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Das G, Damotte V, Gelfand JM, Bevan C, Cree BAC, Do L, Green AJ, Hauser SL, Bove R. Rituximab before and during pregnancy: A systematic review, and a case series in MS and NMOSD. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2018; 5:e453. [PMID: 29564373 PMCID: PMC5858951 DOI: 10.1212/nxi.0000000000000453] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/09/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the safety of rituximab treatment before and during pregnancy in women with MS and neuromyelitis optica spectrum disorders (NMOSDs) who may be at risk of relapses by performing a systematic literature review combined with a retrospective single-center case series. METHODS Studies were systematically identified in the PubMed, Google Scholar, and EMBASE using the key terms "pregnancy" and "rituximab"; 22 articles were included for review (>17,000 screened). Then, patients with MS and NMOSD from 1 center (University of California, San Francisco) exposed to rituximab before conception were identified through medical record review. RESULTS Systematic review: We identified 102 pregnancies with rituximab use within 6 months of conception: 78 resulted in live births and 12 in spontaneous abortions. Of 54 live births with reported gestational age, 31 occurred at term (37 weeks+) and 2 before 32 weeks. When checked, B-cell counts were low in 39% of newborns and normalized within 6 months. Case series: we identified 11 pregnancies (1 ongoing) in 10 women (7 MS and 3 NMOSD) treated with rituximab within 6 months of conception. All completed pregnancies resulted in term live births of healthy newborns (1 lost to follow-up at term). No maternal relapses occurred before/during pregnancy; 1 occurred postpartum (NMOSD). CONCLUSION No major safety signal was observed with rituximab use within 6 months of conception. Beyond the need for monitoring neonatal B cells, these observations support prospectively monitoring a larger patient cohort to determine whether rituximab may safely protect women with MS and NMOSD who are planning a pregnancy against relapses.
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Affiliation(s)
- Gitanjali Das
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Vincent Damotte
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Jeffrey M Gelfand
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Carolyn Bevan
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Bruce A C Cree
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Lynn Do
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Ari J Green
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Stephen L Hauser
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
| | - Riley Bove
- Department of Neurology, Weill Institute for the Neurosciences, University of California, San Francisco
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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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Holmqvist P, Hammar M, Landtblom AM, Brynhildsen J. Symptoms of multiple sclerosis in women in relation to cyclical hormone changes. EUR J CONTRACEP REPR 2011; 14:365-70. [PMID: 19916763 DOI: 10.3109/13625180903137329] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To prospectively investigate if women with multiple sclerosis (MS) experience changes in MS-symptoms in relation to cyclical hormonal changes. METHODS Sixty-three women with MS, either with regular, spontaneous menstrual cycles or taking combined oral contraceptives (COCs), were asked to score their MS symptoms every day during three cycles. Symptom scores were analysed in relation to different phases of the spontaneous menstrual- or pill-driven cycle. RESULTS Twenty-three women completed the score record. Among the 16 women who were not using a COC there were no significant differences in symptom scores between the phases of the menstrual cycle. The seven women taking a COC reported significantly higher symptom score points for weakness, numbness and tiredness during the pill-free interval compared with the phase during which they took the COC daily. CONCLUSIONS This prospective study appears to contradict earlier retrospective studies regarding variations in MS symptoms in relation to the menstrual cycle in women who are not using a COC. The lower symptom scores during the three weeks of pill taking suggest a positive effect of the steroids on the manifestations of MS. Further studies concerning both short- and long-term effects of OC-use on MS symptoms are needed.
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Affiliation(s)
- Per Holmqvist
- Division of Obstetrics & Gynaecology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden.
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4
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Holmqvist P, Hammar M, Landtblom AM, Brynhildsen J. Age at onset of multiple sclerosis is correlated to use of combined oral contraceptives and childbirth before diagnosis. Fertil Steril 2011; 94:2835-7. [PMID: 20807659 DOI: 10.1016/j.fertnstert.2010.06.045] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 06/03/2010] [Accepted: 06/16/2010] [Indexed: 11/15/2022]
Abstract
The aim of this study was to evaluate whether age of onset of multiple sclerosis is related to use of combined oral contraceptives and/or timing of childbirth. The results showed that use of combined oral contraceptives and childbirth before the first multiple sclerosis symptom was correlated to a higher mean age at the onset of the disease.
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Affiliation(s)
- Per Holmqvist
- Division of Womens and Childrens Health, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden.
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5
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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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6
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Grossesse et sclérose en plaques. Presse Med 2010; 39:389-94. [DOI: 10.1016/j.lpm.2009.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Revised: 07/03/2009] [Accepted: 07/22/2009] [Indexed: 11/21/2022] Open
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Fernández Liguori N, Klajn D, Acion L, Cáceres F, Calle A, Carrá A, Cristiano E, Deri N, Garcea O, Jaureguiberry A, Onaha P, Patrucco L, Riccio P, Rotta Escalante R, Saladino ML, Sinay V, Tarulla A, Villa A. Epidemiological characteristics of pregnancy, delivery, and birth outcome in women with multiple sclerosis in Argentina (EMEMAR study). Mult Scler 2009; 15:555-62. [DOI: 10.1177/1352458509102366] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The influence of pregnancy on Multiple Sclerosis (MS) has been extensively studied but such influence on Latin American women with MS has not been characterized. Our objective was to describe the course of pregnancy and birth outcome in Argentinean MS patients and the evolution of MS during pregnancy and after delivery. Method We used a retrospective design in eight MS centers in Argentina and administered a survey to women with definite MS (Mc Donald) with pregnancies during or after MS onset. We contacted 355 women of which 81 met inclusion criteria. We recorded 141 pregnancies. Results Involuntary abortion was observed in 16% of pregnancies (95% CI = 10–23). Thirty five women received immunomodulatory therapy (IMT) before 42 pregnancies. Twenty three (55%) out of 42 pregnancies were exposed to IMT. The mean time of IMT discontinuation before conception in 19 (45.2%) pregnancies without exposure, was 104 days (95% CI = 61.0–147.0). There were 103 deliveries: 79% full term. Birth defects were detected in 19% of pregnancies exposed to IMT (95% CI = 4–46) and in 2% of non-exposed (95% CI = 0.3–8.0). The mean relapse rate was: pre-pregnancy year: 0.22 (95% CI = 0.12–0.32); pregnancy: 0.31 in 1st (95% CI = 0.10–0.52), 0.19 (95% CI = 0.03–0.36) in 2nd, and 0.04 in 3rd trimester (95% CI = –0.04–0.12); 1st trimester post delivery: 0.82 (95% CI = 0.42–1.22). Conclusion We observed a higher rate of birth defects among infants exposed to immunomodulators in utero than those not exposed. The reduction in MS relapses during 2nd and 3rd trimester of pregnancy and its increase during postpartum is consistent with previous reports.
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Affiliation(s)
| | - D Klajn
- Neurology Hospital E.Tornú, Buenos Aires, Argentina
| | - L Acion
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - F Cáceres
- Multiple Sclerosis Clinic Instituto Neurociencias Buenos Aires (INEBA), Buenos Aires, Argentina
| | - A Calle
- Multiple Sclerosis Section Hospital Francés, Buenos Aires, Argentina
| | - A Carrá
- Multiple Sclerosis Section Hospital Británico, Buenos Aires, Argentina
| | - E Cristiano
- Multiple Sclerosis Section Hospital Italiano, Buenos Aires, Argentina
| | - N Deri
- Multiple Sclerosis Section Hospital J. Fernández, Buenos Aires, Argentina
| | - O Garcea
- Neuroimmmunology Unit Hospital J.M Ramos Mejía, Buenos Aires, Argentina
| | - A Jaureguiberry
- Neuroimmmunology Unit Hospital J.M Ramos Mejía, Buenos Aires, Argentina
| | - P Onaha
- Multiple Sclerosis Section Hospital Británico, Buenos Aires, Argentina
| | - L Patrucco
- Multiple Sclerosis Section Hospital Italiano, Buenos Aires, Argentina
| | - P Riccio
- Multiple Sclerosis Section Hospital Italiano, Buenos Aires, Argentina
| | - R Rotta Escalante
- Multiple Sclerosis Section Policlínico Bancario, Buenos Aires, Argentina
| | - ML Saladino
- Multiple Sclerosis Section Hospital E.Tornú, Buenos Aires, Argentina; Multiple Sclerosis Clinic Instituto Neurociencias Buenos Aires (INEBA), Buenos Aires, Argentina
| | - V Sinay
- Multiple Sclerosis Section Hospital Francés, Buenos Aires, Argentina
| | - A Tarulla
- Multiple Sclerosis Section Policlínico Bancario, Buenos Aires, Argentina
| | - A Villa
- Neuroimmmunology Unit Hospital J.M Ramos Mejía, Buenos Aires, Argentina
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Holmqvist P, Wallberg M, Hammar M, Landtblom AM, Brynhildsen J. Symptoms of multiple sclerosis in women in relation to sex steroid exposure. Maturitas 2006; 54:149-53. [PMID: 16293376 DOI: 10.1016/j.maturitas.2005.10.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2005] [Accepted: 10/07/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To investigate if women with multiple sclerosis (MS) experience changes in MS symptoms related to pregnancy, the postpartum period, menopause or use of oral contraception (OC) or postmenopausal hormone therapy (HT). METHODS Women with diagnosed MS were recruited from registers of all MS patients known in two counties of Sweden, respectively. Ninety-four women were recruited in Linköping and 52 in Sundsvall. The women answered a questionnaire with categorized alternatives regarding their MS symptoms related to menstruation, pregnancy, delivery, menopause and use of OC or HT. RESULTS Forty percent of the women reported worsening of MS symptoms related to menopause, whereas 56% reported no change of symptoms and 5% reported decreased symptoms. More than a fourth of the women reported decreased symptoms during pregnancy, 64% reported unchanged symptoms and 10% reported increased symptoms. Every third woman reported increased symptoms after delivery, 59% reported no change and 5% reported decreased symptoms. Few women reported changes in MS symptoms in relation to use of HT or OC. CONCLUSION The presented data indicate a relationship between high-oestrogen states and ameliorated symptoms whereas low-oestrogen states seem to relate to a worsening of the disease. A majority of women, however, reported no changes in MS symptoms in relation to the different oestrogen states.
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Affiliation(s)
- Per Holmqvist
- Division of Obstetrics & Gynaecology, Department of Molecular and Clinical Medicine, Faculty of Health Sciences, Linköping University, S-581 85 Linköping, and Department of Obstetrics & Gynaecology, County Hospital Sundsvall, Sweden.
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9
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Abstract
The influence of pregnancy in multiple sclerosis (MS) has been a matter of controversy for a long time. Women with MS were often discouraged to envisage pregnancy. The Pregnancy in Multiple Sclerosis (PRIMS) study was the first large-scale prospective study aimed at assessing the possible influence of pregnancy and delivery on the clinical course of MS. Two hundred and fifty-four women with a diagnosis of MS were included during pregnancy and followed-up till the end of the second year post partum. The results were a reduction in the relapse rate during pregnancy, in comparison to the year before pregnancy, especially marked in the third trimester, and a significant increase in the relapse rate in the first trimester post partum. From the second trimester post partum on however, the relapse rate did not significantly differ from the pre-pregnancy rate. About one third of the women experienced a post partum relapse. Pregnancy did not influence disability progression. The clinical factors likely to predict a relapse in the three months after delivery were analyzed by logistic regression analysis. Women with a greater disease activity in the year before pregnancy and during pregnancy had a higher risk of relapse in the post partum three months. Neither breast-feeding, nor epidural analgesia correlated with presence of a post partum relapse. When comparing the predicted and observed status however, only 72 percent of the women were correctly classified by the multivariate model. It seems unwise therefore to use this kind of model to select women that would benefit from a putative preventive therapy. The PRIMS study had other major consequences: it fostered the development of specific therapeutic strategies to prevent post partum relapses (IV immunoglobulins, IV methylprednisolone), and suggested a potential role of sexual hormones in the natural history of MS during pregnancy and the post partum, therefore identifying them as a preferential target for prevention. The preventive effect of progesterone combined with estradiol on post partum relapses will be tested in a large-scale randomized and placebo-controlled European trial, the POPART'MUS study.
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Affiliation(s)
- S Vukusic
- Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer, 59, boulevard Pinel, 69677 Bron Cedex.
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10
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Abstract
The influence of pregnancy on multiple sclerosis (MS) has long been a matter of controversy. Women with MS were often discouraged to consider pregnancy. The PRegnancy In Multiple Sclerosis (PRIMS) study was the first large prospective study aimed at assessing the possible influence of pregnancy and delivery on the clinical course of MS. Two hundred and fifty-four women with the diagnosis of MS were included during pregnancy and followed until the end of the second year post partum. The results were a reduction in the relapse rate during pregnancy, in comparison to the year before pregnancy, especially marked in the third trimester, and a significant increase in the relapse rate in the first trimester post partum. Starting in the second trimester post partum, the relapse rate did not significantly differ from the pre-pregnancy rate. About one third of the women experienced a post partum relapse. Pregnancy did not influence disability progression. Women with greater disease activity in the year before and during pregnancy had a higher risk of relapse in the first three months post partum. Neither breastfeeding, nor epidural analgesia correlated with the presence of a post partum relapse. When comparing predicted and observed status, 72% of the women were correctly classified by the multivariate model; it therefore seems unwise to use such a model to select women who would benefit from a putative preventive therapy. The PRIMS study had other major consequences: it fostered the development of specific therapeutic strategies to prevent post partum relapses (i.v. immunoglobulins, i.v. methylprednisolone), and suggested a potential role for sex hormones in the natural history of MS during pregnancy and the post partum. The preventive effect of progesterone combined with estradiol on post partum relapses is about to be tested in a large randomized and placebo-controlled European trial, the POPART'MUS study.
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Affiliation(s)
- Sandra Vukusic
- The European Database for Multiple Sclerosis Coordinating Center and Service de Neurologie A, INSERM U 433, Hôpital Neurologique Pierre Wertheimer, 59 Boulevard Pinel, 69677 Lyon-Bron Cedex, France.
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11
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El-Etr M, Vukusic S, Gignoux L, Durand-Dubief F, Achiti I, Baulieu EE, Confavreux C. Steroid hormones in multiple sclerosis. J Neurol Sci 2005; 233:49-54. [PMID: 15878598 DOI: 10.1016/j.jns.2005.03.004] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The possible influence of steroid hormones in multiple sclerosis (MS) has been a matter of great interest. A first illustration comes from the analyses of the influence of gender on susceptibility to MS and on MS severity. A series of arguments emerge in favour of a possible influence of steroid hormones in MS. The menstrual cycle, and even more pregnancy, may influence the clinical evolution of MS. In the PRIMS study, there was a dramatic decrease in the relapse rate during pregnancy, especially in the third trimester, with a rebound increase in the 3 months post partum. Animal studies have provided further confirmatory results. Many experiments have shown that sex steroids may have immunological effects, in preventing or treating experimental allergic encephalomyelitis. They could also have an effect on myelinating and remyelinating the peripheral and possibly the central nervous system. These clinical and experimental data have led to consider sexual steroids as potential therapeutic tools for preventing relapses in women with MS, in particular in the post-partum period.
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12
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Affiliation(s)
- Kelly A Bennett
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.
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13
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Vukusic S, Hutchinson M, Hours M, Moreau T, Cortinovis-Tourniaire P, Adeleine P, Confavreux C. Pregnancy and multiple sclerosis (the PRIMS study): clinical predictors of post‐partum relapse. Brain 2004; 127:1353-60. [PMID: 15130950 DOI: 10.1093/brain/awh152] [Citation(s) in RCA: 356] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The influence of pregnancy in multiple sclerosis has been a matter of controversy for a long time. The Pregnancy in Multiple Sclerosis (PRIMS) study was the first large prospective study which aimed to assess the possible influence of pregnancy and delivery on the clinical course of multiple sclerosis. We report here the 2-year post-partum follow-up and an analysis of clinical factors which might predict the likelihood of a relapse in the 3 months after delivery. The relapse rate in each trimester up to the end of the second year post-partum was compared with that in the pre-pregnancy year. Clinical predictors of the presence or absence of a post-partum relapse were analysed by logistic regression analysis. Using the best multivariate model, women were classified as having or not having a post-partum relapse predicted, and this was compared with the observed outcome. The results showed that, compared with the pre-pregnancy year, there was a reduction in the relapse rate during pregnancy, most marked in the third trimester, and a marked increase in the first 3 months after delivery. Thereafter, from the second trimester onwards and for the following 21 months, the annualized relapse rate fell slightly but did not differ significantly from the relapse rate recorded in the pre-pregnancy year. Despite the increased risk for the 3 months post-partum, 72% of the women did not experience any relapse during this period. Confirmed disability continued to progress steadily during the study period. Three indices, an increased relapse rate in the pre-pregnancy year, an increased relapse rate during pregnancy and a higher DSS (Kurtzke's Disability Status Scale) score at pregnancy onset, significantly correlated with the occurrence of a post-partum relapse. Neither epidural analgesia nor breast-feeding was predictive. When comparing the predicted and observed status, however, only 72% of the women were correctly classified by the multivariate model. In conclusion, the results for the second year post-partum confirm that the relapse rate remains similar to that of the pre-pregnancy year, after an increase in the first trimester following delivery. Women with greater disease activity in the year before pregnancy and during pregnancy have a higher risk of relapse in the post- partum 3 months. This is, however, not sufficient to identify in advance women with multiple sclerosis who are more likely to relapse, especially for planning therapeutic trials aiming to prevent post-partum relapses.
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Affiliation(s)
- Sandra Vukusic
- Service de Neurologie A, Hôpital Neurologique Pierre Wertheimer, 59 boulevard Pinel, 69394 Lyon cedex 03, France
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14
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Zhang B, Harness J, Somodevilla-Torres MJ, Hillyard NC, Mould AW, Alewood D, Love SG, Alewood PF, Greer JM, Cavanagh AC, McCombe PA, Morton H. Early pregnancy factor suppresses experimental autoimmune encephalomyelitis induced in Lewis rats with myelin basic protein and in SJL/J mice with myelin proteolipid protein peptide 139-151. J Neurol Sci 2000; 182:5-15. [PMID: 11102634 DOI: 10.1016/s0022-510x(00)00432-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Early pregnancy factor (EPF) is a secreted protein with immunosuppressive and growth factor properties. During pregnancy, it appears in maternal serum within 6-24 h of fertilization, is present for at least the first two-thirds of pregnancy in all species studied and is essential for embryonic survival. It is a homologue of chaperonin 10, a heat shock protein, but, unlike other members of this family, EPF has an extracellular role. As it has the ability to modulate CD4+ T cell-dependent immune responses, its role in treatment of experimental autoimmune encephalomyelitis (EAE) was investigated. EAE is a CD4+ T cell-mediated disease, the best available animal model of multiple sclerosis (MS). Two models of EAE were investigated, acute EAE induced in Lewis rats by inoculation with myelin basic protein (MBP-EAE) and chronic relapsing EAE induced in SJL/J mice by inoculation with myelin proteolipid protein peptide (residues 139-151) (PLP-EAE). EPF, delivered intraperitoneally or orally to rats or intraperitoneally to mice, suppressed clinical signs of disease. Mice with PLP-EAE were also treated with interferon-beta, with and without EPF. Both EPF and IFN-beta suppressed clinical signs of EAE and, when administered together, gave greater suppression than when given separately. These findings suggest that EPF may be a potential candidate for use in treatment of MS and may be of use in combined therapy with IFN-beta.
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MESH Headings
- Adjuvants, Immunologic/pharmacology
- Adjuvants, Immunologic/therapeutic use
- Animals
- Chaperonin 10
- Drug Evaluation, Preclinical
- Encephalomyelitis, Autoimmune, Experimental/chemically induced
- Encephalomyelitis, Autoimmune, Experimental/drug therapy
- Encephalomyelitis, Autoimmune, Experimental/immunology
- Female
- Immunosuppressive Agents/pharmacology
- Immunosuppressive Agents/therapeutic use
- Interferon-beta/pharmacology
- Interferon-beta/therapeutic use
- Lymphocyte Activation/drug effects
- Lymphocyte Activation/immunology
- Mice
- Myelin Basic Protein
- Myelin Proteolipid Protein
- Peptides/pharmacology
- Peptides/therapeutic use
- Pregnancy
- Pregnancy Proteins
- Rats
- Rats, Inbred Lew
- Suppressor Factors, Immunologic
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Affiliation(s)
- B Zhang
- Department of Surgery, The University of Queensland, Royal Brisbane Hospital, 4029, Queensland, Australia
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15
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Abstract
Early pregnancy factor (EPF) has been identified as a homologue of chaperonin 10 (cpn10) with immunosuppressive and growth factor properties. As a homologue of cpn10, it belongs to the heat shock family of proteins (hsp) but, unlike other members of this family, EPF is detected extracellularly. Early pregnancy factor was first discovered in pregnancy serum by the rosette inhibition test, and the novelty of its discovery was that its presence could diagnose pregnancy within 6-24 h of a fertile mating. As well as being a monitor of the presence of a viable embryo, it is necessary for embryonic survival. In this capacity it acts as both an immunosuppressant and growth factor. Early pregnancy factor is also a product of proliferating primary and neoplastic cells and functions as an autocrine growth factor both in vivo and in vitro. It has a modifying effect on the outcome of experimental autoimmune encephalomyelitis, an animal model of multiple sclerosis. Early pregnancy factor is considered to be one of the major factors involved in the modification of multiple sclerosis observed during pregnancy.
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Affiliation(s)
- H Morton
- University of Queensland, Department of Surgery, Clinical Sciences Building, Royal Brisbane Hospital, Brisbane, Queensland, Australia
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Taylor RS. Multiple Sclerosis Potpourri: Paroxysmal Symptoms, Seizures, Fatigue, Pregnancy, and More. Phys Med Rehabil Clin N Am 1998. [DOI: 10.1016/s1047-9651(18)30248-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Confavreux C, Hutchinson M, Hours MM, Cortinovis-Tourniaire P, Moreau T. Rate of pregnancy-related relapse in multiple sclerosis. Pregnancy in Multiple Sclerosis Group. N Engl J Med 1998; 339:285-91. [PMID: 9682040 DOI: 10.1056/nejm199807303390501] [Citation(s) in RCA: 986] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND METHODS Multiple sclerosis often occurs in young women, and the effect of pregnancy on the disease is poorly understood. We studied 254 women with multiple sclerosis during 269 pregnancies in 12 European countries. The women were followed during their pregnancies and for up to 12 months after delivery to determine the rate of relapse per trimester and the score on the Kurtzke Expanded Disability Status Scale (range, 0 to 10, with higher scores indicating more severe disability). The relapse rate in each trimester was compared with the rate during the year before the pregnancy. The effects of epidural analgesia and breast-feeding on the frequency of relapse during the first three months post partum and the disability score at 12 months post partum were also determined. RESULTS The mean (+/-SD) rate of relapse was 0.7+/-0.9 per woman per year in the year before pregnancy; it was 0.5+/-1.3 during the first trimester (P=0.03 for the comparison with the rate before pregnancy), 0.6+/-1.6 during the second trimester (P=0.17), and 0.2+/-1.0 during the third (P<0.001). The rate increased to 1.2+/-2.0 during the first three months post partum (P<0.001) and then returned to the prepregnancy rate. The mean Kurtzke disability score worsened by 0.7 point during 33 months of follow-up, with no apparent acceleration during the post-partum period. Neither breast-feeding nor epidural analgesia had an adverse effect on the rate of relapse or on the progression of disability in multiple sclerosis. CONCLUSIONS In women with multiple sclerosis, the rate of relapse declines during pregnancy, especially in the third trimester, and increases during the first three months post partum before returning to the prepregnancy rate.
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Affiliation(s)
- C Confavreux
- European Database for Multiple Sclerosis Coordinating Center and the Service de Neurologie, Hôpital de l'Antiquaille, Lyons, France
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Bódis L, Szupera Z, Pierantozzi M, Bandini F, Sas K, Kovács L, Vécsei L, Bódis I. Neurological complications of pregnancy. J Neurol Sci 1998; 153:279-93. [PMID: 9511884 DOI: 10.1016/s0022-510x(97)00297-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- L Bódis
- Department of Obstetrics and Gynecology, Albert Szent-Györgyi University Medical School, Szeged, Hungary
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Abstract
In this review, we summarize the available information on the short- and long-term effects of pregnancy on the course of multiple sclerosis (MS). Published studies that used established criteria for the diagnosis of MS were given more weight than studies in which the criteria for diagnosis were unstated or unclear. Population-based studies were emphasized more than clinic-based studies, unless the clinic base was well defined and thought to be reasonably representative of the MS population in the geographic area. For completeness, small studies were also included but weighted accordingly in our overall conclusions. Methodologic limitations and biases inherent in the study methods are discussed. We conclude that patients with relapsing MS have an increased risk of relapse during the initial 6-month postpartum period. This increased risk does not seem to have a detrimental effect on the rate of developing sustained disability. In fact, a full-term pregnancy may increase the time interval to reaching a common disability endpoint-walking with the aid of a cane or crutch--or to having a secondarily progressive course. Evidence indicates that pregnancy may alter T-lymphocyte functions and cause clinically relevant consequences. The specific biochemical mechanisms responsible for these observations, however, remain undefined. Because of limitations of current knowledge, our conclusions are tentative at best. The data are most applicable to patients with relapsing-remitting MS in its early stages. MS is an unpredictable disease and is only one of many factors that patients must consider when a pregnancy is contemplated.
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Affiliation(s)
- D M Damek
- Department of Neurology, Mayo Clinic Jacksonville, Florida, USA
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