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Juriol L, Valeff N, Dibo M, Ventimiglia MS, Correale J, Jensen F. Human chorionic gonadotropin regulates cytokine production by lymphocytes from patients with multiple sclerosis. J Reprod Immunol 2024; 164:104280. [PMID: 38908336 DOI: 10.1016/j.jri.2024.104280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 06/09/2024] [Accepted: 06/10/2024] [Indexed: 06/24/2024]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system (CNS) that primarily affects young adults, predominantly females. This was partially attributed to sex differences in immunity, which are influenced by changes in sex hormones occurring during women's life, among other factors. Furthermore, MS patients experience significant improvement in their symptoms during pregnancy when levels of female sex-hormones significantly increase. This phenomenon was attributed to immune adaptations occurring during gestation which are regulated by paternal antigens and sex hormones. The human chorionic gonadotropin (hCG) was shown to have strong immunosuppressive abilities. We aimed to analyze here the capacity of the hCG to regulate pro- and anti-inflammatory cytokine production by PBMC from MS patients. PBMC isolated from 17 MS patients receiving IFNβ1a treatment were cultured with or without recombinant or urinary hCG. Cytokine production in the supernatants was assessed using a CBA array and cytokine production by lymphocytes and expression of co-stimulatory molecules in B-lymphocytes were evaluated by flow cytometry. hCG reduced the production of TNF by PBMC from MS patients while lowering the percentages of TNF producing T cells and diminishing the production of TNF by B cells. hCG significantly boosted the production of IL-10 by regulatory T cells and CD19high B cells from MS patients. Furthermore, hCG treatment lowered the percentages of CD80+CD86+ expressing B cells within PBMC from MS patients. Overall, our results described a novel and not yet explored mechanisms of action of hCG in the context of MS.
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Affiliation(s)
- Lorena Juriol
- Center for Pharmacological and Botanical Studies (CEFYBO-UBA-CONICET), Graduate School of Medicine, University of Buenos Aires, 2155 Paraguay St. 16th Floor, Ciudad Autónoma de Buenos Aires C1121ABG, Argentina
| | - Natalín Valeff
- Center for Pharmacological and Botanical Studies (CEFYBO-UBA-CONICET), Graduate School of Medicine, University of Buenos Aires, 2155 Paraguay St. 16th Floor, Ciudad Autónoma de Buenos Aires C1121ABG, Argentina
| | - Marcos Dibo
- Center for Pharmacological and Botanical Studies (CEFYBO-UBA-CONICET), Graduate School of Medicine, University of Buenos Aires, 2155 Paraguay St. 16th Floor, Ciudad Autónoma de Buenos Aires C1121ABG, Argentina
| | - María Silvia Ventimiglia
- Center for Pharmacological and Botanical Studies (CEFYBO-UBA-CONICET), Graduate School of Medicine, University of Buenos Aires, 2155 Paraguay St. 16th Floor, Ciudad Autónoma de Buenos Aires C1121ABG, Argentina
| | - Jorge Correale
- Fleni, 2325 Montañeses St., Ciudad Autónoma de Buenos Aires C1428AQK, Argentina; Instituto de Química y Fisicoquímica Biológicas (IQUIFIB CONICET-UBA), Graduate School of Pharmacy and Biochemistry, University of Buenos Aires, 956 Junin St., Ciudad Autónoma de Buenos Aires C1113AAD, Argentina
| | - Federico Jensen
- Center for Pharmacological and Botanical Studies (CEFYBO-UBA-CONICET), Graduate School of Medicine, University of Buenos Aires, 2155 Paraguay St. 16th Floor, Ciudad Autónoma de Buenos Aires C1121ABG, Argentina; Centro Integrativo de Biología Y Química Aplicada, Universidad Bernardo O'Higgins, Santiago 8307993, Chile.
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Siracusano M, Carloni E, Riccioni A, Ferrara M, Scoppola C, Arturi L, Niolu C, Marfia GA, Mazzone L. Maternal Multiple Sclerosis and Offspring's Cognitive and Behavioral Development: What Do We Know until Now? CHILDREN (BASEL, SWITZERLAND) 2022; 9:1716. [PMID: 36360444 PMCID: PMC9689039 DOI: 10.3390/children9111716] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/03/2022] [Accepted: 11/05/2022] [Indexed: 11/26/2023]
Abstract
Multiple Sclerosis (MS) is a chronic pathological condition representing one of the main causes of neurological disability in the female young population. MS, as an immune disorder, could impact fetus development, and, considering the need for and the possibility of pharmacological treatment during pregnancy, the possible influence of medication on developmental trajectories represents a topic of great interest. We provide an overview of the available literature on the influence of maternal Multiple Sclerosis on offspring cognitive and behavioral development. A study was conducted on Pubmed, Medline and Google Scholar, considering empirical studies and reviews exclusively in the English language. Maternal MS appears not to be associated with emotional and behavioral problems, as evaluated through retrospective studies. However, a specific cognitive and behavioral phenotype, through the administration of standardized instruments, has not been delineated yet. Available studies on the topic are characterized by poor methodology and do not lead to conclusions. This overview highlights implications for further longitudinal studies which should delineate offspring developmental trajectories, taking into consideration maternal confounding factors and the exposure to pharmacological treatment in pregnancy.
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Affiliation(s)
- Martina Siracusano
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
| | - Elisa Carloni
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
| | - Assia Riccioni
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
- Systems Medicine Department, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy
| | - Marialaura Ferrara
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
| | - Chiara Scoppola
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
- Systems Medicine Department, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy
| | - Lucrezia Arturi
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
- Systems Medicine Department, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy
| | - Cinzia Niolu
- Systems Medicine Department, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy
- Psychiatry and Clinical Psychology Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
| | - Girolama Alessandra Marfia
- MS Clinical and Research Unit, Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Luigi Mazzone
- Child Neurology and Psychiatry Unit, Department of Neurosciences, Policlinico Tor Vergata Foundation Hospital, Viale Oxford 81, 00133 Rome, Italy
- Systems Medicine Department, University of Rome Tor Vergata, Montpellier Street 1, 00133 Rome, Italy
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The Rate of Hospitalization of Pregnant Women with Multiple Sclerosis in Poland. J Clin Med 2022; 11:jcm11195615. [PMID: 36233482 PMCID: PMC9572960 DOI: 10.3390/jcm11195615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/07/2022] [Accepted: 09/20/2022] [Indexed: 11/28/2022] Open
Abstract
Multiple sclerosis (MS) is most often diagnosed in women of childbearing age. Therefore, it is important to examine the impact of pregnancy on the course of MS and to enable patients to make decisions about motherhood based on reliable data. The main objective of this study was to assess the impact of pregnancy on the course of MS by comparing the frequency of MS-related hospitalizations during pregnancy and 40 weeks postpartum versus 40 weeks before pregnancy. We used administrative health claims to identify female patients with MS, their deliveries, and their MS-related hospital admissions and calculated the frequency of MS-related hospital admissions before, during, and after pregnancy. We observed that MS is diagnosed approximately three times less often during pregnancy than before or after pregnancy. The number of MS-related hospital admissions decreased during pregnancy, especially in the third trimester. In contrast with other studies, we did not observe an increased level of MS-related admissions postpartum. The number of hospitalizations reported with steroid injections and emergency department visits also decreased during pregnancy. Our results show that pregnancy has a protective effect on the course of MS.
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Villaverde-González R. Updated Perspectives on the Challenges of Managing Multiple Sclerosis During Pregnancy. Degener Neurol Neuromuscul Dis 2022; 12:1-21. [PMID: 35023987 PMCID: PMC8743861 DOI: 10.2147/dnnd.s203406] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/20/2021] [Indexed: 11/23/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic immune-mediated, inflammatory, and degenerative disease that is up to three times more frequent in young women. MS does not alter fertility and has no impact on fetal development, the course of pregnancy, or childbirth. The Pregnancy in Multiple Sclerosis Study in 1998 showed that pregnancy, mostly in untreated women, did not adversely affect MS, as disease activity decreased during pregnancy (although it significantly increased in the first trimester postpartum). These findings, together with the limited information available on the potential risks of fetal exposure to disease modifying treatments (DMTs), meant that women were advised to delay the onset of DMTs, stop them prior to conception, or, in case of unplanned pregnancy, discontinue them when pregnancy was confirmed. Now, many women with MS receive DMTs before pregnancy and, despite being considered a period of MS stability, up to 30% of patients could relapse in the first trimester postpartum. Factors associated with an increased risk of relapse and disability during pregnancy and postpartum include relapses before and during pregnancy, a greater disability at the time of conception, the occurrence of relapses after DMT cessation before conception, and the use of high-efficacy DMTs before conception, especially natalizumab or fingolimod. Strategies to prevent postpartum activity are needed in some patients, but consensus is lacking regarding the therapeutic strategies for women with MS of a fertile age. This, along with the increasing number of DMTs, means that the decision-making processes in aspects related to family planning and therapeutic strategies before, during, and after pregnancy are increasingly more complex. The purpose of this review is to provide an update on pregnancy-related issues in women with MS, including recommendations for counseling, general management, use of DMTs in pre-pregnancy, pregnancy, and postpartum periods, and breastfeeding-related aspects of DMTs.
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Uher T, Kubala Havrdova E, Vodehnalova K, Krasensky J, Capek V, Vaneckova M, Horakova D. Pregnancy-induced brain MRI changes in women with multiple sclerosis. Eur J Neurol 2022; 29:1446-1456. [PMID: 35015921 DOI: 10.1111/ene.15245] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/30/2021] [Accepted: 12/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The effect of pregnancy on brain changes and radiological disease activity in women with multiple sclerosis (MS) is not well understood. AIMS To describe the dynamic of lesion activity and brain volume changes during the pregnancy and postpartum periods. METHODS This observational study of 62 women with relapsing-remitting MS included MRI (221 scans) as well as clinical visits at baseline (<24 and >6 months before), prepregnancy (<6 months before), postpartum (<3 months after), and the follow-up (>12 and <24 months after delivery) period. RESULTS The majority of women had a mild disability and a short disease duration (median 5.5 years). Eighteen (29.0%) women had a relapse during the year preceding pregnancy onset, 9 (14.5%) during pregnancy, and 20 (32.3%) in the year following delivery. Disability status remained unchanged during follow-up. Women in the postpartum period (n=62) had higher T2 lesion volume (median: 0.94 ml vs. 1.18 ml), greater annualized T2 lesion volume increase (0.0 ml vs. 0.23 ml), lower brain parenchymal fraction (86.4% vs. 85.6%) and greater annualized brain volume loss (-0.16% vs. -1.74%) compared with the prepregnancy period (all p<0.001). At 12-24 months after delivery women (n=41) had higher T2 lesion volume (1.0 ml vs. 1.16 ml) and lower brain parenchymal fraction (86.5% vs. 86.0%) compared to the prepregnancy period (both p<0.001). CONCLUSIONS The postpartum period was associated with an increase in T2 lesion volume and accelerated brain volume loss in a considerable proportion of women. This should be considered in treatment decision-making and designing clinical trials.
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Affiliation(s)
- Tomas Uher
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Karolina Vodehnalova
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Jan Krasensky
- Department of Radiology, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic
| | - Vaclav Capek
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Manuela Vaneckova
- Department of Radiology, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
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Thiel S, Ciplea AI, Gold R, Hellwig K. The German Multiple Sclerosis and Pregnancy Registry: rationale, objective, design, and first results. Ther Adv Neurol Disord 2021; 14:17562864211054956. [PMID: 34840606 PMCID: PMC8613898 DOI: 10.1177/17562864211054956] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/04/2021] [Indexed: 12/16/2022] Open
Abstract
Objectives: Multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD) predominantly affect women of reproductive age. During the last few decades many disease-modifying therapies (DMTs) have been approved. It is therefore important to provide epidemiological structures for the collection of safety information on exposed pregnancies. Data on disease activity after withdrawal of DMTs are in high demand especially as severe relapses have been described after ceasing highly effective DMTs. Although breastfeeding is recommended, it is still unclear if the early reintroduction, especially of highly effective DMTs, has a beneficial effect on postpartum relapse risk or a combination of both, however safety data are lacking. Methods: The German MS and Pregnancy Registry (DMSKW) is a nationwide, observational, cohort study of pregnant women with MS or NMOSD, founded in 2006. As the study procedure has undergone important adaptation in recent years, described here is the updated methodology including data source and acquisition as well as variables collected within the DMSKW. Results: As of December 2020, the DMSKW database comprises 2579 pregnancies, 2568 with MS and 11 with NMOSD. Women are enrolled at a median gestational week of 11 (range: 0.02–42.1), have a median postpartum follow up of 1.2 years (range: 0–9.2) with 76% of all pregnancies being exposed to a DMT, mostly in the first trimester. Spontaneous abortion and preterm birth occurred in 7% and 10%, respectively; 19% of all women suffered from at least one relapse during pregnancy, with a minimum of 6% during the third trimester of pregnancy. Conclusion: The DMSKW is a valuable structure in providing safety data on drug exposure during pregnancy and lactation in combination with information on disease activity up to 6 years postpartum. This article will be the reference for describing the methods of future publications from the DMSKW.
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Affiliation(s)
- Sandra Thiel
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum GmbH, Ruhr University Bochum, Bochum, Germany
| | - Andrea I Ciplea
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum GmbH, Ruhr University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum GmbH, Ruhr University Bochum, Bochum, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital - Katholisches Klinikum Bochum GmbH, Ruhr University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
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Thalamus Atrophy in the Peri-Pregnancy Period in Clinically Stable Multiple Sclerosis Patients: Preliminary Results. Brain Sci 2021; 11:brainsci11101270. [PMID: 34679335 PMCID: PMC8534211 DOI: 10.3390/brainsci11101270] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 09/14/2021] [Accepted: 09/23/2021] [Indexed: 11/22/2022] Open
Abstract
Radiological activity in the post-partum period in MS patients is a well-known phenomenon, but there is no data concerning the influence of pregnancy on regional brain atrophy. The aim of this article was to investigate local brain atrophy in the peri-pregnancy period (PPP) in patients with MS. Thalamic volume (TV); corpus callosum volume (CCV) and classical MRI activity (new gadolinium enhancing lesions (Gd+), new T2 lesions, T1 lesions volume (T1LV) and T2 lesions volume (T2LV)) were analyzed in 12 clinically stable women with relapsing–remitting MS and with MRI performed in the PPP. We showed that there was a significant decrease in TV (p = 0.021) in the PPP. We also observed a significant increase in the T1 lesion volume (p = 0.028), new gadolinium-enhanced and new T2 lesions (in 46% and 77% of the scans, respectively) in the post-partum period. Our results suggest that the PPP in MS may be associated not only with classical MRI activity but, also, with regional brain atrophy.
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Lehmann H, Zveik O, Levin N, Brill L, Imbar T, Vaknin-Dembinsky A. Brain MRI activity during the year before pregnancy can predict post-partum clinical relapses. Mult Scler 2021; 27:2232-2239. [PMID: 33783260 DOI: 10.1177/13524585211002719] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are fewer multiple sclerosis (MS) relapses during pregnancy, although relapse risk increases in the early post-partum period, as has been predicted by pre-pregnancy or pregnancy disease activity in some studies. OBJECTIVE The aim of this study was to evaluate the correlation between magnetic resonance imaging (MRI) changes in the year before pregnancy and the relapse rate in the year post-partum. METHODS An observational retrospective case-control study included 172 pregnancies in 118 females with MS. Statistical analyses were used to evaluate the correlation between MRI and post-partum relapses. Clustered logistic regression was used to investigate the predictors of early post-partum relapses. RESULTS We found a significant correlation for an active-MRI pre-pregnancy and relapses in the first 3 months post-partum (p < 0.001). Expanded Disability Status Scale (EDSS) pre-pregnancy and relapses in the first 3 months post-partum were also significantly correlated (p = 0.009). Using a multivariate model, we predicted which women will not experience post-partum relapse by EDSS and by an active-MRI pre-pregnancy (96.7% specificity; p < 0.001). CONCLUSION An active-MRI pre-pregnancy is a strong and sensitive predictor of early post-partum relapse, regardless of whether the woman had clinical evidence of disease activity prior to conception and delivery. This finding could provide clinicians with a strategy to minimize post-partum relapse risk in women with MS planning pregnancy.
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Affiliation(s)
- Hillel Lehmann
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah Medical Center, Jerusalem, Israel
| | - Omri Zveik
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah Medical Center, Jerusalem, Israel
| | - Netta Levin
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah Medical Center, Jerusalem, Israel
| | - Livnat Brill
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah Medical Center, Jerusalem, Israel
| | - Tal Imbar
- Department of Obstetrics and Gynecology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Adi Vaknin-Dembinsky
- Faculty of Medicine, Hebrew University of Jerusalem, Department of Neurology and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah Medical Center, Jerusalem, Israel
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Anderson A, Krysko KM, Rutatangwa A, Krishnakumar T, Chen C, Rowles W, Zhao C, Houtchens MK, Bove R. Clinical and Radiologic Disease Activity in Pregnancy and Postpartum in MS. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/2/e959. [PMID: 33608303 PMCID: PMC8105896 DOI: 10.1212/nxi.0000000000000959] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/14/2020] [Indexed: 11/23/2022]
Abstract
Objective To evaluate radiologic and clinical inflammatory activity in women with MS during pregnancy and postpartum. Methods We performed a retrospective analysis of prospectively collected clinical and MRI reports for women who became pregnant while followed at the University of California, San Francisco MS Center between 2005 and 2018. Proportion of brain MRIs with new T2-hyperintense or gadolinium enhancing (Gd+) lesions (primary outcome) and annualized relapse rate (ARR; secondary) were compared before and after pregnancy. Results We identified 155 pregnancies in 119 women (median Expanded Disability Status Scale [EDSS] 2.0). For the 146 live birth pregnancies, prepregnancy ARR was 0.33; ARR decreased during pregnancy, particularly the third trimester (ARR 0.10, p = 0.017) and increased in the 3 months postpartum (ARR 0.61, p = 0.012); and 16% of women experienced a clinically meaningful increase in EDSS. Among 70 pregnancies with paired brain MRIs available, 53% had new T2 and/or Gd+ lesions postpartum compared with 32% prepregnancy (p < 0.001). Postpartum clinical relapses were associated with Gd+ lesions (p < 0.001). However, even for patients without postpartum relapses, surveillance brain MRIs revealed new T2 and/or Gd+ lesions in 31%. Protective effects of exclusive breastfeeding for ≥3 months (odds ratio = 0.3, 95% confidence interval 0.1–0.9) were observed for relapses. Conclusions Building on previous reports of increased relapse rate in the first 3 months postpartum, we report a significant association between inflammation on MRI and this clinical activity. We also detected postpartum radiologic activity in the absence of relapses. Both clinical and radiologic reassessment may inform optimal treatment decision-making during the high-risk early postpartum period.
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Affiliation(s)
- Annika Anderson
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - Kristen M Krysko
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - Alice Rutatangwa
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - Tanya Krishnakumar
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - Chelsea Chen
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - William Rowles
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - Chao Zhao
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - Maria K Houtchens
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA
| | - Riley Bove
- From the Weill Institute for Neurosciences (A.A., K.M.K.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (K.M.K., R.B.), School of Medicine, University of California San Francisco, San Francisco, CA; Weill Institute for Neurosciences (A.R., T.K., C.C., W.R., C.Z., R.B.), Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Neurology (M.H.), Brigham and Womens Hospital, Harvard Medical School, Boston MA.
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Houtchens M, Bove R, Healy B, Houtchens S, Kaplan TB, Mahlanza T, Chitnis T, Bakshi R. MRI activity in MS and completed pregnancy: Data from a tertiary academic center. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/6/e890. [PMID: 32917773 PMCID: PMC7643615 DOI: 10.1212/nxi.0000000000000890] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/19/2020] [Indexed: 12/12/2022]
Abstract
Objective To evaluate postpartum MRI activity in patients with MS and a completed
pregnancy and to compare these results to an age-matched untreated
nonpregnant MS cohort. Methods Patient with MS from a tertiary care MS center between 2006 and 2015, with
prepartum and postpartum neurologic follow-ups and MRI scans were analyzed.
Clinical activity and inflammatory brain MRI activity (new T2-hyperintense
or gadolinium-enhancing [Gd+] lesions) were assessed peripartum. The
results were compared with untreated reproductive-age patients with MS from
the placebo arm of the clinical trials. Results A total of 123 pregnancies in 123 women (median Expanded Disability Status
Scale 1.0) were analyzed. Approximately 7.2% relapsed during pregnancy and
48.7% relapsed postpartum. Of pregnancies with prepartum and postpartum
gadolinium (Gd)-enhanced MRI (n = 112), 8% had Gd+ lesions
prepartum and 33% had new Gd+ lesions postpartum. Overall, 54.4% had
either new T2 or Gd+ lesions postpartum. Seventy-nine percent of
subjects with postpartum relapse had new MRI activity compared with 37.1%
without relapse (p < 0.001). Twenty-five percent had
both clinical and radiographic activity and only 24.9% maintained no
evidence of disease activity status postpartum. There was no association
between postpartum MRI activity and disease-modifying treatments (DMTs)
(p > 0.5). MRI and clinical outcomes were also
assessed for 126 nonpregnant untreated female patients with MS. Comparing
pregnancy and no pregnancy groups, there was no difference in MRI activity
at follow-up. Conclusions There was a high level of inflammatory radiographic disease activity which
was related to relapses in postpartum patients with MS. Further studies are
needed to determine whether hormonal fluctuations vs extended time off DMTs
may be the underlying cause of our observations.
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Affiliation(s)
- Maria Houtchens
- From the Department of Neurology (M.H., B.H., T.B.K., T.M., T.C., R. Bakshi), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Neurology (R. Bove), School of Medicine, University of California, San Francisco; and National Forensic Cybersecurity Alliance (S.H.), Pittsburgh, PA.
| | - Riley Bove
- From the Department of Neurology (M.H., B.H., T.B.K., T.M., T.C., R. Bakshi), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Neurology (R. Bove), School of Medicine, University of California, San Francisco; and National Forensic Cybersecurity Alliance (S.H.), Pittsburgh, PA
| | - Brian Healy
- From the Department of Neurology (M.H., B.H., T.B.K., T.M., T.C., R. Bakshi), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Neurology (R. Bove), School of Medicine, University of California, San Francisco; and National Forensic Cybersecurity Alliance (S.H.), Pittsburgh, PA
| | - Stepan Houtchens
- From the Department of Neurology (M.H., B.H., T.B.K., T.M., T.C., R. Bakshi), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Neurology (R. Bove), School of Medicine, University of California, San Francisco; and National Forensic Cybersecurity Alliance (S.H.), Pittsburgh, PA
| | - Tamara Bockow Kaplan
- From the Department of Neurology (M.H., B.H., T.B.K., T.M., T.C., R. Bakshi), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Neurology (R. Bove), School of Medicine, University of California, San Francisco; and National Forensic Cybersecurity Alliance (S.H.), Pittsburgh, PA
| | - Tatenda Mahlanza
- From the Department of Neurology (M.H., B.H., T.B.K., T.M., T.C., R. Bakshi), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Neurology (R. Bove), School of Medicine, University of California, San Francisco; and National Forensic Cybersecurity Alliance (S.H.), Pittsburgh, PA
| | - Tanuja Chitnis
- From the Department of Neurology (M.H., B.H., T.B.K., T.M., T.C., R. Bakshi), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Neurology (R. Bove), School of Medicine, University of California, San Francisco; and National Forensic Cybersecurity Alliance (S.H.), Pittsburgh, PA
| | - Rohit Bakshi
- From the Department of Neurology (M.H., B.H., T.B.K., T.M., T.C., R. Bakshi), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Neurology (R. Bove), School of Medicine, University of California, San Francisco; and National Forensic Cybersecurity Alliance (S.H.), Pittsburgh, PA
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Villaverde-González R, Candeliere-Merlicco A, Alonso-Frías MA, Aparicio Castro E, Carrillo Alcaraz A, Mallada Frechín J, Pérez Sempere Á. Discontinuation of disease-modifying treatments in multiple sclerosis to plan a pregnancy: A retrospective registry study. Mult Scler Relat Disord 2020; 46:102518. [PMID: 32977075 DOI: 10.1016/j.msard.2020.102518] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/13/2020] [Accepted: 09/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND For safety reasons multiple sclerosis (MS) treatment guidelines recommend stopping or delaying the onset of disease-modifying therapies (DMT) before a planned pregnancy, but disease stability after DMT discontinuation is not well studied. The objective of this study is to describe the course of MS in patients who interrupted DMT before a planned pregnancy. METHODS This was a retrospective study using 2008-2016 data from a multicenter register of pregnancies in women with MS. In this paper, we present data from the subgroup of women with relapsing-remitting MS (RRMS) who interrupted DMT to try to conceive. Data from 1 and 3 years before DMT interruption, the period between DMT interruption and conception or resuming DMT, during pregnancy and one year postpartum were analyzed. Annualized relapse rates (ARR), Expanded Disability Status Scale (EDSS) scores, and magnetic resonance imaging (MRI), obstetric, and neonatal data were collected. RESULTS Twenty-seven women interrupted DMT (19 β-interferon, 5 glatiramer acetate, 2 natalizumab and 1 fingolimod) to try to conceive. After a mean of 10.6 months 6 women stopped trying to conceive and resumed DMT, while 21 women became pregnant after a mean of 7.0 months. In the overall cohort, in the period from when DMT was discontinued to when pregnancy was confirmed or DMT resumed, the ARR was 1.08, which was significantly higher than the ARR 1 year (0.44; p = 0.01) and 3 years (0.4; p = 0.06) before DMT discontinuation. The mean EDSS score when pregnancy was confirmed or DMT resumed was significantly higher than at DMT discontinuation (1.8 vs 1.36, p = 0.011). In the subgroup of patients who became pregnant, the ARR in the untreated period before pregnancy was 0.98, which was significantly higher than the ARR 1 year (0.38; p = 0.03) and 3 years (0.39; p = 0.0077) before DMT discontinuation. The ARR decreased to 0.51 during pregnancy and then increased to 0.76 during the first postpartum trimester (not significant). One year after delivery, the mean EDSS score (1.86) was significantly higher than at DMT cessation (1.35, p = 0.027) or pregnancy confirmation (1.45, p = 0.026). Patients who suffered relapses following DMT cessation before becoming pregnant had an 11-fold higher risk of relapse during pregnancy (relative risk [RR] = 11.1 [95%CI 1.6, 75], p = 0.002) and a 3-fold higher risk during the postpartum year (RR = 3.0 [95%CI 1.3,6.6], p = 0.007) than those who did not suffer relapses in period between DMT withdrawal and pregnancy. CONCLUSIONS In this retrospective registry study, discontinuation of DMT (mostly immunomodulatory drugs), to try to conceive resulted in an increase in MS relapse rates and disability progression.
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Affiliation(s)
| | | | | | | | - Andrés Carrillo Alcaraz
- Intensive Care Unit, Hospital General Universitario José María Morales Meseguer, Murcia, Spain.
| | | | - Ángel Pérez Sempere
- Department of Neurology, Hospital General Universitario de Alicante, Alicante, Spain.
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Vukusic S, Michel L, Leguy S, Lebrun-Frenay C. Pregnancy with multiple sclerosis. Rev Neurol (Paris) 2020; 177:180-194. [PMID: 32736812 DOI: 10.1016/j.neurol.2020.05.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/05/2020] [Accepted: 05/05/2020] [Indexed: 10/23/2022]
Abstract
Multiple sclerosis (MS) is usually diagnosed between twenty and forty years of age, when people often plan to have children. A lot has been said about the effect of pregnancy on the course of MS. The individual factors responsible for the disease modifying effect of pregnancy are not well determined. Having MS neither affects the fertility or the course of pregnancy itself. During pregnancy, many women find that their symptoms stay the same or even improve. Epidural and spinal analgesia appear to be safe and in general are not contraindicated for patients with MS. The management of disease-modifying treatments (DMTs) in pregnancy is a new issue for consideration in the clinical practice. There is limited information available into the safety of DMT use during pregnancy, especially for the most recent ones. In general, discontinuation of DMTs is recommended before conception to minimize risk of fetal harm. Women with very active MS before pregnancy who stop second-line treatments may show an increase in disease activity during pregnancy. Therefore, it might be discussed to maintain patients on DMTs until pregnancy is confirmed, and sometimes throughout pregnancy, to avoid a rebound of disease activity and severe relapses during pregnancy in very active patients.
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Affiliation(s)
- S Vukusic
- Service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation et centre de recherche, ressources et compétences sur la sclérose en plaques, hospices civils de Lyon, 69677 Bron, France; Inserm 1028 et CNRS UMR 5292, observatoire français de la sclérose en plaques, centre de recherche en neurosciences de Lyon, 69003 Lyon, France; Université de Lyon, université Claude-Bernard Lyon 1, 69000 Lyon, France; Eugène Devic EDMUS Foundation against multiple sclerosis, state-approved foundation, 69677 Bron, France
| | - L Michel
- Inserm, CIC 1414 [(centre d'investigation clinique de Rennes)], neurology, université Rennes, CHU Rennes, 35000 Rennes, France; Inserm, établissement français du sang, unité mixte de recherche (UMR) S1236, university of Rennes, Rennes, France
| | - S Leguy
- Inserm, CIC 1414 [(centre d'investigation clinique de Rennes)], neurology, université Rennes, CHU Rennes, 35000 Rennes, France
| | - C Lebrun-Frenay
- CRCSEP, CHU de Nice Pasteur 2, Université Nice Côte d'Azur UR2CA URRIS, Nice, France.
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Xie Y, Tian Z, Han F, Liang S, Gao Y, Wu D. Factors associated with relapses in relapsing-remitting multiple sclerosis: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e20885. [PMID: 32629678 PMCID: PMC7337585 DOI: 10.1097/md.0000000000020885] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The relapse is character of relapsing-remitting multiple sclerosis. The therapeutic goal is to reduce the risk of relapse. Factors associated with relapses can help to manage and prevent relapses. In addition, patients and doctors all pay attention to it. However, there are differences between studies. Our aim is to summarize factors associated with relapses in relapsing-remitting multiple sclerosis (RRMS). METHODS PubMed, EMBASE, Web of science, Cochrane library, CNKI, Wanfang, SinoMed, and VIP were searched to identify risk factors about relapses in RRMS, which should be in cohort or case-control studies. This article was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The quality of studies was evaluated by the Newcastle-Ottawa Scale (NOS). Meta-analysis, subgroup and sensitivity analyses, and publication bias were all performed with Stata. This research has been registered on the international prospective register of systematic reviews (PROSPERO, CRD42019120502). RESULTS 43 articles were included. Infection, postpartum period, risk gene, stress, and vitamin D were risk factors for relapses in RRMS. Pregnancy period was the protective factor. Among those, infection increased the risk of relapses in infection period (relative risk [RR], 2.07 [confidence interval (CI), 1.64 to 2.60]). Women in the postpartum period increased the risk of relapses compared with women before pregnancy (RR, 1.43 [CI, 1.19 to 1.72]), or women in pregnancy period (RR, 2.07 [CI, 1.49 to 2.88]). Women in the pregnancy period decreased the risk of relapses (RR, 0.56 [CI, 0.37 to 0.84]) compared with women before pregnancy. However, fewer studies, heterogeneity, and sample size were the limitations. CONCLUSION It is reliable to adopt results about infection, pregnancy period, and postpartum period.
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Affiliation(s)
- Yao Xie
- Department of Neurology, Affiliated Hospital of Hunan Academy of Traditional Chinese Medicine, Changsha
- Department of Neurology, Dongzhimen Hospital affiliated to Beijing University of Chinese Medicine
| | - Ziyu Tian
- Department of Neurology, Dongzhimen Hospital affiliated to Beijing University of Chinese Medicine
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine
| | - Fang Han
- Office of Academic Research, Beijing Hospital of Traditional Chinese Medicine affiliated to Capital Medical University, Beijing
| | - Shibing Liang
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine
- College of Basic Medical Sciences, Shanxi University of Traditional Chinese Medicine, Taiyuan, China
| | - Ying Gao
- Department of Neurology, Dongzhimen Hospital affiliated to Beijing University of Chinese Medicine
| | - Dahua Wu
- Department of Neurology, Affiliated Hospital of Hunan Academy of Traditional Chinese Medicine, Changsha
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Dobson R, Yam C. Pregnancy in multiple sclerosis: influence on disease trajectory. ADVANCES IN CLINICAL NEUROSCIENCE & REHABILITATION 2020. [DOI: 10.47795/rmtu3215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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15
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Intravenous immunoglobulins for the prevention of postpartum relapses in multiple sclerosis. Mult Scler Relat Disord 2020; 38:101519. [DOI: 10.1016/j.msard.2019.101519] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/03/2019] [Accepted: 11/10/2019] [Indexed: 11/18/2022]
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Canibaño B, Deleu D, Mesraoua B, Melikyan G, Ibrahim F, Hanssens Y. Pregnancy-related issues in women with multiple sclerosis: an evidence-based review with practical recommendations. J Drug Assess 2020; 9:20-36. [PMID: 32128285 PMCID: PMC7034025 DOI: 10.1080/21556660.2020.1721507] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 01/21/2020] [Indexed: 12/18/2022] Open
Abstract
Objective: To review the current evidence regarding pregnancy-related issues in multiple sclerosis (MS) and to provide recommendations specific for each of them. Research design and methods: A systematic review was performed based on a comprehensive literature search. Results: MS has no effect on fertility, pregnancy or fetal outcomes, and pregnancies do not affect the long-term disease course and accumulation of disability. There is a potential risk for relapse after use of gonadotropin-releasing hormone agonists during assisted reproduction techniques. At short-term, pregnancy leads to a reduction of relapses during the third trimester, followed by an increased risk of relapses during the first three months postpartum. Pregnancies in MS are not per se high risk pregnancies, and MS does not influence the mode of delivery or anesthesia unless in the presence of significant disability. MRI is not contraindicated during pregnancy; however, gadolinium contrast media should be avoided whenever possible. It is safe to use pulse dose methylprednisolone infusions to manage acute disabling relapses during pregnancy and breastfeeding. However, its use during the first trimester of pregnancy is still controversial. Women with MS should be encouraged to breastfeed with a possible favorable effect of exclusive breastfeeding. Disease-modifying drugs can be classified according to their potential for pregnancy-associated risk and impact on fetal outcome. Interferon beta (IFNβ) and glatiramer acetate (GA) may be continued until pregnancy is confirmed and, after consideration of the individual risk-benefit if continued, during pregnancy. The benefit of continuing natalizumab during the entire pregnancy may outweigh the risk of recurring disease activity, particularly in women with highly active MS. GA and IFNβ are considered safe during breastfeeding. The use of natalizumab during pregnancy or lactation requires monitoring of the newborn. Conclusions: This review provides current evidence and recommendations for counseling and management of women with MS preconception, during pregnancy and postpartum.
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Affiliation(s)
- Beatriz Canibaño
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Dirk Deleu
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Boulenouar Mesraoua
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Gayane Melikyan
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Faiza Ibrahim
- Department of Neurology, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Yolande Hanssens
- Clinical Services Unit, Pharmacy, Hamad Medical Corporation, Doha, Qatar
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17
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LaHue SC, Gelfand AA, Bove RM. Navigating monoclonal antibody use in breastfeeding women: Do no harm or do little good? Neurology 2019; 93:668-672. [PMID: 31492717 DOI: 10.1212/wnl.0000000000008213] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/05/2019] [Indexed: 11/15/2022] Open
Abstract
Many neurologic diseases disproportionately affect women, particularly during their reproductive years. For many of these diseases, monoclonal antibodies (mAbs) are becoming widely available as a treatment option, for example, in migraine, multiple sclerosis, and myasthenia gravis. Yet, despite how common pregnancy is (latest estimates suggest that 86% of US women ages 40-44 have given birth), there is a paucity of research on the safety of prescription medications, including mAbs, during the peripartum period. In this article, we focus on the safety of mAbs during breastfeeding. We summarize how pregnancy affects the trajectory of these diseases and explore the benefit derived from mAb therapies. We posit that as neurologists, we are uniquely poised to lead the study of peripartum safety for the mAbs now on the market and provide a framework for their future study.
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Affiliation(s)
- Sara C LaHue
- From the Department of Neurology, School of Medicine, and Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco
| | - Amy A Gelfand
- From the Department of Neurology, School of Medicine, and Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco
| | - Riley M Bove
- From the Department of Neurology, School of Medicine, and Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco.
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18
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Khalid F, Healy BC, Dupuy SL, Chu R, Chitnis T, Bakshi R, Houtchens M. Quantitative MRI analysis of cerebral lesions and atrophy in post-partum patients with multiple sclerosis. J Neurol Sci 2018; 392:94-99. [DOI: 10.1016/j.jns.2018.06.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/06/2018] [Accepted: 06/28/2018] [Indexed: 12/31/2022]
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20
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Thöne J, Thiel S, Gold R, Hellwig K. Treatment of multiple sclerosis during pregnancy - safety considerations. Expert Opin Drug Saf 2017; 16:523-534. [PMID: 28333552 DOI: 10.1080/14740338.2017.1311321] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Women with multiple sclerosis (MS) are treated early in the disease course with disease modifying therapies (DMT). Updated information is needed on pregnancy outcomes of DMT-exposed pregnancies and the effect of the drug withdrawal on MS disease activity. Areas covered: In this review, we will cover the most important updated management strategies in planning a pregnancy when having MS. Expert opinion: MS itself does not increase the risk of adverse pregnancy outcomes and does not negatively influence the long-term course of the disease. As MS became a treatable disease, management of DMTs before, during and after pregnancy is important. This requires updated knowledge on safety of DMTs as well as data of the effect on disease activity after drug withdrawal. A special challenge is the handling of women with highly active MS, as pregnancy might not be powerful enough to suppress the risk of rebound relapses. Exclusive breastfeeding is an option for many women who want to do so, but in cases of high disease activity and those women who do not want to breastfeed, early reintroduction of MS therapies should be considered.
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Affiliation(s)
- Jan Thöne
- a Department of Neurology , University Hospital Essen , Essen , Germany
| | - Sandra Thiel
- b Department of Neurology, St. Josef-Hospital , Ruhr-University Bochum , Bochum , Germany
| | - Ralf Gold
- b Department of Neurology, St. Josef-Hospital , Ruhr-University Bochum , Bochum , Germany
| | - Kerstin Hellwig
- b Department of Neurology, St. Josef-Hospital , Ruhr-University Bochum , Bochum , Germany
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21
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Fares J, Nassar AH, Gebeily S, Kobeissy F, Fares Y. Pregnancy outcomes in Lebanese women with multiple sclerosis (the LeMS study): a prospective multicentre study. BMJ Open 2016; 6:e011210. [PMID: 27178979 PMCID: PMC4874157 DOI: 10.1136/bmjopen-2016-011210] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 02/22/2016] [Accepted: 04/20/2016] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The Lebanese Multiple Sclerosis (LeMS) study aims to assess the influence of pregnancy and delivery on the clinical course of multiple sclerosis (MS) in Lebanese women. SETTING This prospective multicentre study took place in three MS referral university medical centres in Lebanon. PARTICIPANTS Included were 29 women over 18 years who had been diagnosed with MS according to the McDonald criteria, and became pregnant between 1995 and 2015. Participating women should have stopped treatment 3 months before conception and become pregnant after the onset of MS. Women were followed up from 1 year preconceptionally and for 4 years postpartum. MAIN OUTCOME MEASURES The annualised relapse rates per participant during each 3-month period during pregnancy and each year postpartum were compared with the relapse rate during the year before pregnancy using the paired two-tailed t test. p Values <0.05 were considered statistically significant for all analyses (95% CI). RESULTS 64 full-term pregnancies were recorded. All pregnancies (100%) resulted in live births, with no complications or other diseases. In comparison with the prepregnancy year, in which the mean relapse rate±SE was 0.17±0.07, there was a significant reduction in the relapse rate during pregnancy and in the first year postpartum (p=0.02), but an increase in the rate in the second year postpartum (0.21±0.08). Thereafter, from the third year postpartum through the following fourth year, the annualised relapse rate fell slightly but did not differ from the annualised relapse rate recorded in the prepregnancy year (0.17±0.07). CONCLUSIONS Pregnancy in Lebanese women with MS does not seem to increase the risk of complications. No relapses were observed during pregnancy and in the first year postpartum; however, relapses rebounded in the second year postpartum, and over the long term, returned to the levels that preceded pregnancy.
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Affiliation(s)
- Jawad Fares
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Anwar H Nassar
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Souheil Gebeily
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
- Department of Neurology, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Firas Kobeissy
- Department of Psychiatry, College of Medicine & McKnight Brain Institute, University of Florida, Gainesville, Florida, USA
- Department of Biochemistry and Molecular Genetics, American University of Beirut Medical Center, Beirut, Lebanon
| | - Youssef Fares
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
- Department of Neurosurgery, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
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Coyle PK. Management of women with multiple sclerosis through pregnancy and after childbirth. Ther Adv Neurol Disord 2016; 9:198-210. [PMID: 27134675 DOI: 10.1177/1756285616631897] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Multiple sclerosis (MS) is a major acquired neurologic disease of young adults. The prototypic patient is a young woman of reproductive age. Gender preference is becoming more pronounced, since MS is increasing specifically among women. Any healthcare provider who deals with MS must be prepared to discuss pregnancy issues, and provide appropriate counseling. This is now complicated by the availability of multiple treatment options. There is growing literature on which to base recommendations, particularly regarding washout periods. After a brief background introduction, this review will discuss state-of-the-art family planning counseling in the treatment era, divided into prepregnancy, pregnancy, and postpartum MS issues.
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Affiliation(s)
- Patricia K Coyle
- Dept. of Neurology HSC, T12 Stony Brook University Medical Center Stony Brook, NY 11794, USA
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23
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Silva JVMD, Oliveira BFAD, Nascimento OJMD, Farinhas JGD, Cavaliere MG, Cal HDSR, Matta APDC. Increased multiple sclerosis relapses related to lower prevalence of pain. ARQUIVOS DE NEURO-PSIQUIATRIA 2015. [PMID: 26200054 DOI: 10.1590/0004-282x20150073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The study aims to investigate the presence of pain amongst multiple sclerosis (MS) patients. METHOD One hundred MS patients responded to questionnaires evaluating neuropathic and nociceptive pain, depression and anxiety. Statistical analysis was performed using the Mann-Whitney U, Chi-Square and two-tailed Fisher's exact tests and multivariate logistic regression. RESULTS Women had a statistically higher prevalence of pain (p = 0.037), and chances of having pain after the age of 50 reduced. Women with pain had a statistically significant lower number of relapses (p = 0.003), restricting analysis to those patients with more than one relapse. After the second relapse, each relapse reduced the chance of having pain by 46%. Presence of pain was independent of Expanded Disability Status Scale (EDSS) anxiety, and depression. CONCLUSION Our findings suggest a strong inverse association between relapses and pain indicating a possible protective role of focal inflammation in the control of pain.
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Affiliation(s)
- José Vinícius Martins da Silva
- Centro de Pesquisas Clínicas em Neurologia/Neurociência, Departamento de Neurologia, Universidade Federal Fluminense, Niteroi, RJ, Brazil
| | | | - Osvaldo José Moreira do Nascimento
- Centro de Pesquisas Clínicas em Neurologia/Neurociência, Departamento de Neurologia, Universidade Federal Fluminense, Niteroi, RJ, Brazil
| | - João Gabriel Dib Farinhas
- Centro de Pesquisas Clínicas em Neurologia/Neurociência, Departamento de Neurologia, Universidade Federal Fluminense, Niteroi, RJ, Brazil
| | | | - Henrique de Sá Rodrigues Cal
- Centro de Pesquisas Clínicas em Neurologia/Neurociência, Departamento de Neurologia, Universidade Federal Fluminense, Niteroi, RJ, Brazil
| | - André Palma da Cunha Matta
- Centro de Pesquisas Clínicas em Neurologia/Neurociência, Departamento de Neurologia, Universidade Federal Fluminense, Niteroi, RJ, Brazil
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Airas L. Hormonal and gender-related immune changes in multiple sclerosis. Acta Neurol Scand 2015; 132:62-70. [PMID: 26046561 DOI: 10.1111/ane.12433] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2015] [Indexed: 01/10/2023]
Abstract
Similarly to many other autoimmune diseases, multiple sclerosis (MS) is more common among women than men, and its incidence among women is rising. There are also qualitative differences in the disease course between men and women, with male patients experiencing increased disease progression, brain atrophy, and cognitive impairment. During pregnancy, women with MS typically have a greatly reduced relapse rate, whereas very soon after the delivery, the disease activity returns, often even at a higher level than seen in the prepregnancy year. The reasons for the increased postpartum activity are not entirely clear, but factors such as the abrupt decrease in estrogen levels immediately after the delivery and the loss of the immunosuppressive state of pregnancy are likely of importance. There is compelling evidence that estrogen, progesterone, and testosterone control MS pathology by influencing immune responses and by contributing to repair mechanisms in the nervous system. Hormones may thus offer important insights into MS disease prevention and treatment. In this review, the possible reasons for the sex bias in autoimmune diseases will be discussed. The pregnancy-related alterations in MS, including the effect of pregnancy on disease activity, long-term disability accumulation, and prevalence will be reviewed, as well as the hormonal and immunological mechanisms potentially underlying these changes. Finally, the present thinking on the effect of hormones on the changing incidence of MS will be elucidated.
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Affiliation(s)
- L. Airas
- Division of Clinical Neurosciences; Turku University Hospital; Turku Finland
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26
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Management of multiple sclerosis during pregnancy and the reproductive years: a systematic review. Obstet Gynecol 2015; 124:1157-1168. [PMID: 25415167 DOI: 10.1097/aog.0000000000000541] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To examine the evidence guiding management of multiple sclerosis (MS) in reproductive-aged women. DATA SOURCES We conducted an electronic literature search using PubMed, ClinicalTrials.gov, and other available resources. The following keywords were used: "multiple sclerosis" and "pregnancy." We manually searched the reference lists of identified studies. METHODS OF STUDY SELECTION Two reviewers categorized all studies identified in the search by management topic, including effect of pregnancy on MS course, fetal risks associated with disease-modifying treatments during pregnancy, and management of patients off disease-modifying treatment. We categorized studies by strength of evidence and included prior meta-analyses and systematic studies. These studies were then summarized and discussed by an expert multidisciplinary team. TABULATION, INTEGRATION, AND RESULTS The risk of MS relapses is decreased during pregnancy and increased postpartum. Data are lacking regarding the risks of disease-modifying treatments during pregnancy. There may be an increased risk of MS relapses after use of assisted reproductive techniques. There does not appear to be a major increase in adverse outcomes in newborns of mothers with MS. CONCLUSION Although there are many unmet research needs, the reviewed data support the conclusion that in the majority of cases, women with MS can safely choose to become pregnant, give birth, and breastfeed children. Clinical management should be individualized to optimize both the mother's reproductive outcomes and MS course.
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Elevated concentration of C-reactive protein is associated with pregnancy-related co-morbidities but not with relapse activity in multiple sclerosis. Neurol Sci 2014; 36:441-7. [PMID: 25308726 DOI: 10.1007/s10072-014-1980-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 10/06/2014] [Indexed: 01/29/2023]
Abstract
During pregnancy, alterations take place in mother's immune system with the goal of maintaining a successful pregnancy, and delivering healthy offspring. Immune alterations include activation of the innate immune system and dampening of cell-mediated adaptive immunity. Due to these alterations, cell-mediated autoimmune diseases typically ameliorate during pregnancy. The objectives of this study were to evaluate whether C-reactive protein (CRP) concentration, a sensitive marker of systemic inflammation (1) is increased during MS pregnancy (2) predicts pregnancy-related co-morbidities associated with MS (3) predicts MS disease activity after delivery. CRP concentration was measured using a high sensitivity assay from seven prospectively collected serum samples of 41 MS patients and 19 controls during pregnancy and 6 months after delivery. Annualized relapse rates, EDSS, fatigue scores and obstetric details of the patients were recorded. Delivery-related CRP levels were significantly elevated both among MS patients and in controls. CRP levels were higher during pregnancy than during the postpartum period in both study groups. Delivery-related elevated CRP levels did not correlate with postpartum disease activity. MS patients with eventual gestational diabetes had a significantly higher median CRP in the beginning of pregnancy compared to non-diabetic MS patients (9.28 vs. 2.98 mg/l, p = 0.0025). MS patients reporting fatigue had a significantly higher CRP throughout pregnancy compared to patients without fatigue. Higher CRP values were associated with pregnancy-related co-morbidities but not with MS disease activity.
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Bodiguel E, Bensa C, Brassat D, Laplaud D, Le Page E, Ouallet JC, Zephir H, De Seze J. Multiple sclerosis and pregnancy. Rev Neurol (Paris) 2014; 170:247-65. [PMID: 24684929 DOI: 10.1016/j.neurol.2013.09.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 09/26/2013] [Indexed: 10/25/2022]
Abstract
The question of pregnancy in patients with multiple sclerosis is regularly raised due to the prevalence of the disease in middle age women. The multiple sclerosis think tank (Groupe de Réflexion sur la Sclérose en Plaques [GRESEP]) decided to develop recommendations on this issue, with consideration to both the impact of multiple sclerosis on pregnancy, and that of pregnancy on the disease. As with topics of previous works, the formal expert consensus method was used. The working group was composed of hospital-based and private practice neurologists. The reading group was composed of neurologists, anaesthetists and obstetricians. Each recommendation is presented with the relevant level of consensus.
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Affiliation(s)
- E Bodiguel
- Hôpital européen Georges-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France; Service de neurologie, centre hospitalier Sainte-Anne, 1, rue Cabanis, 75014 Paris, France; Faculté de médecine, université Paris Descartes, Sorbonne Paris Cité, 12, rue de l'École de Médecine, 75270 Paris cedex 06, France.
| | - C Bensa
- Service de neurologie, fondation Rothschild, 25, rue Manin, 75019 Paris, France
| | - D Brassat
- Inserm U1043, pôle des neurosciences, hôpital Purpan, université Toulouse-3, place du Dr-Baylac, BP 3028, 31024 Toulouse cedex 3, France
| | - D Laplaud
- Inserm UMR643, service de neurologie, pavillon Jean-Monnet, hôtel-Dieu, CHU de Nantes, 30, boulevard Jean-Monnet, 44093 Nantes 01, France; Faculté de médecine de Nantes, 1, rue Gaston-Veïl, 44000 Nantes, France
| | - E Le Page
- CIC-P 0203 Inserm, pôle des neurosciences cliniques, CHU Pontchaillou, pavillon Clemenceau, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex 9, France
| | - J-C Ouallet
- Pôle des neurosciences cliniques, université de Bordeaux Segalen, CHU de Bordeaux Pellegrin Tripode, 1, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France
| | - H Zephir
- Pôle de neurologie, hôpital Roger-Salengro, CHRU de Lille, avenue du Pr-Émile-Laine, 59037 Lille, France
| | - J De Seze
- Service de neurologie, laboratoire d'imagerie et de neurosciences cognitives (LINC), CNRS, centre d'investigation clinique (CIC) de Strasbourg, université de Strasbourg, CHU de Strasbourg, 1, place de l'Hôpital, 67000 Strasbourg, France
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Abstract
Pregnancy creates alterations in maternal physiology which predispose to unique neurologic disorders. Pre-eclampsia, eclampsia, certain types of ischemic and hemorrhagic stroke, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, and thunderclap headache all appear to share a common origin from vascular endothelial dysfunction, with overlapping clinical presentations. Multiple sclerosis often improves during pregnancy. Compression mononeuropathies may occur in the extremities. Myasthenia gravis may affect second stage labor. Various inflammatory peripheral neuropathies, dystrophies, myopathies may occur during pregnancy. The safety of specific immune suppressants is reviewed. Epilepsy does not have a significant effect upon the course of pregnancy, albeit there is a modest increase in the need for cesarean section. Certain antiepileptic drugs may produce fetal malformations, most notably valproic acid. Brain tumors are rare during pregnancy, but may increase in size due to activation of hormonal receptors on tumor cells surfaces, water retention, and engorged blood vessels.
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Affiliation(s)
- H Steven Block
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - José Biller
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA.
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Hughes SE, Spelman T, Gray OM, Boz C, Trojano M, Lugaresi A, Izquierdo G, Duquette P, Girard M, Grand’Maison F, Grammond P, Oreja-Guevara C, Hupperts R, Bergamaschi R, Giuliani G, Lechner-Scott J, Barnett M, Edite Rio M, van Pesch V, Amato MP, Iuliano G, Slee M, Verheul F, Cristiano E, Fernández-Bolaños R, Poehlau D, Saladino ML, Deri N, Cabrera-Gomez J, Vella N, Herbert J, Skromne E, Savino A, Shaw C, Moore F, Vucic S, Petkovska-Boskova T, McDonnell G, Hawkins S, Kee F, Butzkueven H, Paolicelli D, Lucchese G, Iaffaldano P, Zwanikken C, De Luca G, Di Tommaso V, Travaglini D, Pietrolongo E, di Ioia M, Farina D, Mancinelli L, Marriott M, Kilpatrick T, King J, van der Walt A, Skibina O, Haartsen J, Chamorro B, Petersen T, Cartechini E, Pucci E, William D, Dark L, Fiol M, Correale J, Ysrraelit C, Den Braber-Moerland L, Jaacks G, Laffue A, Fernanda Páez M, Muñoz D, Oleschko Arruda W, Paine M, Vella M, Vetere S. Predictors and dynamics of postpartum relapses in women with multiple sclerosis. Mult Scler 2013; 20:739-46. [DOI: 10.1177/1352458513507816] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Several studies have shown that pregnancy reduces multiple sclerosis (MS) relapses, which increase in the early postpartum period. Postpartum relapse risk has been predicted by pre-pregnancy disease activity in some studies. Objective: To re-examine effect of pregnancy on relapses using the large international MSBase Registry, examining predictors of early postpartum relapse. Methods: An observational case–control study was performed including pregnancies post-MS onset. Annualised relapse rate (ARR) and median Expanded Disability Status Scale (EDSS) scores were compared for the 24 months pre-conception, pregnancy and 24 months postpartum periods. Clustered logistic regression was used to investigate predictors of early postpartum relapses. Results: The study included 893 pregnancies in 674 females with MS. ARR (standard error) pre-pregnancy was 0.32 (0.02), which fell to 0.13 (0.03) in the third trimester and rose to 0.61 (0.06) in the first three months postpartum. Median EDSS remained unchanged. Pre-conception ARR and disease-modifying treatment (DMT) predicted early postpartum relapse in a multivariable model. Conclusion: Results confirm a favourable effect on relapses as pregnancy proceeds, and an early postpartum peak. Pre-conception DMT exposure and low ARR were independently protective against postpartum relapse. This novel finding could provide clinicians with a strategy to minimise postpartum relapse risk in women with MS planning pregnancy.
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Affiliation(s)
- Stella E Hughes
- Department of Neurology, Royal Victoria Hospital, Belfast, UK
- UKCRC Centre of Excellence for Public Health Research, Queen’s University Belfast, UK
| | - Tim Spelman
- Department of Neurology, Royal Melbourne Hospital, Victoria, Australia
| | | | - Cavit Boz
- Karadeniz Technical University, Trabzon, Turkey
| | | | - Alessandra Lugaresi
- MS Center, Department of Neuroscience and Imaging, University ‘G. d’Annunzio’, Chieti, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Dieter Poehlau
- Multiple Sclerosis Centre Kamillus-Klinik, Asbach, Germany
| | | | - Norma Deri
- Hospital Fernandez, Buenos Aires, Argentina
| | | | | | | | - Eli Skromne
- Hospital de Especialidades, Centro Medico Nacional Siglo XXI, Mexico
| | - Aldo Savino
- Consultorio Privado, Buenos Aires, Argentina
| | | | | | - Steve Vucic
- Westmead Hospital, New South Wales, Australia
| | | | - Gavin McDonnell
- Department of Neurology, Royal Victoria Hospital, Belfast, UK
| | - Stanley Hawkins
- Department of Neurology, Royal Victoria Hospital, Belfast, UK
- Centre for Medical Education, Queen’s University Belfast, UK
| | - Frank Kee
- UKCRC Centre of Excellence for Public Health Research, Queen’s University Belfast, UK
| | - Helmut Butzkueven
- Department of Neurology, Royal Melbourne Hospital, Victoria, Australia
- Department of Medicine, Melbourne Brain Centre, The University of Melbourne, Australia
- Department of Neurology, Box Hill Hospital, Monash University, Australia
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D'hooghe MB, D'Hooghe T, De Keyser J. Female gender and reproductive factors affecting risk, relapses and progression in multiple sclerosis. Gynecol Obstet Invest 2013; 75:73-84. [PMID: 23343711 DOI: 10.1159/000346319] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 12/05/2012] [Indexed: 11/19/2022]
Abstract
Multiple sclerosis (MS), a chronic inflammatory demyelina-ting and degenerative disease of the central nervous system, is a frequent cause of neurological disability in young adults. Female predominance has increased over the last decades. Although female gender carries a higher risk of developing relapsing remitting MS, being female and at child-bearing age also appears to provide some protection against cognitive decline and against progressive onset MS, an adverse predictive factor when considering long-term disability in MS. The risk of MS in women has been associated with an earlier age at menarche. In most studies, parity did not impact MS risk. However, the recently published association of higher parity and offspring number with a reduced risk of a first demyelinating event suggests a potential suppressive effect. Pregnancy in MS patients has been associated with a reduced relapse rate and a reduction of neurological symptoms, especially in the third trimester. Despite the increased relapse risk in the postpartum period, there is no indication of an adverse effect of childbirth on the long-term course of MS. Fertility treatment in MS has been associated with an increased relapse risk in the following 3-month period, especially when the procedure did not result in pregnancy and gonadotrophin-releasing hormone agonists were used. Altogether, there is substantial evidence to support a regulatory role of sex steroid hormones in MS. In the absence of correlations with single hormone blood levels, we can only speculate about the underlying mechanisms. In conclusion, the increased MS risk in women and the changes in relapse and progression risk in association with reproductive events suggest significant and complex interactions between immune, neuroendocrine and reproductive systems in MS.
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Affiliation(s)
- M B D'hooghe
- National Center for Multiple Sclerosis, Melsbroek, Belgium.
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Abstract
The relapse rate of multiple sclerosis (MS) is typically reduced during late pregnancy but increases in the postpartum period. The reasons for the increased postpartum activity are not entirely clear, but factors such as the abrupt decrease in oestrogen levels immediately after the delivery and the loss of the immunosuppressive state of pregnancy are likely of importance. There is a general view that MS does not affect the course or outcome of pregnancy.
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Affiliation(s)
- Laura Airas
- Department of Neurology, Turku University Hospital , PO Box 52, 20521 Turku
| | - Risto Kaaja
- Satakunta Central Hospital, Pori, Finland and Turku University , Turku , Finland
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Paavilainen T, Kurki T, Färkkilä M, Salonen O, Parkkola R, Airas L. Lower brain diffusivity in postpartum period compared to late pregnancy: results from a prospective imaging study of multiple sclerosis patients. Neuroradiology 2011; 54:823-8. [DOI: 10.1007/s00234-011-0994-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 11/29/2011] [Indexed: 11/29/2022]
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Jobin C, Larochelle C, Parpal H, Coyle PK, Duquette P. Gender issues in multiple sclerosis: an update. ACTA ACUST UNITED AC 2011; 6:797-820. [PMID: 21118039 DOI: 10.2217/whe.10.69] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Although multiple sclerosis (MS) affects both women and men, women are more susceptible to MS than men. Accumulating evidence indicates that the incidence and prevalence of MS is increasing, more so in women than in men. Owing to pregnancy, differing hormonal states and distinct social roles, the impact of MS differs between women and men. Since Patricia K Coyle published a review on gender issues in MS, multiple studies have added to the body of knowledge. This update will summarize the current thinking on gender-related issues in MS and we will address incidence and prevalence, hormonal factors, pregnancy and breastfeeding, genetics, course and prognosis, imaging, treatment and psychosocial aspects. Future progression within this field will help elucidate the cause of and define the treatment of MS.
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Huang YH, Airas L, Schwab N, Wiendl H. Janus head: the dual role of HLA-G in CNS immunity. Cell Mol Life Sci 2011; 68:407-16. [PMID: 21086150 PMCID: PMC11114849 DOI: 10.1007/s00018-010-0582-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Accepted: 10/22/2010] [Indexed: 10/25/2022]
Abstract
The central nervous system (CNS) is considered an immune-privileged organ that maintains an adaptable immune surveillance system. Dysregulated immune function within the CNS contributes to the development of brain tumor growth, and robust immune activation results in excessive inflammation. Human lymphocyte antigen-G (HLA-G) proteins with tolerogenic immunoreactivity have been implicated in various pathophysiological processes including immune surveillance, governing homeostasis and immune regulation. In this review, we describe the wealth of evidence for the involvement of HLA-G in the CNS under physiological and pathological conditions. Further, we review regulatory functions that may be applicable as beneficial strategies in the therapeutic manipulation of immune-mediated CNS immune responses. Additionally, we try to understand how this molecule cooperates with other CNS-resident cells to maintain normal immune homeostasis, while still facilitating the development of the appropriate immune responses.
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Affiliation(s)
- Yu-Hwa Huang
- Department of Neurology, Inflammatory Disorders of the Nervous System and Neurooncology, University of Müenster, Domagkstr. 13, 48149 Müenster, Germany
| | - Laura Airas
- Department of Neurology, MediCity Research Laboratory, Turku University Hospital, Turku, Finland
| | - Nicholas Schwab
- Department of Neurology, Inflammatory Disorders of the Nervous System and Neurooncology, University of Müenster, Domagkstr. 13, 48149 Müenster, Germany
| | - Heinz Wiendl
- Department of Neurology, Inflammatory Disorders of the Nervous System and Neurooncology, University of Müenster, Domagkstr. 13, 48149 Müenster, Germany
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D'hooghe MB, Nagels G, Bissay V, De Keyser J. Modifiable factors influencing relapses and disability in multiple sclerosis. Mult Scler 2010; 16:773-85. [PMID: 20483884 DOI: 10.1177/1352458510367721] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A growing body of literature indicates that the natural course of multiple sclerosis can be influenced by a number of factors. Strong evidence suggests that relapses can be triggered by infections, the postpartum period and stressful life events. Vaccinations against influenza, hepatitis B and tetanus appear to be safe. Surgery, general and epidural anaesthesia, and physical trauma are not associated with an increased risk of relapses. Factors that have been associated with a reduced relapse rate are pregnancy, exclusive breastfeeding, sunlight exposure and higher vitamin D levels. A number of medications, including hormonal fertility treatment, seem to be able to trigger relapses. Factors that may worsen progression of disability include stressful life events, radiotherapy to the head, low levels of physical activity and low vitamin D levels. Strong evidence suggests that smoking promotes disease progression, both clinically and on brain magnetic resonance imaging. There is no evidence for an increased progression of disability following childbirth in women with multiple sclerosis. Moderate alcohol intake and exercise might have a neuroprotective effect, but this needs to be confirmed.
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Affiliation(s)
- M B D'hooghe
- National Center For Multiple Sclerosis, Melsbroek, Belgium.
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Abstract
During the previous decades, women with Multiple Sclerosis (MS) were discouraged from having children, as pregnancy was deemed dangerous for pregnancy outcome and a contributing factor for exacerbation of MS. Current knowledge shows that women with MS are no more likely to have pregnancy or delivery complications compared to healthy women. Immunomodulatory therapies should be avoided during pregnancy and while breastfeeding. However, despite that it is still not recommended during pregnancy, Glatiramer acetate has fewer risks than the other MS drugs with respect to pregnancy outcome. IVIg treatment appears to be safe in unblinded studies and may be used after the first trimester to prevent the exacerbation of postpartum relapses. Gestation is a period of decreased risk for a relapse, whereas relapses are more common in the first six months after childbirth, compared to the pre-pregnancy period. Breastfeeding and epidural anaesthesia are not associated with increased incidence of post-partum relapses.
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Affiliation(s)
- Andreas A Argyriou
- Department of Neurology, Saint Andrew's General Hospital of Patras, Greece.
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Iorio R, Frisullo G, Nociti V, Patanella KA, Bianco A, Marti A, Mirabella M, Tonali PA, Batocchi AP. T-bet, pSTAT1 and pSTAT3 expression in peripheral blood mononuclear cells during pregnancy correlates with post-partum activation of multiple sclerosis. Clin Immunol 2008; 131:70-83. [PMID: 19097824 DOI: 10.1016/j.clim.2008.10.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Revised: 10/15/2008] [Accepted: 10/31/2008] [Indexed: 10/21/2022]
Abstract
In pregnant women affected by multiple sclerosis (MS) we observed increased percentages of CD4(+)CD25(+)Foxp3(+) T regulatory cells at the 1st and the 2nd trimester of gestation that was associated with a decreased T-bet expression in CD4(+) T cells. In women showing clinical relapse and/or new lesions at MRI after delivery we found, a higher expression of T-bet, pSTAT1 and pSTAT3 in CD4(+), CD8(+) T cells and CD14(+) cells, associated with an increase of IFNgamma and IL17 production by PBMC at the 3rd trimester of gestation and after delivery. Our data suggest that the expansion of circulating CD4(+)CD25(+)Foxp3(+) regulatory T cells and the lower expression of T-bet in CD4(+) T cells may account for the decreased MS activity during pregnancy. The expression of T-bet, pSTAT1 and pSTAT3 in peripheral blood CD4(+) and CD8(+) T cells and monocytes could be useful to identify MS patients who will develop a relapse after delivery.
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Affiliation(s)
- R Iorio
- Institute of Neurology, Department of Neuroscience, Catholic University, Rome, Italy
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