Risk factors for peripartum depression in women with multiple sclerosis

Postpartum depression and autoimmune disease: a bidirectional Mendelian randomization study

Purpose

The rising prevalence of postpartum depression (PPD) is harmful to women and families. While there is a growing body of evidence suggesting an association between PPD and autoimmune diseases (ADs), the direction of causality remains uncertain. Therefore, Mendelian randomization (MR) study was employed to investigate the potential causal relationship between the two.

Methods

This study utilized large-scale genome-wide association study genetic pooled data from two major databases: the IEU OpenGWAS project and the FinnGen databases. The causal analysis methods used inverse variance weighting (IVW). The weighted median, MR-Egger method, MR-PRESSO test, and the leave-one-out sensitivity test have been used to examine the results' robustness, heterogeneity, and horizontal pleiotropy.

Results

A total of 23 ADs were investigated in this study. In the IVW model, the MR study showed that PPD increased the risk of type 1 diabetes (OR , = 1.15 (1.05-1.26),p<0.01),Hashimoto's thyroiditis((OR) = 1.21 (1.09-1.34),p<0.0001),encephalitis((OR) = 1.66 (1.06-2.60),p<0.05). Reverse analysis showed that ADs could not genetically PPD. There was no significant heterogeneity or horizontal pleiotropy bias in this result.

Conclusion

Our study suggests that PPD is a risk factor for type 1 diabetes, Hashimoto's thyroiditis, and encephalitis from a gene perspective, while ADs are not a risk factor for PPD. This finding may provide new insights into prevention and intervention strategies for ADs according to PPD patients.

Pregnancy and reproductive health in women with multiple sclerosis: an update

PURPOSE OF REVIEW

Multiple sclerosis (MS) is a chronic immune-mediated, inflammatory, neuro-degenerative disease of the central nervous system, prevalent in women of reproductive age. Today, many women want to start a family after MS diagnosis. There are over 20 treatments for MS, and safely navigating family planning is important. We review updated information on family planning, preconception, and peri-partum considerations, and reproductive concerns in special populations with MS.

RECENT FINDINGS

There are no MS-related restrictions on any available and appropriate contraceptive method in women with MS. The question of MS and pregnancy outcomes following assisted reproduction, remains somewhat unsettled. In many studies, no elevated relapse risk is confirmed regardless of the type of fertility treatment. MRI status may offer better assessment of postpartum disease stability than relapse rate alone. Ongoing effective MS treatments during fertility assistance and before pregnancy, can further reduce the relapse risk. B-cell depleting therapies are emerging as safe and effective treatments for peripartum MS patients.

SUMMARY

Patients with MS should receive accurate support and counseling related to their reproductive options. The general outlook on pregnancy and MS remains positive. The ever-increasing therapeutic complexity of MS calls for ongoing education and updated guidance for neuroimmunology and obstetrics healthcare providers.

Bidirectional association between autoimmune disease and perinatal depression: a nationwide study with sibling comparison

Although major depression, characterized by a pro-inflammatory profile, genetically overlap with autoimmune disease (AD) and the perinatal period involve immune system adaptations and AD symptom alterations, the bidirectional link between perinatal depression (PND) and AD is largely unexplored. Hence, the objective of this study was to investigate the bidirectional association between PND and AD. Using nationwide Swedish population and health registers, we conducted a nested case-control study and a matched cohort study. From 1,347,901 pregnancies during 2001-2013, we included 55,299 incident PND, their unaffected full sisters, and 10 unaffected matched women per PND case. We identified 41 subtypes of AD diagnoses recorded in the registers and compared PND with unaffected population-matched women and full sisters, using multivariable regressions. Women with an AD had a 30% higher risk of subsequent PND (95% CI 1.2-1.5) and women exposed to PND had a 30% higher risk of a subsequent AD (95% CI 1.3-1.4). Comparable associations were found when comparing exposed women with their unaffected sisters (nested case-control OR: 1.3, 95% CI 1.2-1.5, matched cohort HR: 1.3, 95% CI 1.1-1.6), and when studying antepartum and postpartum depression. The bidirectional association was more pronounced among women without psychiatric comorbidities (nested case-control OR: 1.5, 95% CI 1.4-1.6, matched cohort HR: 1.4, 95% CI 1.4-1.5) and strongest for multiple sclerosis (nested case-control OR: 2.0, 95% CI 1.6-2.3, matched cohort HR: 1.8, 95% CI 1.0-3.1). These findings demonstrate a bidirectional association between AD and PND independent of psychiatric comorbidities, suggesting possibly shared biological mechanisms. If future translational science confirms the underlying mechanisms, healthcare providers need to be aware of the increased risk of PND among women with ADs and vice versa.

Women's Health and Pregnancy in Multiple Sclerosis

Multiple sclerosis has a 3:1 female-to-male predominance and commonly presents in young adult women. The hormonal changes in women throughout their lifetime do affect the underlying pathology of multiple sclerosis, and the needs of women therefore change with age. Although multiple sclerosis does not adversely affect fertility or pregnancy, there are many factors to consider when caring for women throughout family planning, pregnancy, and the postpartum period. The care of these women and complex decisions regarding disease-modifying therapy use in family planning should be individualized and comprehensive.

Family planning considerations in people with multiple sclerosis

Multiple sclerosis is often diagnosed in patients who are planning on having children. Although multiple sclerosis does not negatively influence most pregnancy outcomes, less is known regarding the effects of fetal exposure to novel disease-modifying therapies (DMTs). The withdrawal of some DMTs during pregnancy can modify the natural history of multiple sclerosis, resulting in a substantial risk of pregnancy-related relapse and disability. Drug labels are typically restrictive and favour fetal safety over maternal safety. Emerging data reporting outcomes in neonates exposed to DMTs in utero and through breastfeeding will allow for more careful and individualised treatment decisions. This emerging research is particularly important to guide decision making in women with high disease activity or who are treated with DMTs associated with risk of discontinuation rebound. As increasing data are generated in this field, periodic updates will be required to provide the most up to date guidance on how best to achieve multiple sclerosis stability during pregnancy and post partum, balanced with fetal and newborn safety.

Neuroimmunological Disorders

Multiple sclerosis is a disease that tends to affect women during their childbearing years. Although relapse risk decreases during pregnancy, patients should still be optimized on disease-modifying therapy before and after pregnancy to minimize gaps in treatment. Exclusive breastfeeding may reduce the chances of disease relapse postpartum, and many disease-modifying therapies are considered to be safe while breastfeeding. Treatments for other neuroimmunologic disorders such as neuromyelitis optica spectrum disorder, myelin oligodendrocyte glycoprotein antibody-associated disease, neurosarcoidosis, and central nervous system vasculitis may require rituximab before and prednisone or intravenous immunoglobulin therapy during pregnancy.

Depressive symptoms during the perinatal period by disability status: Findings from the United States Pregnancy Risk Assessment Monitoring System

AIMS

The aim of the current study was to compare the prevalence of depressive symptoms during the perinatal period among respondents with a disability as compared to those without a disability.

DESIGN

We conducted a secondary analysis of nationally representative data from the Pregnancy Risk Assessment Monitoring System data from 24 participating United States between 2018 and 2020.

METHODS

A cross-sectional sample of 37,989 respondents provided data on disability, including difficulty in vision, hearing, ambulation, cognition, communication and self-care. The outcome of interest was perinatal depressive symptoms, defined as experiencing depressive symptoms during the antenatal period or postpartum period. Regression models were used to calculate odds of depressive symptoms during these two time periods by disability status while controlling for relevant sociodemographic characteristics and depressive symptoms prior to pregnancy.

RESULTS

Respondents with disabilities experienced a higher prevalence of depressive symptoms in both the antenatal period and postpartum period as compared to those without disabilities. In fully adjusted models, respondents with disabilities had 2.4 times the odds of experiencing depressive symptoms during pregnancy and 2.1 times the odds of experiencing postpartum depressive symptoms as compared to respondents without disabilities.

CONCLUSION

Respondents with disabilities experience a higher prevalence of depressive symptoms throughout the perinatal period thereby increasing the risk for adverse maternal, neonatal and infant health outcomes.

IMPACT

Perinatal depression is a significant public health issue globally, and our findings suggest that persons with disability are at an increased risk for depressive symptoms both during pregnancy and in the postpartum period. Our findings represent a call to action to improve clinical and supportive services for women with disabilities during the perinatal period to improve their mental health and the consequent health of their offspring.

PATIENT OR PUBLIC CONTRIBUTION

We thank our Community Advisory Board members who have been instrumental in the conception of this study.