Pregnancy in multiple sclerosis: Data from an administrative claims database

Potential Protective Role of Pregnancy and Breastfeeding in Delaying Onset Symptoms Related to Multiple Sclerosis

The impact of pregnancy and breastfeeding on the development and outcomes of Multiple sclerosis (MS) has been debated for decades. Since several factors can influence the evolution of the disease, the protective role of multiparity and breastfeeding remains uncertain, as well the role of hormone replacement therapy in the perimenopausal period. We report two cases of relatively late-onset MS in two parous women, who developed their first neurological symptoms after six and nine pregnancies, respectively. Both women breastfed each of their children for 3 to 12 months. One of them underwent surgical menopause and received hormone replacement therapy for 7 years before MS onset. We performed a systematic literature review to highlight the characteristics shared by women who develop the disease in similar conditions, after unique hormonal imbalances, and to collect promising evidence on this controversial issue. Several studies suggest that the beneficial effects of pregnancy and breastfeeding on MS onset and disability accumulation may only be realized when several pregnancies occur. However, these data on pregnancy and breastfeeding and their long-term benefits on MS outcomes suffer from the possibility of reverse causality, as women with milder impairment might choose to become pregnant more readily than those with a higher level of disability. Thus, the hypothesis that multiparity might have a protective role on MS outcomes needs to be tested in larger prospective cohort studies of neo-diagnosed women, evaluating both clinical and radiological features at presentation.

Medically Refractory Multiple Sclerosis Is Successfully Treated with Plasmapheresis in a Super Morbidly Obese Pregnant Patient

Multiple sclerosis (MS) is a relapse remitting immune-mediated demyelinating neurological disorder that primarily affects women of childbearing age. In most patients, the hormonal changes during pregnancy are protective against MS relapses. When relapses do occur, treatment options are limited to use of intravenous steroids and plasmapheresis rescue therapy. We present a case of steroid refractory MS-transverse myelitis with quadriplegia in a 25-year-old pregnant super morbidly obese woman. Our clinical case is unique because the severity of her relapse early in pregnancy, which was intractable and resistant to steroids. This may have been a rebound demyelination due to the discontinuation of fingolimod; a newly recognized entity by the FDA. Our case report therefore seeks to raise awareness about a potential complication of discontinuing MS disease modifying therapies, highlighting that these rebound relapses can be steroid resistant and occur despite the usual protective hormonal influence of early pregnancy and that plasma exchange is a valid treatment option. Finally, we discuss the challenges of determining exchange volumes for plasmapheresis in the super morbid obese population to secure good maternal and fetal outcomes.

Canadian Multiple Sclerosis Pregnancy Study (CANPREG-MS): Rationale and Methodology

BACKGROUND

Multiple sclerosis (MS) is the most common cause of neurological disability, other than trauma, among young adults of reproductive age. In contrast to the past, today there is very little lag time from clinical onset to diagnosis. Disease-modifying therapies are also now available outside of clinical trials. However, there is very little evidence-based population data to help an individual with MS make informed decisions with respect to reproductive options.

OBJECTIVE

The objective of this study is to develop a Canada-wide, prospective population-based registry of women with MS who are either trying to become pregnant and/or have become pregnant.

METHODS

The study represents a "real-world" scenario. Women with MS are invited to participate, regardless of clinical course, therapy, disease duration, and/or disability. The methodology to develop such a registry is very complex making it imperative to understand the design and rationale when interpreting results for clinical purposes.

RESULTS

This paper is a comprehensive discussion of the study rationale and methodology.

CONCLUSIONS

The study is ongoing, with over 100 potential participants. Numerous future publications are envisioned as the study progresses. The present paper is thus designed to be the key referral paper for subsequent publications in which it will not be possible to provide the necessary detailed information on rationale and methodology.