Pregnancy Data in a Turkish Multiple Sclerosis Population

Conceiving complexity: Biological mechanisms underpinning the lasting effect of pregnancy on multiple sclerosis outcomes

Multiple sclerosis (MS) is an autoimmune, demyelinating disease with the highest incidence in women of childbearing age. The effect of pregnancy on disease activity and progression is a primary concern for women with MS and their clinical teams. It is well established that inflammatory disease activity is naturally suppressed during pregnancy, followed by an increase postpartum. However, the long-term effect of pregnancy on disease progression is less understood. Having had a pregnancy before MS onset has been associated with an older age at first demyelinating event, an average delay of 3.4 years. After MS onset, there is conflicting evidence about the impact of pregnancy on long-term outcomes. The study with the longest follow-up to date showed that pregnancy was associated with a 0.36-point lower disability score after 10-years of disease in 1830 women. Understanding the biological mechanism by which pregnancy induces long-term beneficial effects on MS outcomes could provide mechanistic insights into the elusive determinants of secondary progression. Here, we review potential biological processes underlying this effect, including evidence that acute sex hormone exposure induces lasting changes to neurobiological and DNA methylation patterns, and how sustained methylation changes in immune cells can alter immune composition and function long-term.

Knowledge and worries on motherhood choice in multiple sclerosis - a cross-sectional study on patient-reported outcome measures

BACKGROUND

Since multiple sclerosis (MS) is often diagnosed in young women, pregnancy is a common topic for women with MS (wwMS). The study aimed to assess the measurement properties of two patient-reported outcome measures on motherhood choice in MS, and to explore the information and support needs of wwMS concerning motherhood.

METHODS

We conducted an anonymous web-based survey to validate the motherhood/pregnancy choice and worries questionnaire (MPWQ, 31 items plus up to 3 additional items) and the motherhood choice knowledge questionnaire (MCKQ, 16 items). We used mailing lists and social media for nationwide recruitment in Germany, and included women of childbearing age with relapsing-remitting MS, clinically isolated syndrome or suspected MS who were considering pregnancy or were pregnant. For the MPWQ, we assessed item difficulty, discriminatory power, and internal consistency (Cronbach's alpha; CA). We analysed construct validity using the Leipzig Questionnaire of Motives to have a Child, the Decisional Conflict Scale, the Hospital Anxiety and Depression Scale, and the Pregnancy-Related Anxiety Questionnaire-revised 2. We studied the structural validity using exploratory factor analysis (EFA). The MCKQ was evaluated descriptively. We explored the information and support needs of wwMS on motherhood descriptively. We examined correlations between MCKQ, MPWQ and clinical characteristics and performed exploratory group comparisons considering the following binary variables: having children and being pregnant.

RESULTS

325 wwMS started the survey; 232 wwMS met our inclusion criteria and were analysed. Their mean age was 30 years (SD 5). Most women had relapsing-remitting MS (n = 218; 94%), 186 (80%) had no children, and 38 (16%) were pregnant. Internal consistency was good for the worries subscale (CA>0.8), while it was unsatisfactory for the attitude and coping subscales (CA<0.7). The EFA did not support the three-scale structure (coping, attitude, and worries). Due to these findings, we decided to keep the worries scale without any subscale. The items from the coping scale and attitude scale could be assessed as additional descriptive items. Convergent and divergent construct validity of the MPWQ was satisfactory. 206 wwMS (89%) completed the MCKQ. On average, 9 of 16 (56%) items were answered correctly (range 2-15), and the questionnaire showed a good balance between easy and difficult items. Questions on immunotherapy, disease activity, and breastfeeding were the most challenging. WwMS were confident in getting pregnant and raising a child (n = 222; 96%). Most wwMS were worried about postpartum relapses (n = 200; 86%) and the long-term effects of pregnancy on disease evolution (n = 149; 64%). About half of the wwMS (n = 124; 54%) did not know where to find professional help and 127 (55%) had no strategies to cope with future impairments so that they could take care of a child.

CONCLUSION

Our results support the suitability and acceptability of both questionnaires as potential patient-reported measures for assessment of knowledge and worries around motherhood/pregnancy in MS. The survey results highlight the need for evidence-based information on motherhood in MS to increase knowledge, reduce worries and support wwMS in making informed decisions.

Investigating the Long-term Effect of Pregnancy on the Course of Multiple Sclerosis Using Causal Inference

BACKGROUND AND OBJECTIVES

The question of the long-term safety of pregnancy is a major concern in patients with multiple sclerosis (MS), but its study is biased by reverse causation (women with higher disability are less likely to experience pregnancy). Using a causal inference approach, we aimed to estimate the unbiased long-term effects of pregnancy on disability and relapse risk in patients with MS and secondarily the short-term effects (during the perpartum and postpartum years) and delayed effects (occurring beyond 1 year after delivery).

METHODS

We conducted an observational cohort study with data from patients with MS followed in the Observatoire Français de la Sclérose en Plaques registry between 1990 and 2020. We included female patients with MS aged 18-45 years at MS onset, clinically followed up for more than 2 years, and with ≥3 Expanded Disease Status Scale (EDSS) measurements. Outcomes were the mean EDSS score at the end of follow-up and the annual probability of relapse during follow-up. Counterfactual outcomes were predicted using the longitudinal targeted maximum likelihood estimator in the entire study population. The patients exposed to at least 1 pregnancy during their follow-up were compared with the counterfactual situation in which, contrary to what was observed, they would not have been exposed to any pregnancy. Short-term and delayed effects were analyzed from the first pregnancy of early-exposed patients (who experienced it during their first 3 years of follow-up).

RESULTS

We included 9,100 patients, with a median follow-up duration of 7.8 years, of whom 2,125 (23.4%) patients were exposed to at least 1 pregnancy. Pregnancy had no significant long-term causal effect on the mean EDSS score at 9 years (causal mean difference [95% CI] = 0.00 [-0.16 to 0.15]) or on the annual probability of relapse (causal risk ratio [95% CI] = 0.95 [0.93-1.38]). For the 1,253 early-exposed patients, pregnancy significantly decreased the probability of relapse during the perpartum year and significantly increased it during the postpartum year, but no significant delayed effect was found on the EDSS and relapse rate.

DISCUSSION

Using a causal inference approach, we found no evidence of significantly deleterious or beneficial long-term effects of pregnancy on disability. The beneficial effects found in other studies were probably related to a reverse causation bias.

Parity is associated with long-term differences in DNA methylation at genes related to neural plasticity in multiple sclerosis

BACKGROUND

Pregnancy in women with multiple sclerosis (wwMS) is associated with a reduction of long-term disability progression. The mechanism that drives this effect is unknown, but converging evidence suggests a role for epigenetic mechanisms altering immune and/or central nervous system function. In this study, we aimed to identify whole blood and immune cell-specific DNA methylation patterns associated with parity in relapse-onset MS.

RESULTS

We investigated the association between whole blood and immune cell-type-specific genome-wide methylation patterns and parity in 192 women with relapse-onset MS, matched for age and disease severity. The median time from last pregnancy to blood collection was 16.7 years (range = 1.5-44.4 years). We identified 2965 differentially methylated positions in whole blood, 68.5% of which were hypermethylated in parous women; together with two differentially methylated regions on Chromosomes 17 and 19 which mapped to TMC8 and ZNF577, respectively. Our findings validated 22 DMPs and 366 differentially methylated genes from existing literature on epigenetic changes associated with parity in wwMS. Differentially methylated genes in whole blood were enriched in neuronal structure and growth-related pathways. Immune cell-type-specific analysis using cell-type proportion estimates from statistical deconvolution of whole blood revealed further differential methylation in T cells specifically (four in CD4⁺ and eight in CD8⁺ T cells). We further identified reduced methylation age acceleration in parous women, demonstrating slower biological aging compared to nulligravida women.

CONCLUSION

Differential methylation at genes related to neural plasticity offers a potential molecular mechanism driving the long-term effect of pregnancy on MS outcomes. Our results point to a potential 'CNS signature' of methylation in peripheral immune cells, as previously described in relation to MS progression, induced by parity. As the first epigenome-wide association study of parity in wwMS reported, validation studies are needed to confirm our findings.

Hormone therapy and disease activity in Danish women with multiple sclerosis - a population-based cohort study

Background and purpose

Sex differences in multiple sclerosis (MS) prevalence and disease course are thought to be driven by hormones. Exogenous exposure to estrogens may affect MS disease course. Thus, our aim was to investigate the association between hormone therapy (HT) and disease activity and disability accrual among women with MS.

Methods

A register‐based cohort study was conducted with prospectively enrolled cases from the Danish MS registry. Information on hormone exposure was retrieved from the National Prescription Registry. Outcomes were relapse rate, relapse rate ratio, recurrent relapses, 6‐month confirmed and sustained Expanded Disability Status Scale (EDSS) milestones 4 and 6, and recurrent EDSS worsening.

Results

In all, 3325 women were eligible for analyses, of whom 333 (10%) were ever on HT at some time during follow‐up. We found no association between HT and disability accrual, although a trend for increasing risk with increasing length of use was seen. The risk of reaching 6‐month confirmed and sustained EDSS 4 among users was 0.6 (95% confidence interval [CI] = 0.3–1.2) after <1 year of use and 1.4 (95% CI = 0.9–2.2) after >5 years of HT compared to never use. The risk of recurrent relapse was increased by 20% (95% CI = 1.0–1.4) among current users of HT compared to nonusers. However, the risk of recurrent relapses was driven by the first calendar period (1996–2005) before the introduction of high‐efficacy disease‐modifying therapy.

Conclusions

Our findings from this nationwide MS population suggest that HT does not affect disability accrual in women with MS, especially if used for <5 years.

Pregnancy in women with MS: Impact on long-term disability accrual in a nationwide Danish Cohort

BACKGROUND

Pregnancy is considered to influence the disease course in women with multiple sclerosis (MS).

OBJECTIVE

The aim of this study was to investigate the effect of pregnancy on long-term disability accrual in women with MS.

METHODS

The Danish Multiple Sclerosis Registry (DMSR) was used to identify women diagnosed with clinically isolated syndrome or relapsing-remitting MS. Cox models with pregnancy as a time-dependent exposure and propensity score (PS) models were used to evaluate time to reach confirmed Expanded Disability Status Scale (EDSS) score of 4 and 6.

RESULTS

A total of 425 women became parous and 840 remained nulliparous. When including pregnancy as a time-dependent exposure, a non-significant association with time to reach EDSS 4 (hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.61-1.20) and EDSS 6 (HR 0.70, 95% CI 0.40-1.20) was found. Correspondingly, the PS model showed no association with pregnancy on time to reach EDSS 4 (HR 0.85, 95% CI 0.56-1.28).

CONCLUSION

This study concludes that pregnancy does not affect long-term disability accumulation.

Outcomes of pregnancy in Egyptian women with multiple sclerosis in the new treatment era: a multi-center retrospective observational study

Background

Pregnancy is a recent growing issue in multiple sclerosis (MS) and the update in the diagnostic criteria of MS and introduction of many disease-modifying therapies (DMTs) may cause changes in the relationship between MS, pregnancy, and breastfeeding. This study aimed to investigate the effect of pregnancy and breastfeeding on MS and vice versa. A retrospective observational study was conducted to include MS women with a history of at least one pregnancy during the last 7 years. Data were collected from the archived files in addition to a self-administrating questionnaire. The annualized relapsing rate (ARR) was calculated before, during, and after pregnancy.

Results

We included 116 successful pregnancies from 93 MS women with mean age 32.74 ± 5.12 years. Interferon-beta was the commonly used DMT during and after pregnancy. Despite the ARR during the two years preceding the conception was 0.36 (95% CI 0.32–0.41), this rate was significantly decreased during first, second, and third trimester (0.07; 95% CI 0.04–0.15, 0.10; 95% CI 0.03–0.17, and 0.15; 95% CI 0.08–0.24, respectively; P-value < 0.001 in all). Furthermore, this ARR was significantly decreased during the first and last three months after delivery (0.27; 95% CI 0.16–0.39; P-value = 0.037, and 0.24; 95% CI 0.17–0.38; P-value = 0.023). Exclusive breastfeeding was associated with deceased risk of postpartum relapse, with HR 0.31 (95% CI 0.12–0.67; P = 0.002).

Conclusions

Pregnancy is protective from MS relapse, with a significant decrease of ARR from the pre-pregnancy period. Postpartum reactivation of the disease occurs from the third month after labor, rather than the early postpartum period. Exclusive breastfeeding for at least 2 months decreased the risk of postpartum relapse.

Pregnancy in patients with multiple sclerosis

Multiple sclerosis (MS) is an autoimmune disorder that affects ~2.5 million people globally. Women of reproductive age are highly susceptible to this disease. This study aims to explore the association between MS and pregnancy. Articles related to the topic under investigation were identified; the search terms included "pregnancy", "multiple sclerosis", "MS", and "women". Only articles published between 2010 and 2020 were included in the review. This review shows that researchers have attempted to explore the link between pregnancy and MS, and the results from previous studies indicate that pregnancy reduces the risk of MS relapse. However, evidence suggesting that pregnancy can affect the long-term progression of MS is lacking. The research results also indicate that MS does not increase the risk of maternal and fetal complications. MS remains a serious autoimmune disorder that affects many women worldwide. The data gathered during this review indicate that a significant correlation exists between pregnancy and MS relapse rates. The findings presented in this review can aid in the management of MS during pregnancy. Furthermore, these research results provide vital insights that caregivers can use to monitor patients with MS during pregnancy.

Multiple Sclerosis in Pregnancy and its Role in Female Fertility: A Systematic Review

Multiple sclerosis (MS) is a neurological disease that typically affects young women of reproductive age. There are still many questions and heterogeneous clinical approaches partly due to the lack of consensus and guidelines. For many years, women with MS have been discouraged from getting pregnant for fears that the disease might negatively affect the fetus or increase their obstetric risk or for claims that the disease might decrease fertility. However, fertility does not seem to be impaired to a larger extent in women with MS. Therefore, all healthcare providers involved in the follow-up of multiple sclerosis patients must be prepared to discuss future fertility, pregnancy, and others matters, in addition to providing them with the best possible counseling. This study presents data based on updated evidence and discusses fertility and pregnancy in patients with MS with respect to the impacts of pregnancy on the risk and prognostic factors tied to MS, and the impact of MS on pregnancy outcomes and fertility treatments administered to females with MS. In conclusion, a clear relationship between infertility and MS has not been established. There seems to exist a link between disease aggressiveness and progression with several processes that might impair fertility. However, MS does not stand as a contraindication to assisted reproductive technology. From the several studies analyzed, it is possible to conclude that pregnancy is possible in women with MS. It is important to discuss and plan the ideal moment to start treatment and managing pregnancy and contraception aiming at better results.

The MSBase pregnancy, neonatal outcomes, and women's health registry

Background:

Family planning and pregnancy decisions are key considerations in the management of women with multiple sclerosis (MS), who are typically diagnosed between the ages of 20–40 years. Despite a strong evidence base that pregnancy is not harmful for women with MS, many knowledge gaps remain. These include: best management strategies through pregnancy in the era of highly effective disease-modifying therapies (DMT); foetal risks associated with DMT exposure in utero or in relation to breastfeeding; knowledge base around the use of assisted reproductive technologies; the long-term impact of pregnancy on disease outcomes, as well as the impact of long-term DMT use on women’s health and cancer risk.

Methods:

Here, we describe the new MSBase pregnancy, neonatal outcomes and women’s health registry. We provide the rationale for, and detailed description of, the variables collected within the registry, together with data acquisition details.

Conclusion:

The present paper will act as a reference document for future studies.

The Potential Preventive Effect of Pregnancy and Breastfeeding on Multiple Sclerosis

BACKGROUND

Multiple sclerosis (MS) is an inflammatory demyelinating chronic neurological disease that affects the central nervous system of young adults and their quality of life. Several studies have investigated the effects of pregnancy and breastfeeding on MS. However, the evidence regarding the influence of pregnancy and breastfeeding on MS is still accumulating. This review aimed to summarize the current evidence regarding the effects of pregnancy and breastfeeding on MS.

SUMMARY

A systematic electronic literature search of the PubMed and Embase databases was conducted to determine relevant published articles. The eligible studies were summarized and evaluated in tables. Key Messages: The majority of the studies indicated that pregnancy appears to lower the rate of MS relapses, particularly in the third trimester. The evidence regarding the effect of breastfeeding on MS remains inconsistent. Despite reports of negative obstetric outcomes in some pregnant women with MS, pregnancies in women with MS should not be categorized as high-risk pregnancies.

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

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

Pregnancy and multiple sclerosis: Clinical effects across the lifespan

Multiple sclerosis (MS) is commonly diagnosed in women of childbearing age. Having a greater understanding of the effects of pregnancy on the course of MS will lead to improved family-planning counselling for women. We found well-established evidence for a protective effect of pregnancy on relapse occurrence in historical cohorts. More recent studies suggest that the protective effect of pregnancy against relapse may be lost in those women with more active disease treated with high efficacy therapies. Furthermore, a strong body of evidence suggests that gravidity after diagnosis of MS does not lead to worse long-term outcomes. More contentious however, is whether pregnancy can delay a first episode of demyelination or a confirmed diagnosis of MS. This review provides a detailed analysis of the literature relating to the clinical effects of pregnancy on MS outcomes across a woman's reproductive lifespan.

Management strategies for female patients of reproductive potential with multiple sclerosis: An evidence-based review

Multiple sclerosis (MS) is an inflammatory, demyelinating, neurodegenerative, immune-mediated disease primarily diagnosed in early adulthood. Multiple sclerosis mostly impacts women of reproductive potential, with pregnancy and birth outcomes being major concerns for many patients. While there is ample evidence that the disease itself has no impact on pregnancy, many women living with MS still question their ability to have children, and the impact of childbearing on their disease in the short and long term. Such questions emphasize the importance of proper guidance from healthcare professionals, particularly neurologists. Management considerations are also complicated by the growing list of available treatment options. This review will summarize current evidence and expert opinion around the management of female MS patients of reproductive potential, from family planning to the postpartum period. Current guidelines on the use of disease-modifying therapies throughout pregnancy will be discussed, as well as other general medical recommendations, to minimize MS disease activity in the peripartum period.

The Short and Long-Term Effects of Pregnancy on Multiple Sclerosis and Experimental Autoimmune Encephalomyelitis

The role of pregnancy in multiple sclerosis (MS) is of importance because many patients with MS are young women in the childbearing age who require information to inform their reproductive decisions. Pregnancy is now well-known to be associated with fewer relapses of MS and reduced activity of autoimmune encephalomyelitis (EAE). However, in women with multiple sclerosis, this benefit is not always sufficient to protect against a rebound of disease activity if disease-modulating therapy is ceased for pregnancy. There is concern that use of assisted reproductive therapies can be associated with relapses of MS, but more data are required. It is thought that the beneficial effects of pregnancy are due to the pregnancy-associated changes in the maternal immune system. There is some evidence of this in human studies and studies of EAE. There is also evidence that having been pregnant leads to better long-term outcome of MS. The mechanism for this is not fully understood but it could result from epigenetic changes resulting from pregnancy or parenthood. Further studies of the mechanisms of the beneficial effects of pregnancy could provide information that might be used to produce new therapies.

Maternal and perinatal outcomes in pregnancies with multiple sclerosis: a case-control study

OBJECTIVE

To assess whether maternal multiple sclerosis (MS) is associated with adverse pregnancy outcomes by determining the clinical course of disease during pregnancy and postpartum throughout a 10-year-period in a single tertiary center.

METHODS

We conducted a case-control study that included pregnancies with a definitive diagnosis of MS (n=43), matched with 100 healthy pregnant women with similar characteristics. Maternal and perinatal data were retrieved from hospital files. Groups were compared with the Mann-Whitney and χ2 tests. Logistic regression models were constructed to determine independent effects.

RESULTS

Maternal demographic and baseline laboratory data were similar across the groups. Rates of preterm delivery, fetal growth restriction, preeclampsia, gestational diabetes, stillbirth, cesarean delivery, congenital malformation, and 5-min Apgar score were comparable (P>0.05 for all). General anesthesia during cesarean delivery (96% vs. 39%, P=0.002), urinary tract infection (UTI) (12% vs. 3%, P=0.04), low 1-min Apgar score (21% vs. 9%, P=0.04), and nonbreastfeeding (33% vs. 2%, P=0.001) were more frequent in women with MS. The low 1-min Apgar score and breastfeeding rates were independent of general anesthesia and UTI in regression models.

CONCLUSION

MS during pregnancy was not associated with adverse maternal and perinatal outcomes except UTI, low 1-min Apgar scores, and decreased breastfeeding rates.

Pregnancy and the Use of Disease-Modifying Therapies in Patients with Multiple Sclerosis: Benefits versus Risks

The burden of multiple sclerosis (MS) in women of childbearing potential is increasing, with peak incidence around the age of 30 years, increasing incidence and prevalence, and growing female : male ratio. Guidelines recommend early use of disease-modifying therapies (DMTs), which are contraindicated or recommended with considerable caution, during pregnancy/breastfeeding. Many physicians are reluctant to prescribe them for a woman who is/is planning to be pregnant. Interferons are not absolutely contraindicated during pregnancy, since interferon-β appears to lack serious adverse effects in pregnancy, despite a warning in its labelling concerning risk of spontaneous abortion. Glatiramer acetate, natalizumab, and alemtuzumab also may not induce adverse pregnancy outcomes, although natalizumab may induce haematologic abnormalities in newborns. An accelerated elimination procedure is needed for teriflunomide if pregnancy occurs on treatment or if pregnancy is planned. Current evidence supports the contraindication for fingolimod during pregnancy; data on other DMTs remains limited. Increased relapse rates following withdrawal of some DMTs in pregnancy are concerning and require further research. The postpartum period brings increased risk of disease reactivation that needs to be carefully addressed through effective communication between treating physicians and mothers intending to breastfeed. We address the potential for use of the first- and second-line DMTs in pregnancy and lactation.