotoxic. Randomized controlled trials of medication safety - if used during pregnancy, are prohibited for ethical reasons; hence, the evidence is continuously gathered from observational data, post-authorization studies and pregnancy registries.

Neuroimmunologic disorders in pregnancy

Pregnancy influences the course of neuroimmunologic conditions, which include multiple sclerosis (MS), neuromyelitis optica spectrum disorder, and autoimmune encephalitis. The outcomes differ significantly for each disorder, reflecting the impact of hormonal changes, T-cell subsets, and placental factors on disease pathogenesis. In recent years, numerous data have emerged regarding MS activity throughout pregnancy and postpartum. Historically, the misconception that pregnancy worsens MS outcomes led patients to abstain from childbearing. Now, more women with these disorders, empowered by up-to-date information and better baseline disease control, are choosing to conceive. Nevertheless, the management of MS and related disorders in the pregnancy and postpartum period is complicated and requires a nuanced approach. Since standardized treatment guidelines around pregnancy are currently lacking, neurologists, together with obstetricians, must engage patients in a shared decision-making process that weighs the benefits to the mother and risks to the fetus. This chapter outlines the pathophysiology of neuroimmunologic disorders during pregnancy and postpartum, the impact of these diseases on childbearing, including fertility, pregnancy, delivery, and peurperium, as well as existing recommendations for treatment.

Epidemiology of neurologic disease in pregnancy

Many neurologic diseases in women are influenced by the physiologic and hormonal changes of pregnancy, and pregnancy itself poses challenges in both treatment and evaluation of these conditions. Some diseases, such as epilepsy and multiple sclerosis, have a high enough prevalence in the young female population to support robust epidemiologic data while many other neurologic diseases, such as specific myopathies and muscular dystrophies, have a low prevalence, with data limited to case reports and small case series. This chapter features epidemiologic information regarding a breadth of neurologic conditions, including stroke, epilepsy, demyelinating disease, peripheral neuropathies, migraine, sleep-disordered breathing, and meningioma, in women in the preconception, pregnancy, and postpartum stages.

B cell depletion and pregnancy: Review and applications for MS treatment

Multiple sclerosis (MS) is a chronic autoimmune condition primarily affecting young adults. As there are numerous uncertainties faced by young women of childbearing age who are living with this chronic condition and the gender ratio is increasingly skewed towards women, it has become critical to define a clear approach to questions of disease management prior to and during pregnancy. With the approval of B cell depletion therapy for treatment of relapsing remitting and primary progressive MS, we explore the available data on using this type of therapy in the setting of pregnancy. We also provide recommendations regarding use of B-cell depleting therapies for patients who are considering or attempting conception.

Reproductive history of the Danish multiple sclerosis population: A register-based study

Background:

A diagnosis of multiple sclerosis (MS) may impact the choice of parenthood.

Objective:

To investigate the number of live births, abortions and ectopic pregnancies among persons with MS.

Methods:

From the Danish Multiple Sclerosis Registry, we extracted data from all persons diagnosed with MS from 1960 to 1996 and matched each MS person with four reference persons. We used a negative binomial regression model for the live births and Poisson regression model for abortions and ectopic pregnancies. The total fertility rate (TFR) during 1960–2016 and the annual number of live births in the MS population were analysed.

Results:

Persons with MS had fewer children than reference persons. Fewer women with MS had elective abortions after diagnosis (incidence rate ratio (IRR) = 0.88; 95% confidence interval (CI) = 0.78–1.00) than reference persons. There was no difference regarding the number of elective abortions, spontaneous abortions or ectopic pregnancies after onset. The TFR was lower for women with MS than for reference persons, and the number of annual live births by MS persons increased during 1960–2016.

Conclusion:

MS seems to considerably impact reproductive choices, especially after clinical diagnosis, resulting in the MS population having fewer children than the general population.

Women's Health: Contemporary Management of MS in Pregnancy and Post-Partum

Multiple sclerosis (MS) primarily affects women in childbearing age and is associated with an increased risk of adverse post-partum outcomes. Relapses and now fetal exposure to disease modifying treatments in the early phase of pregnancy and thereafter are of concern. Safe and effective contraception is required for women who wish to delay or avoid pregnancy while on disease-modifying treatments. Counseling and planning is essential to assess the risk of both fetal and maternal complications, particularly now in the era of highly efficient and riskier therapies. The purpose of this review is to provide a practical framework using the available data surrounding pregnancy in MS with the goal of optimizing outcomes during this phase in MS.

Pregnancy Outcomes in Women With Multiple Sclerosis

Few studies have assessed the risk of adverse pregnancy outcomes in women with multiple sclerosis (MS). We used 2 large US administrative databases, the Truven Health MarketScan Database (2011-2015; Truven Health Analytics Inc., Ann Arbor, Michigan) and the Nationwide Inpatient Sample (2007-2011), to identify delivery cohorts. MS and pregnancy outcomes (infections, cesarean delivery, preterm delivery, poor fetal growth, preeclampsia, chorioamnionitis, postpartum hemorrhage, stillbirth, and infant malformations) were identified during pregnancy and at delivery. We calculated adjusted risk ratios according to MS status and relapse(s) in the year before delivery. Among over 5 million pregnancies, we identified 3,875 pregnancies in women with MS. Women with MS had an increased risk of infections during pregnancy (Truven Health: adjusted risk ratio (aRR) = 1.22, 95% confidence interval (CI): 1.16, 1.27) and preterm delivery (Truven Health: aRR = 1.19 (95% CI: 1.04, 1.35); Nationwide Inpatient Sample: aRR = 1.30 (95% CI: 1.16, 1.44)). The risks of other outcomes were similar for women with and without MS. In the Truven Health database, risk ratios for the pregnancy outcomes in women experiencing relapses versus those without relapses were between 0.9 and 1.4, and confidence intervals overlapped the null. Overall, women with MS had an increased risk of infections and preterm delivery; however, their risks for other adverse pregnancy outcomes were not elevated. Disease activity before delivery was not a strong predictor of outcomes.

Pregnancy Outcomes in Men and Women Treated With Teriflunomide. A Population-Based Nationwide Danish Register Study

Background: The majority of persons diagnosed with multiple sclerosis (MS) experience their first MS symptoms in the reproductive age. Teriflunomide (TFL, Aubagio), was first released in Denmark for relapsing-remitting MS in December 2013. TFL treatment is contraindicated in women of childbearing potential who are not using reliable contraception. TFL can be transmitted via semen and a low risk of male-mediated embryo-fetal toxicity is described. Objective: To report pregnancy outcomes of TFL-treated women and partners to TFL-treated men: gestation week. Methods: Prospective cohort study comparing pregnancy outcomes of TFL-treated men and women, matched on age at conception, 1:4 with controls from the general population. Data on TFL-treated patients treated 1st of January 2014-31st of December 2016 for at least 30 consecutive days prior to conception, and with conception occurring latest 2 years after treatment discontinuation were extracted from The Danish Multiple Sclerosis Registry and merged with several national reproductive registries. Logistic regression was used to analyse the association between TFL exposure and any adverse event. Results: A total of 31 pregnancies were recorded, 13 women and 18 of partners to a TFL-treated man. All 18 partners of TFL-treated men completed their pregnancies: livebirth (18), gestation time >37 weeks (17), gestation time 33-36 weeks (1), normal birth weight (18), spontaneous and elective abortion (0), congenital malformation (plagiocephali) (1), normal delivery (14), induced delivery (2), cesarean section (2), Apgar score ≥7 (18). Among the 13 pregnancies in women exposed to TFL: elective abortion (11), spontaneous abortion (0), livebirth (2), gestation time >37 weeks (2), normal birth weight (2), congenital malformations (0), normal delivery (1), induced delivery (1), Apgar score ≥7 (2). The TFL group was associated with a 22% reduction in the odds of any adverse event relative to controls, although this association was not significant (OR 0.78; 95% CI 0.16-3.72, p = 0.753). Conclusion: Pregnancy outcomes were consistent with those of the general population. The malformation reported of the partner to a TFL-treated man is comparable to the rate of plagiocephaly reported in Denmark.

Pregnancy rates and outcomes in women with and without MS in the United States

OBJECTIVE

To compare pregnancy prevalence and complications in women with and without multiple sclerosis (MS).

METHODS

This retrospective US administrative claims study used data from January 1, 2006, to June 30, 2015. All data for women with MS were included. A nationally representative 5% random sample from approximately 58 million women without MS was used to compute the dataset. Annual pregnancy rates, identified via diagnosis/procedure codes and adjusted for covariates, were estimated via logistic regression. Claims for pregnancy and labor/delivery complications were compared using propensity score matching.

RESULTS

From 2006 to 2014, the adjusted proportion of women with MS and pregnancy increased from 7.91% to 9.47%; the adjusted proportion without MS and with pregnancy decreased from 8.83% to 7.75%. The difference in linear trend (0.17% increase and 0.15% decrease in per-annum pregnancy rates) was significant (t statistic = 7.8; p < 0.0001). After matching (n = 2,115 per group), a higher proportion of women with MS than without had claims for premature labor (31.4% vs 27.4%; p = 0.005), infection (13.3% vs 10.9%; p = 0.016), cardiovascular disease (3.0% vs 1.9%; p = 0.028), anemia/acquired coagulation disorders (2.5% vs 1.3%; p = 0.007), neurologic complications (1.6% vs 0.6%; p = 0.005), sexually transmitted diseases (0.4% vs 0.1%; p = 0.045), acquired fetal damage (27.8% vs 23.5%; p = 0.002), and congenital fetal malformations (13.2% vs 10.3%; p = 0.004).

CONCLUSIONS

Pregnancy rates in this population of women with MS have been increasing. High rates of claims for several peripartum complications were observed in women with and those without MS. Claims data provide knowledge of interactions patients have with the health care system and are valuable initial exploratory analyses.

Assessment of recording bias in pregnancy studies using health care databases: An application to neurologic conditions

BACKGROUND

Pre-existing conditions are imperfectly recorded in health care databases. We assessed whether pre-existing neurologic conditions (epilepsy, multiple sclerosis [MS]) were differentially recorded in the presence of major obstetric outcomes (Caesarean delivery, preterm delivery, preeclampsia) in delivery records. We also evaluated the impact of differential recording on measures of frequency and association between the conditions and outcomes.

METHODS

The 2011-2014 Truven Health MarketScan® Commercial Claims Dataset was used to identify pregnancies. We calculated the relative recording of epilepsy and MS at delivery hospitalization compared with a 270-day pre-delivery window both overall and by the presence of major obstetric outcomes. We estimated risk ratios for the association between epilepsy and MS with the outcomes for each ascertainment window.

RESULTS

We identified 909 065 pregnancies in women continuously enrolled from 270-days before the delivery date. Of women with epilepsy identified in the pre-delivery window, 73% had the condition coded at delivery. For MS, the proportion was 60%. MS recording at delivery did not vary by obstetric outcomes, however, delivery-coded epilepsy was less likely confirmed in the pre-delivery window in the presence of preeclampsia. Generally, the period of ascertainment did not meaningfully impact risk ratios, however, the risk ratio for preeclampsia associated with epilepsy was 1.67 (95% CI 1.47, 1.90) when epilepsy was ascertained at delivery and 1.26 (95% CI 1.07, 1.48) when epilepsy was ascertained in the pre-delivery window (heterogeneity, P = .007).

CONCLUSIONS

Ascertainment of epilepsy and MS in delivery hospitalization records underestimated prevalence. However, the window of recording generally did not impact risk ratio estimates of associations with obstetric outcomes.

Insights into Initial Demyelinating Episodes of Central Nervous System during Puerperium

Background:

Inflammatory demyelinating disease of central nervous system (CNS) is an inflammatory disease characterized by a high childbearing female predominance. Labor-related alterations for postpartum demyelinating attacks are not entirely clear. This study aimed to summarize clinical features of female patients of reproductive age with initial CNS inflammatory demyelinating attacks during puerperium.

Methods:

Fourteen female patients with initial demyelinating events during puerperium between January 2013 and December 2016 were retrospectively studied. Records of clinical features, neuroimaging, serum antibodies, cerebrospinal fluid (CSF) findings, annualized relapse rate (ARR), and treatment were analyzed.

Results:

Among 14 patients, 5 patients were diagnosed with multiple sclerosis (MS), four as neuromyelitis optica (NMO), two as longitudinal extensive transverse myelitis, two as clinical isolated syndrome (CIS), and one as acute brainstem syndrome. All the 14 puerperal female patients presented with more than one manifestation of hemiplegia, paraplegia, uroschesis, visual loss or dysarthria, and with mild to moderate abnormalities of CSF. Attacks occurred during the first trimester postpartum and cesarean section was the main delivery way (n = 10). Median Expanded Disability Status Scale (EDSS) scores were 5.0 (range: 2.0–9.0) at the onset and 2.5 (range: 0–7.0) at the end of follow-ups. Patients with MS and CIS had a significantly lower EDSS scores than patients with NMO spectrum disorders (P < 0.05). Median ARR was 0.46 (range: 0–1.16); all patients had a low ARR (0.49 ± 0.34, 95% confidence interval: 0.29–0.69) with standardized treatments.

Conclusion:

Labor-related alterations in the mother's immune system might result in newly-onset demyelinating diseases of central nervous system.

An Update on the Use of Disease-Modifying Therapy in Pregnant Patients with Multiple Sclerosis

The active management of multiple sclerosis (MS) has been made possible during the last two decades with the advent of disease-modifying therapies (DMTs), leading to improved clinical outcomes for many patients. Furthermore, with the realization that MS does not adversely affect pregnancy outcome and that pregnancy does not have an overall negative impact on the long-term disease course of MS, the importance of appropriate counseling and discussion of future pregnancy plans with women of childbearing age is greater than ever. Although several DMTs are licensed for the treatment of MS, none are specifically approved for use during pregnancy or breastfeeding and the use of DMTs during these periods frequently gives rise to concerns regarding potential risks to the fetus. The outcomes of studies in patients with MS treated with DMTs during pregnancy and immediately postpartum have been the focus of several recently published papers. Given the high level of interest surrounding the prescribing of DMTs for MS patients of childbearing age, and the lack of clear guidance in this respect, the current review presents an up-to-date overview of new data, including observational data on real-world outcomes, that have been published during the last 2 years, and could inform future prescribing decisions.