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Potential Protective Role of Pregnancy and Breastfeeding in Delaying Onset Symptoms Related to Multiple Sclerosis. Medicina (B Aires) 2023; 59:medicina59030619. [PMID: 36984620 PMCID: PMC10057678 DOI: 10.3390/medicina59030619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/04/2023] [Accepted: 03/09/2023] [Indexed: 03/22/2023] Open
Abstract
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.
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2
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Collorone S, Kodali S, Toosy AT. The protective role of breastfeeding in multiple sclerosis: Latest evidence and practical considerations. Front Neurol 2023; 13:1090133. [PMID: 36761920 PMCID: PMC9902945 DOI: 10.3389/fneur.2022.1090133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 12/23/2022] [Indexed: 01/25/2023] Open
Abstract
The immunoprotective role of pregnancy in multiple sclerosis (MS) has been known for decades. Conversely, there has been rich debate on the topic of breastfeeding and disease activity in MS. In clinical practice, women are often offered to restart their disease-modifying drug (DMD) soon after delivery to maintain their relapse risk protection. Limited available information about peri-partum DMD safety can discourage women to choose breastfeeding, despite the World Health Organization's recommendation to breastfeed children for the first 6 months of life exclusively. New evidence is emerging about the protective role of exclusive breastfeeding on relapse rate. Research studies shed light on the hormonal and immunological mechanisms driving the risk of relapses during pregnancy and postpartum. Finally, case reports, real-world data, and clinical trials are increasing our knowledge of the safety of DMDs for the fetus and infant. While some DMDs must be avoided, others may be considered in highly active pregnant or lactating women with MS. This mini-review conveys recent evidence regarding the protective role of exclusive breastfeeding in MS and offers clinicians practical considerations for a patient-tailored approach.
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Affiliation(s)
- Sara Collorone
- NMR Research Unit, Department of Neuroinflammation, Queen Square MS Centre, Faculty of Brain Sciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Srikirti Kodali
- NMR Research Unit, Department of Neuroinflammation, Queen Square MS Centre, Faculty of Brain Sciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Ahmed T Toosy
- NMR Research Unit, Department of Neuroinflammation, Queen Square MS Centre, Faculty of Brain Sciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
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3
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Diem L, Hammer H, Hoepner R, Pistor M, Remlinger J, Salmen A. Sex and gender differences in autoimmune demyelinating CNS disorders: Multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD) and myelin-oligodendrocyte-glycoprotein antibody associated disorder (MOGAD). INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 164:129-178. [PMID: 36038203 DOI: 10.1016/bs.irn.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Multiple sclerosis (MS), Neuromyelitis optica spectrum disorder (NMOSD) and Myelin-Oligodendrocyte-Glycoprotein antibody associated disorder (MOGAD) are demyelinating disorders of the central nervous system (CNS) of autoimmune origin. Here, we summarize general considerations on sex-specific differences in the immunopathogenesis and hormonal influences as well as key clinical and epidemiological elements. Gender-specific issues are widely neglected starting with the lacking separation of sex as a biological variable and gender comprising the sociocultural components. As for other autoimmune diseases, female preponderance is common in MS and NMOSD. However, sex distribution in MOGAD seems equal. As in MS, immunotherapy in NMOSD and MOGAD is crucial to prevent further disease activity. Therefore, we assessed data on sex differences of the currently licensed disease-modifying treatments for efficacy and safety. This topic seems widely neglected with only fragmented information resulting from post-hoc analyses of clinical trials or real-world post-marketing studies afflicted with lacking power and/or inherent sources of bias. In summary, biological hypotheses of sex differences including genetic factors, the constitution of the immune system and hormonal influences are based upon human and preclinical data, especially for the paradigmatic disease of MS whereas specific data for NMOSD and MOGAD are widely lacking. Epidemiological and clinical differences between men and women are well described for MS and to some extent for NMOSD, yet, with remaining contradictory findings. MOGAD needs further detailed investigation. Sex-specific analyses of safety and efficacy of long-term immunotherapies need to be addressed in future studies designed and powered to answer the pressing questions and to optimize and individualize treatment.
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Affiliation(s)
- Lara Diem
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Helly Hammer
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Robert Hoepner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Max Pistor
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Jana Remlinger
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland; Department of Biomedical Research and Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Anke Salmen
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland.
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Ostrem BL, Anderson A, Conway S, Healy BC, Oh J, Jacobs D, Dobson R, Graham EL, Sadovnick AD, Zimmerman V, Liu Y, Bove R, Houtchens M. Peripartum disease activity in moderately and severely disabled women with multiple sclerosis. Mult Scler J Exp Transl Clin 2022; 8:20552173221104918. [PMID: 35734229 PMCID: PMC9208060 DOI: 10.1177/20552173221104918] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 05/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background The effects of pregnancy on multiple sclerosis (MS) inflammatory activity are not well described in women with moderate to severe disabilities. Objective To quantify the peripartum annualized relapse rate (ARR) in women with MS with an Expanded Disability Status Scale (EDSS) ≥ 3. Methods We performed a retrospective cohort study of 85 pregnancies in 74 subjects with preconception EDSS ≥ 3. We quantified peripartum ARR and tested for risk factors predictive of peripartum relapses, postpartum brain magnetic resonance imaging activity (new T2 or gadolinium-enhancing lesions), and disability worsening. Results There were 74 live births, with a 56% operative delivery rate. In subjects with relapsing-remitting MS, ARR decreased to 0.11 during the third trimester of pregnancy compared to 0.59 in the year preconception and increased to 1.22 in the 3 months postpartum. Women with a higher preconception EDSS had higher odds of postpartum relapses and clinically significant worsening of disability as compared to subjects with a lower EDSS. Conclusions Moderately to severely disabled women with MS have a lower risk of relapse during pregnancy as compared to preconception, followed by a marked increase postpartum. Further studies are needed to identify ways to reduce peripartum inflammatory activity and disability progression in women with MS with moderate to severe disability.
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Affiliation(s)
- Bridget LaMonica Ostrem
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Annika Anderson
- Department of Neurology, University of California, San Francisco, CA, USA
| | | | - Brian C Healy
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jiwon Oh
- Division of Neurology, Department of Medicine, St. Michaels Hospital, University of Toronto, Toronto, Canada
| | - Dina Jacobs
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Neuroinflammation and Experimental Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | | | - A Dessa Sadovnick
- Departments of Neurology and Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Vanessa Zimmerman
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Neuroinflammation and Experimental Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Yanqing Liu
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Riley Bove
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Maria Houtchens
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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5
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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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Scime NV, Lee S, Jain M, Metcalfe A, Chaput KH. A Scoping Review of Breastfeeding in Women with Chronic Diseases. Breastfeed Med 2021; 16:851-862. [PMID: 34319788 DOI: 10.1089/bfm.2021.0129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Approximately 10-20% of mothers have a chronic disease. Studies on breastfeeding in women with chronic disease span multiple disciplines, and these have not been collated to synthesize knowledge and identify gaps. The objective of this review was to summarize published literature on breastfeeding in women with chronic disease. Methods: We conducted a scoping review of original research and systematic reviews identified in Medline, EMBASE, and CINAHL (1990-2019) and by hand searching on women with chronic diseases reporting on at least one breastfeeding-related topic. Conference abstracts, case-studies, and studies on pregnancy-induced conditions or lactation pharmacology were excluded. Content analysis and narrative synthesis were used to analyze findings. Results: We identified 128 articles that were predominantly quantitative (80.5%), conducted in Europe or North America (65.6%), analyzed sample sizes of <200 (57.0%), and published from 2010 onward (68.8%). Diabetes (42.2%), multiple sclerosis (MS; 19.5%), and epilepsy (13.3%) were the most common diseases studied. Breastfeeding was a primary focus in approximately half (53.1%) of the articles, though definitions were infrequently reported (32.8%). The most-studied topics were breastfeeding duration/exclusivity (55.7%), reasons for feeding behavior (19.1%), and knowledge and attitudes about breastfeeding (18.3%). Less studied topics (<10% of articles each) included milk expression behaviors, breastfeeding difficulties, and feeding supports. Conclusions: Existing literature focuses primarily on diabetes or MS, and breastfeeding behaviors and outcomes. Further research examining a broader range of chronic diseases, with large sample sizes, and sufficient breastfeeding measurement detail can improve our understanding of breastfeeding disparities in this population.
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Affiliation(s)
- Natalie V Scime
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Sangmin Lee
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Mandakini Jain
- Undergraduate Medical Education Program, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Amy Metcalfe
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Undergraduate Medical Education Program, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Obstetrics and Gynaecology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Kathleen H Chaput
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Obstetrics and Gynaecology, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Ahmed AM, Reda MABMG, Elsheshiny AH. Outcomes of pregnancy in Egyptian women with multiple sclerosis in the new treatment era: a multi-center retrospective observational study. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00386-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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8
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Abstract
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.
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Affiliation(s)
- Borros M Arneth
- Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, Universitatsklinikum Giessen und Marburg GmbH, Giessen, Germany
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9
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Simone IL, Tortorella C, Ghirelli A. Influence of Pregnancy in Multiple Sclerosis and Impact of Disease-Modifying Therapies. Front Neurol 2021; 12:697974. [PMID: 34276545 PMCID: PMC8280312 DOI: 10.3389/fneur.2021.697974] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/26/2021] [Indexed: 01/25/2023] Open
Abstract
Purpose of this Review: This article is a systematic review on the influence pregnancy has on multiple sclerosis and the resulting impact of disease-modifying therapies. Findings: Multiple sclerosis predominantly affects young women with a clinical onset most often during the child-bearing age. The impact of multiple sclerosis and disease-modifying therapies on fertility, pregnancy, fetal outcome, and breastfeeding is a pivotal topic when it comes to clinical practice. The introduction of disease-modifying therapies has changed not only the natural history of the disease but also the perspective of pregnancy in women with multiple sclerosis. Family planning requires careful consideration, especially because many disease-modifying drugs are contraindicated during pregnancy. In this article, we review current evidence collected from published literature and drug-specific pregnancy registers on the use of disease-modifying therapies. Additionally, we discuss safety profiles for each drug and correlate them to both risk for the exposed fetus and risk for the mothers interrupting treatments when seeking pregnancy.
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Affiliation(s)
- Isabella Laura Simone
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Carla Tortorella
- Department of Neurosciences, San Camillo-Forlanini Hospital, Rome, Italy
| | - Alma Ghirelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
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10
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Alhomoud MA, Khan AS, Alhomoud I. The Potential Preventive Effect of Pregnancy and Breastfeeding on Multiple Sclerosis. Eur Neurol 2021; 84:71-84. [PMID: 33744881 DOI: 10.1159/000514432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/09/2021] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Mohsen Ali Alhomoud
- Department of Public Health, Ministry of Health, Eastern Province, Al Qatif, Saudi Arabia,
| | - Abdul Sattar Khan
- Family and Community Medicine Department, King Faisal University, Eastern Province, Al Ahsa, Saudi Arabia
| | - Iftetah Alhomoud
- Neurosciences Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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11
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Krysko KM, Rutatangwa A, Graves J, Lazar A, Waubant E. Association Between Breastfeeding and Postpartum Multiple Sclerosis Relapses: A Systematic Review and Meta-analysis. JAMA Neurol 2021; 77:327-338. [PMID: 31816024 DOI: 10.1001/jamaneurol.2019.4173] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Multiple sclerosis (MS) relapses may be increased in the postpartum period, and whether breastfeeding is associated with reduction in the risk of postpartum relapses remains controversial. Objective To perform a systematic review and meta-analysis to evaluate whether breastfeeding is associated with reduction in postpartum MS relapses compared with not breastfeeding. Data Sources PubMed and Embase were searched for studies assessing the association between breastfeeding and MS disease activity published between January 1, 1980, and July 11, 2018, as well as reference lists of selected articles. Study Selection All study designs assessing the association between breastfeeding and postpartum relapses in MS relative to a comparator group were included. Data Extraction and Synthesis Study eligibility assessment and extraction of study characteristics, methods, and outcomes, were performed independently by 2 reviewers following PRISMA guidelines. Risk of bias was evaluated by 2 independent reviewers with the ROBINS-I tool for nonrandomized, interventional studies. Findings from studies with data available for the number of women with postpartum relapses in the breastfeeding and nonbreastfeeding groups were combined with a random-effects model. Main Outcomes and Measures Postpartum MS relapse. Results The search identified 462 unique citations, and 24 (2974 women) satisfied eligibility criteria and were included, of which 16 were included in the quantitative meta-analysis. The pooled summary odds ratio for the association of breastfeeding with postpartum relapses was 0.63 (95% CI, 0.45-0.88; P = .006) compared with a reference of nonbreastfeeding. Pooled adjusted hazard ratio across 4 studies that reported this finding was 0.57 (95% CI, 0.38-0.85; P = .006). There was moderate heterogeneity (I2 = 48%), which was explained by variable prepregnancy relapse rate, postpartum follow-up duration, and the publication year. A stronger association was seen in studies of exclusive rather than nonexclusive breastfeeding, although both demonstrated an association. Studies were rated at moderate and serious risk of bias, with concern for residual confounding, although sensitivity analysis including only moderate quality studies was consistent with a protective outcome of breastfeeding. Conclusions and Relevance These findings suggest that breastfeeding is protective against postpartum relapses in MS, although high-quality prospective studies to date are limited and well-designed observational studies that aim to emulate a randomized trial would be of benefit.
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Affiliation(s)
- Kristen M Krysko
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco
| | - Alice Rutatangwa
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco
| | - Jennifer Graves
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco.,Department of Neurology, University of California, San Diego
| | - Ann Lazar
- Preventive & Restorative Dental Sciences, University of California, San Francisco
| | - Emmanuelle Waubant
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco
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12
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Modrego PJ, Urrea MA, de Cerio LD. The effects of pregnancy on relapse rates, disability and peripartum outcomes in women with multiple sclerosis: a systematic review and meta-analysis. J Comp Eff Res 2021; 10:175-186. [PMID: 33565886 DOI: 10.2217/cer-2020-0211] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Pedro J Modrego
- Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Leyre Diaz de Cerio
- Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain
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13
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Krysko KM, Graves JS, Dobson R, Altintas A, Amato MP, Bernard J, Bonavita S, Bove R, Cavalla P, Clerico M, Corona T, Doshi A, Fragoso Y, Jacobs D, Jokubaitis V, Landi D, Llamosa G, Longbrake EE, Maillart E, Marta M, Midaglia L, Shah S, Tintore M, van der Walt A, Voskuhl R, Wang Y, Zabad RK, Zeydan B, Houtchens M, Hellwig K. Sex effects across the lifespan in women with multiple sclerosis. Ther Adv Neurol Disord 2020; 13:1756286420936166. [PMID: 32655689 PMCID: PMC7331774 DOI: 10.1177/1756286420936166] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune inflammatory demyelinating central nervous system disorder that is more common in women, with onset often during reproductive years. The female:male sex ratio of MS rose in several regions over the last century, suggesting a possible sex by environmental interaction increasing MS risk in women. Since many with MS are in their childbearing years, family planning, including contraceptive and disease-modifying therapy (DMT) counselling, are important aspects of MS care in women. While some DMTs are likely harmful to the developing fetus, others can be used shortly before or until pregnancy is confirmed. Overall, pregnancy decreases risk of MS relapses, whereas relapse risk may increase postpartum, although pregnancy does not appear to be harmful for long-term prognosis of MS. However, ovarian aging may contribute to disability progression in women with MS. Here, we review sex effects across the lifespan in women with MS, including the effect of sex on MS susceptibility, effects of pregnancy on MS disease activity, and management strategies around pregnancy, including risks associated with DMT use before and during pregnancy, and while breastfeeding. We also review reproductive aging and sexual dysfunction in women with MS.
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Affiliation(s)
- Kristen M Krysko
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, 675 Nelson Rising Lane, Suite 221, San Francisco, CA 94158, USA
| | - Jennifer S Graves
- Department of Neurosciences, University of California San Diego, UCSD ACTRI, La Jolla, CA, USA
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Preventive Neurology, Queen Mary University of London, London, UK
| | - Ayse Altintas
- Department of Neurology, School of Medicine, Koc University, Istanbul, Turkey
| | - Maria Pia Amato
- Department NEUROFARBA, Section of Neurosciences, University of Florence, Florence, Italy
| | - Jacqueline Bernard
- Department of Neurology, Oregon Health Science University, Portland, OR, USA
| | - Simona Bonavita
- Department of Advanced Medical and Surgical Sciences, University of Campania, "Luigi Vanvitelli", Naples, Italy
| | - Riley Bove
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco CA, USA
| | - Paola Cavalla
- Department of Neuroscience and Mental Health, City of Health and Science University Hospital of Torino, Turin, Italy
| | - Marinella Clerico
- Department of Clinical and Biological Sciences, University of Torino, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Teresa Corona
- Clinical Laboratory of Neurodegenerative Disease, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Anisha Doshi
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, University College London (UCL) Institute of Neurology, London, UK
| | - Yara Fragoso
- Multiple Sclerosis & Headache Research Institute, Santos, SP, Brazil
| | - Dina Jacobs
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Vilija Jokubaitis
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia
| | - Doriana Landi
- Department of Systems Medicine, Multiple Sclerosis Center and Research Unit, Tor Vergata University and Hospital, Rome, Italy
| | | | | | | | - Monica Marta
- Neurosciences and Trauma Centre, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Luciana Midaglia
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Suma Shah
- Department of Neurology, Duke University, Durham, NC, USA
| | - Mar Tintore
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Rhonda Voskuhl
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
| | - Yujie Wang
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Rana K Zabad
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Burcu Zeydan
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Maria Houtchens
- Department of Neurology, Partners MS Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Liguori NF, Alonso R, Pinheiro AA, Balbuena ME, Barboza A, Bestoso S, Burgos M, Cáceres F, Carnero Contentti E, Carrá A, Cristiano E, Curbelo MC, Deri N, Fiol M, Gaitán MI, Garcea O, Halfon M, Hryb J, Jacobo M, José G, Knorre E, López P, Luetic G, Mainella C, Martínez A, Miguez J, Nofal P, Pagani Cassará F, Marcilla MP, Piedrabuena R, Pita C, Quarracino C, Rojas JI, Silva B, Sinay V, Steinberg J, Tarulla A, Tavolini D, Tkachuk V, Tizio S, Villa A, Vrech C, Ysrraelit C, Patrucco L. Consensus recommendations for family planning and pregnancy in multiple sclerosis in argentina. Mult Scler Relat Disord 2020; 43:102147. [PMID: 32442883 DOI: 10.1016/j.msard.2020.102147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/30/2020] [Accepted: 04/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is the most common chronic immune-mediated neurological disorder in young adults, more frequently found in women than in men. Therefore, pregnancy-related issues have become an object of concern for MS professionals and patients. The aim of this work was to review the existing data to develop the first Argentine consensus for family planning and pregnancy in MS patients. METHODS A panel of expert neurologists from Argentina engaged in the diagnosis and care of MS patients met both virtually and in person during 2019 to carry out a consensus recommendation for family planning and pregnancy in MS. To achieve consensus, the procedure of the "formal consensus-RAND/UCLA method" was used. RESULTS Recommendations were established based on published evidence and expert opinion focusing on pre-pregnancy counseling, pregnancy, and postpartum issues. CONCLUSION The recommendations of these consensus guidelines are intended to optimize the management and treatment of MS patients during their reproductive age in Argentina.
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Affiliation(s)
- Nora Fernández Liguori
- Hospital Universitario Sanatorio Güemes, Buenos Aires, Argentina; Sección Neurología, Hospital Enrique Tornú, Buenos Aires, Argentina.
| | - Ricardo Alonso
- Hospital Universitario Sanatorio Güemes, Buenos Aires, Argentina; Centro Universitario de Esclerosis Múltiple, Hospital Dr. J. M. Ramos Mejía, Buenos Aires, Argentina
| | | | - María E Balbuena
- Sección de Neuroinmunología y Enfermedades Desmielinizantes, Servicio de Neurología, Hospital de Clínicas José de San Martín, Argentina
| | | | | | | | | | | | - Adriana Carrá
- Fundación Favaloro/INECO, Buenos Aires, Argentina; MS Section Hospital Británico, Buenos Aires, Argentina
| | | | | | - Norma Deri
- Centro de Investigaciones Diabaid, Argentina; Hospital Fernández de Buenos Aires, Argentina
| | - Marcela Fiol
- Department of Neurology, Institute for Neurological Research Dr Raul Carrea, FLENI, Argentina
| | - María I Gaitán
- Department of Neurology, Institute for Neurological Research Dr Raul Carrea, FLENI, Argentina
| | - Orlando Garcea
- Centro Universitario de Esclerosis Múltiple, Hospital Dr. J. M. Ramos Mejía, Buenos Aires, Argentina
| | | | - Javier Hryb
- Servicio de Neurología, Hospital Carlos G. Durand, CABA
| | - Miguel Jacobo
- RIAPEM (Red Integral Asistencial al Paciente con EM), Santiago del Estero, Argentina
| | - Gustavo José
- Servicio de Neurología, Hospital Ángel Padilla, Tucumán, Argentina
| | - Eduardo Knorre
- Servicio de Neurología, Hospital Teodoro Álvarez, Buenos Aires, Argentina
| | - Pablo López
- Department of Neuroscience - Neuroimmunology Unit, Hospital Alemán, Buenos Aires, Argentina
| | | | | | | | | | - Pedro Nofal
- Hospital de Clínicas Ntra. Sra. del Carmen, San Miguel de Tucumán, Argentina
| | | | | | | | - Cecilia Pita
- Centro Universitario de Esclerosis Múltiple, Hospital Dr. J. M. Ramos Mejía, Buenos Aires, Argentina
| | - Cecilia Quarracino
- Departamento de neurología, Instituto de Investigaciones Médicas Alfredo Lanari
| | - Juan I Rojas
- Centro de Esclerosis Múltiple de Buenos Aires, Argentina
| | - Berenice Silva
- Centro Universitario de Esclerosis Múltiple, Hospital Dr. J. M. Ramos Mejía, Buenos Aires, Argentina
| | | | | | - Adriana Tarulla
- Hospital de Agudos Parmenio Piñero, Municipalidad de Ciudad de Buenos Aires, MCBA, Argentina
| | - Darío Tavolini
- INECO Neurociencias Oroño. Fundación INECO Rosario, Argentina
| | - Verónica Tkachuk
- Sección de Neuroinmunología y Enfermedades Desmielinizantes, Servicio de Neurología, Hospital de Clínicas José de San Martín, Argentina
| | - Santiago Tizio
- Departamento de Neurología, Hospital Italiano y Español de La Plata, Argentina
| | - Andrés Villa
- Sección Neuroinmunología, Hospital Ramos Mejía, Buenos Aires, Argentina
| | - Carlos Vrech
- Departamento de Enfermedades desmielinizantes, Sanatorio Allende Córdoba, Argentina
| | - Célica Ysrraelit
- Department of Neurology, Institute for Neurological Research Dr Raul Carrea, FLENI, Argentina
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15
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Effect of pregnancy and exclusive breastfeeding on multiple sclerosis relapse rate and degree of disability within two years after delivery. Clin Neurol Neurosurg 2020; 194:105829. [PMID: 32305825 DOI: 10.1016/j.clineuro.2020.105829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 03/28/2020] [Accepted: 04/02/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Pregnancy and lactation are important issues for women with multiple sclerosis (MS). The purpose of this study was to investigate the effect of pregnancy and exclusive breastfeeding on the rate of relapse and degree of disability within two years after delivery among patients with relapsing remitting multiple sclerosis (RRMS). PATIENTS AND METHODS 30 pregnant women with RRMS who had exclusive breastfeeding for 4 months were compared with 67 non-pregnant women with RRMS between 2012 and 2017. Each patient was examined every three months for 33 months. In the study group, patients were examined at the beginning of pregnancy, and then every three months till 24th months after delivery. RESULTS In the study group, Expanded Disability Status Scale (EDSS) during the third trimester of pregnancy, between four to nine month after delivery, and the last 6 months of the study were significantly lower than the control group (p < 0.05). At the end of the study, the mean EDSS of the study group was significantly lower than the control group (p < 0.05). Also, EDSS during the second and third trimesters of pregnancy were significantly lower than the EDSS before pregnancy (p < 0.05). The mean number of relapses in the second and third trimesters of pregnancy, between four to six months after delivery, and the total number of relapses were significantly lower than the control group. CONCLUSION Pregnancy and exclusive breastfeeding can have a positive effect in reducing relapse rate and disability. This effect will continue until the 24th month after childbirth.
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16
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Langer-Gould A, Smith JB, Albers KB, Xiang AH, Wu J, Kerezsi EH, McClearnen K, Gonzales EG, Leimpeter AD, Van Den Eeden SK. Pregnancy-related relapses and breastfeeding in a contemporary multiple sclerosis cohort. Neurology 2020; 94:e1939-e1949. [PMID: 32284359 DOI: 10.1212/wnl.0000000000009374] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 11/27/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether women with multiple sclerosis (MS) diagnosed according to current criteria are at an increased risk of postpartum relapses and to assess whether this risk is modified by breastfeeding or MS disease-modifying therapies (DMTs), we examined the electronic health records (EHRs) of 466 pregnancies among 375 women with MS and their infants. METHODS We used prospectively collected information from the EHR at Kaiser Permanente Southern and Northern California between 2008 and 2016 of the mother and infant to identify treatment history, breastfeeding, and relapses. Multivariable models accounting for measures of disease severity were used. RESULTS In the postpartum year, 26.4% relapsed, 87% breastfed, 36% breastfed exclusively for at least 2 months, and 58.8% did not use DMTs. At pregnancy onset, 67.2% had suboptimally controlled disease. Annualized relapse rates (ARRs) declined from 0.37 before pregnancy to 0.14-0.07 (p < 0.0001) during pregnancy, but in the postpartum period, we did not observe any rebound disease activity. The ARR was 0.27 in the first 3 months postpartum, returning to prepregnancy rates at 4-6 months (0.37). Exclusive breastfeeding reduced the risk of early postpartum relapses (adjusted hazard ratio = 0.37, p = 0.009), measures of disease severity increased the risk, and resuming modestly effective DMTs had no effect (time-dependent covariate, p = 0.62). CONCLUSION Most women diagnosed with MS today can have children without incurring an increased risk of relapses. Women with suboptimal disease control before pregnancy may benefit from highly effective DMTs that are compatible with pregnancy and lactation. Women with MS should be encouraged to breastfeed exclusively.
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Affiliation(s)
- Annette Langer-Gould
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA.
| | - Jessica B Smith
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Kathleen B Albers
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Anny H Xiang
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Jun Wu
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Erica H Kerezsi
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Keeli McClearnen
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Edlin G Gonzales
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Amethyst D Leimpeter
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
| | - Stephen K Van Den Eeden
- From the Department of Neurology (A.L.-G.), Southern California Permanente Medical Group, Los Angeles Medical Center; Department of Research & Evaluation (J.B.S., A.H.X., J.W., E.G.G.), Kaiser Permanente Southern California; and Division of Research (K.B.A., E.H.K., K.M., A.D.L., S.K.V.D.E.), Kaiser Permanente Northern California, Los Angeles, CA
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17
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Deems NP, Leuner B. Pregnancy, postpartum and parity: Resilience and vulnerability in brain health and disease. Front Neuroendocrinol 2020; 57:100820. [PMID: 31987814 PMCID: PMC7225072 DOI: 10.1016/j.yfrne.2020.100820] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/25/2019] [Accepted: 01/21/2020] [Indexed: 02/07/2023]
Abstract
Risk and resilience in brain health and disease can be influenced by a variety of factors. While there is a growing appreciation to consider sex as one of these factors, far less attention has been paid to sex-specific variables that may differentially impact females such as pregnancy and reproductive history. In this review, we focus on nervous system disorders which show a female bias and for which there is data from basic research and clinical studies pointing to modification in disease risk and progression during pregnancy, postpartum and/or as a result of parity: multiple sclerosis (MS), depression, stroke, and Alzheimer's disease (AD). In doing so, we join others (Shors, 2016; Galea et al., 2018a) in aiming to illustrate the importance of looking beyond sex in neuroscience research.
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Affiliation(s)
- Nicholas P Deems
- The Ohio State University, Department of Psychology, Columbus, OH, USA
| | - Benedetta Leuner
- The Ohio State University, Department of Psychology, Columbus, OH, USA.
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18
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Domperidone-induced elevation of serum prolactin levels and immune response in multiple sclerosis. J Neuroimmunol 2019; 334:576974. [PMID: 31174092 DOI: 10.1016/j.jneuroim.2019.576974] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/17/2019] [Accepted: 05/28/2019] [Indexed: 12/21/2022]
Abstract
Increasing systemic prolactin levels improves remyelination and neuronal survival in animal models of Multiple Sclerosis (MS), but it has been suggested that this therapeutic strategy may also increase inflammatory responses, and potentially harm patients. We analyzed serum prolactin and cytokine, chemokine and growth factor levels in sera from MS patients enrolled in two clinical trials who were treated with domperidone, a generic drug that increases systemic prolactin levels. In patients treated with domperidone, molecule levels changed little during follow up, while prolactin levels increased several-fold. We found no significant association between prolactin levels and radiological or clinical outcome.
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19
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Zuluaga MI, Otero-Romero S, Rovira A, Perez-Hoyos S, Arrambide G, Negrotto L, Galán I, Río J, Comabella M, Nos C, Arévalo MJ, Vidal-Jordana A, Castilló J, Rodríguez B, Midaglia L, Mulero P, Mitjana R, Auger C, Sastre-Garriga J, Montalban X, Tintoré M. Menarche, pregnancies, and breastfeeding do not modify long-term prognosis in multiple sclerosis. Neurology 2019; 92:e1507-e1516. [PMID: 30824557 PMCID: PMC6453769 DOI: 10.1212/wnl.0000000000007178] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 11/21/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the effect of menarche, pregnancies, and breastfeeding on the risk of developing multiple sclerosis (MS) and disability accrual using a multivariate approach based on a large prospective cohort of patients with clinically isolated syndrome (CIS). METHODS A cross-sectional survey of the reproductive information of female participants in a CIS cohort was performed. We examined the relationship of age at menarche with the risk of clinically definite MS (CDMS), McDonald 2010 MS, and Expanded Disability Status Scale (EDSS) 3.0 and 6.0. The effect of pregnancy (before and after CIS) and breastfeeding in the risk of CDMS, McDonald 2010 MS, and EDSS 3.0 was also examined. Univariate and multivariate analyses were performed and findings were confirmed using sensitivity analyses and a propensity score model. RESULTS The data of 501 female participants were collected. Age at menarche did not correlate with age at CIS and was not associated with the risk of CDMS or EDSS 3.0 or 6.0. Pregnancy before CIS was protective for CDMS in the univariate analysis, but the effect was lost in the multivariate model and did not modify the risk of EDSS 3.0. Pregnancy after CIS was protective for both outcomes in univariate and multivariate analyses when pregnancy was considered a baseline variable, but the protective effect disappeared when analyzed as a time-dependent event. Breastfeeding did not modify the risk for the 3 outcomes. CONCLUSIONS These results demonstrate that menarche, pregnancies, and breastfeeding did not substantially modify the risk of CDMS or disability accrual using a multivariable and time-dependent approach.
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Affiliation(s)
- María I Zuluaga
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Susana Otero-Romero
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Alex Rovira
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Santiago Perez-Hoyos
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Georgina Arrambide
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Laura Negrotto
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Ingrid Galán
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Jordi Río
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Manuel Comabella
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Carlos Nos
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - María Jesús Arévalo
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Angela Vidal-Jordana
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Joaquin Castilló
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Breogán Rodríguez
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Luciana Midaglia
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Patricia Mulero
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Raquel Mitjana
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Cristina Auger
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Jaume Sastre-Garriga
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Xavier Montalban
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada
| | - Mar Tintoré
- From the Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.I.Z., S.O.-R., G.A., L.N., I.G., J.R., M.C., C.N., M.J.A., A.V.-J., J.C., B.R., L.M., P.M., J.S.-G., X.M., M.T.), and Unitat de RM, Servei de Radiologia (M.I.Z., A.R., L.N., R.M., C.A., X.M.), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona; Unitat d'Estadística i Bioinformàtica (UEB) (M.I.Z., S.P.-H., L.N., X.M.), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Servicio de Neurología (M.I.Z., L.N., X.M.), Instituto Neurológico de Colombia, Medellín, Colombia; Raul Carrea Institute for Neurological Research (L.N., X.M.), FLENI, Buenos Aires, Argentina; and Division of Neurology (X.M.), St. Michael's Hospital, University of Toronto, Canada.
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Portaccio E, Amato MP. Breastfeeding and post-partum relapses in multiple sclerosis patients. Mult Scler 2019; 25:1211-1216. [PMID: 30793658 DOI: 10.1177/1352458519830588] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
While it is acknowledged that exclusive breastfeeding has well-established benefits for both infant/child and mother health, evidence on the relationships between breastfeeding and disease course in women with multiple sclerosis (MS) is still controversial. On one hand, in the post-partum period, a disease worsening is possible, particularly in women with more active MS. On the other hand, the use of disease modifying drugs is currently contraindicated during lactation. In this topical review, we describe available evidence on the relationship between breastfeeding and disease activity in MS. In some studies, a possible protective role for exclusive breastfeeding against the risk of post-partum relapse has been suggested, while, in others, its impact was neutral. Waiting for definitive evidence on this topic, we propose a pragmatic approach to breastfeeding choice, on a case-by-case basis, considering the disease characteristics before and during pregnancy and the patient therapeutic history.
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Affiliation(s)
- Emilio Portaccio
- SOC Neurologia - Firenze, Azienda USL Toscana Centro, Florence, Italy
| | - Maria Pia Amato
- Section of Neurosciences, Department of NEUROFARBA, University of Florence, Florence, Italy/IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
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Ysrraelit MC, Correale J. Impact of sex hormones on immune function and multiple sclerosis development. Immunology 2019; 156:9-22. [PMID: 30222193 PMCID: PMC6283654 DOI: 10.1111/imm.13004] [Citation(s) in RCA: 121] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/25/2018] [Accepted: 09/05/2018] [Indexed: 12/20/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system (CNS) affecting young people and leading to demyelination and neurodegeneration. The disease is clearly more common in women, in whom incidence has been rising. Gender differences include: earlier disease onset and more frequent relapses in women; and faster progression and worse outcomes in men. Hormone-related physiological conditions in women such as puberty, pregnancy, puerperium, and menopause also exert significant influence both on disease prevalence as well as on outcomes. Hormonal and/or genetic factors are therefore believed to be involved in regulating the course of disease. In this review, we discuss clinical evidence for the impact of sex hormones (estrogens, progesterone, prolactin, and testosterone) on MS and attempt to elucidate the hormonal and immunological mechanisms potentially underlying these changes. We also review current knowledge on the relationship between sex hormones and resident CNS cells and provide new insights in the context of MS. Understanding these molecular mechanisms may contribute to the development of new and safer treatments for both men and women.
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Affiliation(s)
- María C. Ysrraelit
- Department of NeurologyRaúl Carrea Institute for Neurological Research (FLENI)Buenos AiresArgentina
| | - Jorge Correale
- Department of NeurologyRaúl Carrea Institute for Neurological Research (FLENI)Buenos AiresArgentina
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22
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Bsteh G, Algrang L, Hegen H, Auer M, Wurth S, Di Pauli F, Deisenhammer F, Berger T. Pregnancy and multiple sclerosis in the DMT era: A cohort study in Western Austria. Mult Scler 2018; 26:69-78. [PMID: 30507345 DOI: 10.1177/1352458518816614] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) predominantly affects women of child-bearing potential. Pregnancy in MS is still a controversial issue lacking standardized treatment recommendations. OBJECTIVE To examine the reciprocal effects of pregnancy, MS, and disease-modifying treatment (DMT). METHODS We analyzed 387 pregnancies in 239 women with relapsing remitting multiple sclerosis (RRMS) and ⩾1 pregnancy, establishment of diagnosis >1 year before conception, and ⩾2 years of follow-up after delivery. Relapse rates and Expanded Disability Status Scale (EDSS) scores were compared in the year before conception, during pregnancy, and 2 years postpartum. Binary logistic regression was used to investigate predictors of risk for relapses and disability progression during pregnancy and postpartum. RESULTS Risk of relapse and disability progression during pregnancy was predicted by pre-conception relapse activity, higher EDSS score at conception, use of highly effective disease-modifying treatment (H-DMT) pre-conception, and prolonged washout period. Postpartum relapse and disability progression was associated with relapse activity pre-conception and during pregnancy and use of H-DMT pre-conception. Early restart of DMT reduced the risk of postpartum relapse. CONCLUSION A personalized approach in planning pregnancy in women with MS while on H-DMT needs to be adopted. It seems reasonable maintaining natalizumab closer to conception and restarting the drug early postpartum to reduce the considerable risk of disease reactivation during early pregnancy and after delivery.
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Affiliation(s)
- Gabriel Bsteh
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Laura Algrang
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Harald Hegen
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Auer
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sebastian Wurth
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Di Pauli
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Deisenhammer
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Berger
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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McCombe PA. The Short and Long-Term Effects of Pregnancy on Multiple Sclerosis and Experimental Autoimmune Encephalomyelitis. J Clin Med 2018; 7:jcm7120494. [PMID: 30486504 PMCID: PMC6306813 DOI: 10.3390/jcm7120494] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/21/2018] [Accepted: 11/21/2018] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Pamela A McCombe
- The University of Queensland, Centre for Clinical Research, Brisbane, QLD 4029, Australia.
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Jesus-Ribeiro J, Correia I, Martins AI, Fonseca M, Marques I, Batista S, Nunes C, Macário C, Almeida MC, Sousa L. Pregnancy in Multiple Sclerosis: A Portuguese cohort study. Mult Scler Relat Disord 2017; 17:63-68. [PMID: 29055477 DOI: 10.1016/j.msard.2017.07.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/26/2017] [Accepted: 07/02/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pregnancy in Multiple Sclerosis (MS) has been a controversial issue, without international standardized treatment recommendations. The goal of our study was to evaluate the clinical course of MS during pregnancy and the respective therapeutic options, obstetrical outcomes and breastfeeding data. METHODS This was a retrospective study including women with a diagnosis of relapsing-remitting MS at least one year before pregnancy. Three periods were evaluated: one year prior to pregnancy, pregnancy and one year postpartum. Information acquired included demographic and disease activity data, treatment options, and obstetrical and breastfeeding data. RESULTS From a cohort of 1134 patients and 777 women, we included 127 pregnancies in 97 women (111 deliveries of a live infant, 11 spontaneous abortions, 3 fetal deaths and 2 voluntary abortions). The annualized relapse rate (ARR) decreased during pregnancy, mainly in the third trimester (prior to pregnancy 0.6 ± 0.8 vs. during pregnancy 0.3 ± 0.6, p = 0.006). There were no significant changes in the ARR in the year after delivery compared to baseline (0.6 ± 0.8 vs. 0.6 ± 0.8, p = 0.895). Patients with relapses in the postpartum period had a shorter disease duration at conception (5.4 ± 3.9 vs. 7.4 ± 4.7; p = 0.029) and breastfed less (53.5% vs. 72.1%, p = 0.046). In the multivariate analysis, relapses during pregnancy predicted postpartum relapses (OR = 4.9, p < 0.005). Neither the previous use of disease modifying therapy (DMT), given to 80.2% of women, nor breastfeeding, caesarean delivery (CD) or epidural analgesia (EA) had an impact on the presence of postpartum relapses. Compared to baseline, the Expanded Disability Status Scale (EDSS) increased in pregnancy and the postpartum period (1.6 ± 0.7 vs. 1.7 ± 0.9 vs. 2.1 ± 1.0, p < 0.001). CD was performed in 43.3% of patients, mainly because of fetal-pelvic incompatibility (35.7%) and EA was performed in 63.9%. The most frequent complications were restriction of fetal growth (4.5%) and gestational diabetes mellitus (3.6%). Concerning newborns, 6.4% had birth asphyxia and 6.1% low birth weight. No malformations were registered. CONCLUSION Despite a reduction in the relapse rate during pregnancy, the presence of relapses during pregnancy predicted postpartum relapses, with impact on disability. DMT appeared to have no influence on clinical or obstetrical outcome. MS did not have a deleterious effect on the pregnancy course. CD and EA were safe procedures, with a tendency towards CD in MS patients, compared to Portuguese women in general. Breastfeeding did not influence MS activity.
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Affiliation(s)
- Joana Jesus-Ribeiro
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Inês Correia
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Ana Inês Martins
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Manuel Fonseca
- Bissaya Barreto Maternity Hospital, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Inês Marques
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Sónia Batista
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Carla Nunes
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Carmo Macário
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Maria Céu Almeida
- Bissaya Barreto Maternity Hospital, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Lívia Sousa
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
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Costanza M, Pedotti R. Prolactin: Friend or Foe in Central Nervous System Autoimmune Inflammation? Int J Mol Sci 2016; 17:ijms17122026. [PMID: 27918427 PMCID: PMC5187826 DOI: 10.3390/ijms17122026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 11/19/2016] [Accepted: 11/28/2016] [Indexed: 12/26/2022] Open
Abstract
The higher prevalence of multiple sclerosis (MS) in females, along with the modulation of disease activity observed during pregnancy and the post-partum period, has suggested a hormonal influence in MS. Even if prolactin (PRL) does not belong to the sex hormones family, its crucial role in female reproduction and lactation has prompted great efforts to understand if PRL could represent a gender factor in the pathogenesis of MS and experimental autoimmune encephalomyelitis (EAE), the animal model for this disease. Extensive literature has documented a remarkable immune-stimulating potential for this hormone, indicating PRL as a disease-promoting factor in MS and EAE. However, recent work has pointed out that PRL is endowed with important neuroprotective and remyelinating properties and has encouraged a reinterpretation of the involvement of this hormone in MS. In this review we summarize both the protective functions that PRL exerts in central nervous system tissue as well as the inflammatory activity of this hormone in the context of autoimmune responses against myelin. Last, we draw future lines of research that might help to better clarify the impact of PRL on MS pathology.
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Affiliation(s)
- Massimo Costanza
- Department of Clinical Neuroscience, Neurological Institute Foundation IRCCS Carlo Besta, 20133 Milan, Italy.
| | - Rosetta Pedotti
- Department of Clinical Neuroscience, Neurological Institute Foundation IRCCS Carlo Besta, 20133 Milan, Italy.
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Pregnancy and multiple sclerosis: from molecular mechanisms to clinical application. Semin Immunopathol 2016; 38:709-718. [PMID: 27501960 DOI: 10.1007/s00281-016-0584-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 07/19/2016] [Indexed: 12/14/2022]
Abstract
Translational research generally refers to a "bench to bedside" approach where basic science discoveries in models move to clinical trials in humans. However, a "bedside to bench to bedside" approach may be more promising with respect to clinical relevance, since it starts with a clinical observation that can serve as a research paradigm to elucidate mechanisms and translate them back into novel therapeutic approaches. The effect of pregnancy on human autoimmune disorders in general, and multiple sclerosis (MS) in particular, serves as an intriguing example of how this can be used to understand disease pathobiology and discover new therapeutic targets. Disease activity in MS undergoes pronounced shifts in the time before, during, and after pregnancy. The most well-known and established example is a reduction in relapse rates in the last trimester by 70-80 %. However, disease activity reappears in the first few months after delivery, temporarily overshooting pre-pregnancy levels. This phenomenon has since its first description served as a model for investigating novel treatment options in animal models and has cumulated in successful phase 2a and 2b trials in female MS patients. However, recently, a number of other clinical observations have been made that might be similarly suitable to offer additional insights into pathobiological mechanisms of MS activity, progression, and possibly even incidence. Here, we outline the various changes in the clinical course of MS that have been described in relation to pregnancy, both short term and long term, and discuss how these may inform the development of novel treatments for autoimmune diseases.
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Shimizu Y, Makioka H, Harada N, Nakabayashi S, Saida T, Kira JI. Outcomes of pregnancy during interferon beta-1a therapy in Japanese patients with multiple sclerosis: Interim results of a postmarketing surveillance study. ACTA ACUST UNITED AC 2015. [DOI: 10.1111/cen3.12231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Yuko Shimizu
- Department of Neurology; Tokyo Women's Medical University School of Medicine; Tokyo Japan
| | | | | | | | - Takahiko Saida
- Department of Neurology; Kansai Multiple Sclerosis Center and Kyoto Min-iren Central Hospital; Kyoto Japan
| | - Jun-ichi Kira
- Department of Neurology; Neurological Institute; Graduate School of Medical Science; Kyushu University; Fukuoka Japan
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Sioka C, Fotopoulos A, Papakonstantinou S, Georgiou A, Pelidou SH, Kyritsis AP, Kalef-Ezra JA. The effect of menarche age, parity and lactation on bone mineral density in premenopausal ambulatory multiple sclerosis patients. Mult Scler Relat Disord 2015. [DOI: 10.1016/j.msard.2015.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Costanza M, Binart N, Steinman L, Pedotti R. Prolactin: A versatile regulator of inflammation and autoimmune pathology. Autoimmun Rev 2015; 14:223-30. [DOI: 10.1016/j.autrev.2014.11.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 11/08/2014] [Indexed: 12/20/2022]
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Fertility, pregnancy and childbirth in patients with multiple sclerosis: impact of disease-modifying drugs. CNS Drugs 2015; 29:207-20. [PMID: 25773609 DOI: 10.1007/s40263-015-0238-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
In recent decades, pregnancy-related issues in multiple sclerosis (MS) have received growing interest. MS is more frequent in women than in men and typically starts during child-bearing age. An increasing number of disease-modifying drugs (DMDs) for the treatment of MS are becoming available. Gathering information on their influences on pregnancy-related issues is of crucial importance for the counselling of MS patients. As for the immunomodulatory drugs (interferons and glatiramer acetate), accumulating evidence points to the relative safety of pregnancy exposure in terms of maternal and foetal outcomes. In case of higher clinical disease activity before pregnancy, these drugs could be continued until conception. As for the 'newer' drugs (fingolimod, natalizumab, teriflunomide, dimethyl fumarate and alemtuzumab), the information is more limited. Whereas fingolimod and teriflunomide are likely associated with an increased risk of foetal malformations, the effects of natalizumab, dimethyl fumarate and alemtuzumab still need to be ascertained. This article provides a review of the available information on the use of DMDs during pregnancy, with a specific focus on fertility, foetal development, delivery and breast-feeding.
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Borisow N, Paul F, Dörr J. Optimal management of multiple sclerosis during pregnancy: current perspectives. Degener Neurol Neuromuscul Dis 2014; 4:111-120. [PMID: 32669905 PMCID: PMC7337198 DOI: 10.2147/dnnd.s48618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 03/06/2014] [Indexed: 11/23/2022] Open
Abstract
Multiple sclerosis (MS) is a common inflammatory demyelinating disorder of the central nervous system. It frequently affects females in their reproductive phase of life. Therefore, family planning, pregnancy, and breastfeeding are important issues in the management of MS, particularly with respect to counseling and drug treatment. This paper reviews currently available data on the outcome of pregnancies in MS patients and the influence of pregnancy on the course of the disease. We give an update on the use of various disease-modifying MS drugs during pregnancy and breastfeeding. In addition to established therapies such as interferon-β, glatiramer acetate, natalizumab, and fingolimod, we also discuss the state of knowledge about new agents such as dimethyl fumarate, teriflunomide, and alemtuzumab in the context of pregnancy and breastfeeding.
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Affiliation(s)
- Nadja Borisow
- NeuroCure Clinical Research Center and Clinical and Experimental Research Center for Multiple Sclerosis, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Friedemann Paul
- NeuroCure Clinical Research Center and Clinical and Experimental Research Center for Multiple Sclerosis, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Dörr
- NeuroCure Clinical Research Center and Clinical and Experimental Research Center for Multiple Sclerosis, Charité – Universitätsmedizin Berlin, Berlin, Germany
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Portaccio E, Ghezzi A, Hakiki B, Sturchio A, Martinelli V, Moiola L, Patti F, Mancardi GL, Solaro C, Tola MR, Pozzilli C, De Giglio L, Totaro R, Lugaresi A, De Luca G, Paolicelli D, Marrosu MG, Comi G, Trojano M, Amato MP. Postpartum relapses increase the risk of disability progression in multiple sclerosis: the role of disease modifying drugs. J Neurol Neurosurg Psychiatry 2014; 85:845-50. [PMID: 24403285 DOI: 10.1136/jnnp-2013-306054] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess relapses, disability progression and the role of disease modifying drugs (DMDs) in the year after delivery in women with multiple sclerosis (MS). METHODS We prospectively followed-up pregnancies occurring between 2002 and 2008 in women with MS, recruited from 21 Italian MS centres. The risk of relapses and disability progression in the year after delivery was assessed using time-dependent Cox regression analysis. RESULTS 350 out of 423 pregnancies were assessed (pregnancies not resulting in live birth and with a postpartum follow-up period shorter than 1 year were excluded from the analysis). 148 patients (42.3%) had at least one relapse in the year after delivery. An Expanded Disability Status Scale (EDSS) score at conception ≥2.0 (HR=1.4; 95% CI 1.1 to 2.0; p=0.046) and a higher number of relapses before (HR=1.5; 95% CI 1.2 to 1.8; p<0.001) and during pregnancy (HR=2.3; 95% CI 1.6 to 3.4; p<0.001) were related to a higher risk of postpartum relapses. On the contrary, early DMD resumption after delivery marginally reduced the risk of postpartum relapses (HR=0.7, 95% CI 0.4 to 1.0; p=0.079). Moreover, 44/338 women progressed by at least one point on the EDSS. Disability progression was associated with a higher number of relapses before (HR=1.4, 95% CI 1.1 to 1.9; p=0.047) and after delivery (HR=2.7, 95% CI 1.4 to 5.2; p=0.002). CONCLUSIONS Our findings show an increased risk of postpartum relapses and disability accrual in women with higher disease activity before and during pregnancy. Since it may reduce the risk of postpartum relapses, early DMD resumption should be encouraged, particularly in patients with more active disease.
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Affiliation(s)
- Emilio Portaccio
- Department of NEUROFARBA, University of Florence, Florence, Italy
| | | | - Bahia Hakiki
- Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Andrea Sturchio
- Department of NEUROFARBA, University of Florence, Florence, Italy
| | | | - Lucia Moiola
- Scientific Institute University Vita-Salute San Raffaele, Milan, Italy
| | - Francesco Patti
- Department of Neurology, University of Catania, Catania, Italy
| | | | | | | | - Carlo Pozzilli
- Department of Neurology and Psychiatry, "La Sapienza" University, Rome, Italy
| | - Laura De Giglio
- Department of Neurology and Psychiatry, "La Sapienza" University, Rome, Italy
| | - Rocco Totaro
- Department of Neurology, University of L'Aquila, L'Aquila, Italy
| | - Alessandra Lugaresi
- Department of Neuroscience and Imaging, University "G. d'Annunzio" of Chieti, Chieti, Italy
| | - Giovanna De Luca
- Department of Neuroscience and Imaging, University "G. d'Annunzio" of Chieti, Chieti, Italy
| | | | - Maria Giovanna Marrosu
- Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy
| | - Giancarlo Comi
- Scientific Institute University Vita-Salute San Raffaele, Milan, Italy
| | - Maria Trojano
- Department of Neurology, University of Bari, Bari, Italy
| | - Maria Pia Amato
- Department of NEUROFARBA, University of Florence, Florence, Italy
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Oreja-Guevara C, Wiendl H, Kieseier BC, Airas L. Specific aspects of modern life for people with multiple sclerosis: considerations for the practitioner. Ther Adv Neurol Disord 2014; 7:137-49. [PMID: 24587828 DOI: 10.1177/1756285613501575] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic, debilitating, neurodegenerative disease that has a high impact on patients' quality of life. Individuals are often diagnosed in early adulthood and are faced with the difficulty of managing their lifestyle within the context of this chronic illness. Here we review factors that influence the disease course and the challenges that might be encountered when managing patients with MS. The majority of diagnosed patients are women of childbearing age, making pregnancy-related issues a key concern. MS typically stabilizes during pregnancy and evidence suggests that the disease has no impact on the risk of complications or outcomes. However, the effect of disease-modifying therapies on outcomes is less clear, and discontinuation of treatment prior to pregnancy or when breastfeeding is recommended. Awareness of genetic risk factors is important for patients planning a family, as several genes increase the risk of MS. Further aspects that require consideration include infections, vaccinations, environmental factors, surgery and the emergence of osteoporosis. Vaccinations are generally not a risk factor for MS and may be beneficial in terms of protection against infection and reducing the number of relapses. Environmental factors such as vitamin D deficiency, low exposure to sunlight, smoking and Epstein-Barr virus infection can all negatively influence the disease course. Furthermore, osteoporosis is generally higher in patients with MS than the general population, and the risk is increased by the environmental and genetic factors associated with the disease; bone mineral density should be assessed and smoking cessation and correction of serum vitamin D levels are recommended. Finally, as patients with MS are typically young, they are at low risk of surgery-related complications, although they should be carefully monitored postoperatively. Awareness of, and planning around, these factors may minimize the impact of the disease on patients' lifestyle.
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Affiliation(s)
- Celia Oreja-Guevara
- Department of Neurology, University Hospital San Carlos, IdISCC, Madrid, Spain
| | - Heinz Wiendl
- Department of Neurology, University of Münster, Münster, Germany
| | - Bernd C Kieseier
- Department of Neurology, Heinrich-Heine-University, Moorenstrasse 5, 40225 Düsseldorf, Germany
| | - Laura Airas
- Department of Neurology, University of Turku, Turku, Finland
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Vukusic S, Confavreux C. One can prevent post-partum MS relapses by exclusive breast feeding: no. Mult Scler 2014; 19:1565-6. [PMID: 24132001 DOI: 10.1177/1352458513503054] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Sandra Vukusic
- Service de Neurologie A and Fondation Eugène Devic EDMUS pour la Sclérose en Plaques, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, F-6977, France
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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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Ghezzi A, Annovazzi P, Portaccio E, Cesari E, Amato MP. Current recommendations for multiple sclerosis treatment in pregnancy and puerperium. Expert Rev Clin Immunol 2014; 9:683-91; quiz 692. [PMID: 23899239 DOI: 10.1586/1744666x.2013.811046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
As multiple sclerosis (MS) typically starts at about 30 years of age, and is twice more frequent in females than in males, women with MS frequently face issues related to pregnancy and to the effects of medications commonly used in MS treatment. In this review, the authors provide and summarize literature data addressing the effect of MS and its treatments on pregnancy, delivery, postpartum and conception. There is a strong evidence that relapses are fewer during pregnancy but more frequent during postpartum, and that IFN-β and glatiramer acetate do not expose patients and their babies to relevant adverse events; nevertheless, these drugs should be discontinued during pregnancy and before conception. However, if their preventive withdrawal exposes patients to a high risk of disease activity, these medications could be continued until proven conception. Little information is available on the effect of natalizumab and fingolimod.
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Affiliation(s)
- Angelo Ghezzi
- UO Neurologia 2 - Centro Studi Sclerosi Multipla, Ospedale di Gallarate, Via Pastori 4, 21013 Gallarate, Italy.
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What do healthcare providers advise women with multiple sclerosis regarding pregnancy? Mult Scler Int 2014; 2014:819216. [PMID: 24872893 PMCID: PMC3964846 DOI: 10.1155/2014/819216] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 01/14/2014] [Accepted: 02/01/2014] [Indexed: 11/21/2022] Open
Abstract
Pregnancy in multiple sclerosis (MS) is considered safe for both the woman and the child. Nevertheless, pregnancy issues in MS are complex both from a patient's and a provider's perspective. In an anonymous survey, 28 healthcare providers in the United States reported on the management of multiple sclerosis (MS) during pregnancy. Participants were asked about their recommendations to patients about the use of disease modifying therapies during pregnancy and breastfeeding and general recommendations about MS and pregnancy. Healthcare providers were also asked about sources from which they receive information about the management of patients with MS. Results suggested that healthcare providers do not discourage pregnancy for women with MS, recommend that women not use disease modifying therapies while pregnant, and have a positive view of breastfeeding for women with MS. Results also indicated the need for guidelines on patient management for pregnant women with MS.
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Avila-Ornelas J, Avila M, Stosic M, Robles L, Prieto PG, Hutton GJ, Rivera VM. The role of postpartum intravenous corticosteroids in the prevention of relapses in multiple sclerosis. Int J MS Care 2014; 13:91-3. [PMID: 24453710 DOI: 10.7224/1537-2073-13.2.91] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Multiple sclerosis (MS) is most prevalent in women of childbearing age. It is well established that the relapse rate decreases during pregnancy but increases significantly during the first postpartum trimester. The objective of this retrospective study was to evaluate the effectiveness of the administration of 1 g of intravenous methylprednisolone (IVMP) after delivery in the prevention of MS relapses. The study involved 47 women with one or more documented pregnancies; each pregnancy was treated as a separate case. There were 50 cases with relapsing-remitting MS and 2 with secondary progressive MS. The cases were divided into two groups: the IVMP group (those who received 1 g of IVMP after delivery) and the no-IVMP group (those who did not receive IVMP after delivery). There were 39 cases in the IVMP group and 13 in the no-IVMP group. During the first postpartum trimester, relapses occurred in 17.9% of the IVMP group, compared with 46.2% of the no-IVMP group (P = .0448). The difference in relapse percentage between the two groups during the second and third postpartum trimesters was not statistically significant. Our study shows a statistically significant benefit of postpartum IVMP administration in reducing MS relapses.
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Affiliation(s)
- Jose Avila-Ornelas
- Maxine Mesinger Multiple Sclerosis Comprehensive Care Center, Baylor College of Medicine, Houston, TX, USA
| | - Mirla Avila
- Maxine Mesinger Multiple Sclerosis Comprehensive Care Center, Baylor College of Medicine, Houston, TX, USA
| | - Milena Stosic
- Maxine Mesinger Multiple Sclerosis Comprehensive Care Center, Baylor College of Medicine, Houston, TX, USA
| | - Liliana Robles
- Maxine Mesinger Multiple Sclerosis Comprehensive Care Center, Baylor College of Medicine, Houston, TX, USA
| | - Pilar Guillermo Prieto
- Maxine Mesinger Multiple Sclerosis Comprehensive Care Center, Baylor College of Medicine, Houston, TX, USA
| | - George J Hutton
- Maxine Mesinger Multiple Sclerosis Comprehensive Care Center, Baylor College of Medicine, Houston, TX, USA
| | - Victor M Rivera
- Maxine Mesinger Multiple Sclerosis Comprehensive Care Center, Baylor College of Medicine, Houston, TX, 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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Costanza M, Musio S, Abou-Hamdan M, Binart N, Pedotti R. Prolactin is not required for the development of severe chronic experimental autoimmune encephalomyelitis. THE JOURNAL OF IMMUNOLOGY 2013; 191:2082-8. [PMID: 23885109 DOI: 10.4049/jimmunol.1301128] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Predominance of multiple sclerosis (MS) in women, reductions of disease flares during pregnancy, and their increase in the postpartum period have suggested a hormonal influence on MS activity. The hormone prolactin (PRL) has long been debated as a potential immune-stimulating factor in several autoimmune disorders, including MS and its animal model experimental autoimmune encephalomyelitis (EAE). However, to date, no data clearly ascribe a pathogenic role to PRL in these diseases. Using PRL receptor-deficient (Prlr(-/-)) and PRL-deficient (Prl(-/-)) mice, we show that PRL plays a redundant role in the development of chronic EAE. In Prlr(-/-) and Prl(-/-) mice, EAE developed with a delayed onset compared with littermate control mice, but with full clinical severity. In line with the clinical outcome, T cell proliferation and production of IFN-γ, IL-17A, and IL-6 induced by myelin Ag were delayed in Prlr(-/-) and Prl(-/-) mice. Ag-specific IgG Ab responses were not affected by PRLR or PRL deficiency. We also show that mouse lymph node cells and purified CD4(+) T cells express transcript for Prlr, but not for Prl. These results reveal that PRL does not play a central role in the development of chronic EAE and optimal Th1 and Th17 responses against myelin. Moreover, they also rule out a possible contribution of PRL secreted by immune cells to the modulation of autoreactive T cell response in this model.
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Affiliation(s)
- Massimo Costanza
- Neuroimmunology and Neuromuscular Disorder Unit, Foundation IRCCS Neurological Institute Carlo Besta, 20133 Milan, Italy
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Jalkanen A, Saraste M, Gfeller A, Surcel HM, Airas L. Increased thyroid autoimmunity among women with multiple sclerosis in the postpartum setting. Mult Scler 2013; 19:1734-42. [DOI: 10.1177/1352458513485148] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Multiple sclerosis (MS) patients are predisposed to thyroid abnormalities, but the risk for pregnancy-related thyroid pathology among MS patients has not been evaluated. Objectives: The objectives of this research are to prospectively evaluate the prevalence of thyroid autoimmunity among MS patients in relation to pregnancy, and to investigate its impact on pregnancy outcome, postpartum depression and fatigue. Methods: Forty-six pregnant MS patients underwent repeat testing for serum thyroid antibodies (Abs), clinical evaluation and thyroid hormone measurement. Results were compared to 35 age-matched healthy mothers. Results: At six months postpartum 35.3% of MS patients presented elevated levels of thyroid Abs compared to 5.7% of controls, p = 0.01. Mean thyroid Ab concentrations among MS patients were significantly reduced during pregnancy and returned to maximal levels at six months postpartum. The proportion of individuals with postpartum thyroid dysfunction did not differ significantly between MS patients and healthy controls (3.4% vs 2.9%, p = 1.00). Elevated thyroid Ab levels did not increase the risk for adverse pregnancy outcome, fatigue or postpartum depression. Conclusions: Considering the tendency of MS mothers to develop thyroid autoimmunity postpartum and in association to treatments, we recommend screening MS patients for thyroid dysfunction (TSH) during early pregnancy and after delivery.
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Affiliation(s)
- A Jalkanen
- Department of Neurology, Turku University Hospital, Finland
| | - M Saraste
- MediCity Research Laboratory, University of Turku, Finland
| | - A Gfeller
- Department of Neurology, Turku University Hospital, Finland
| | - HM Surcel
- Finnish Maternity Cohort, National Institute for Health and Welfare, Finland
| | - L Airas
- Department of Neurology, Turku University Hospital, Finland
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Pastò L, Portaccio E, Ghezzi A, Hakiki B, Giannini M, Razzolini L, Piscolla E, De Giglio L, Pozzilli C, Paolicelli D, Trojano M, Marrosu MG, Patti F, La Mantia L, Mancardi GL, Solaro C, Totaro R, Tola MR, Di Tommaso V, Lugaresi A, Moiola L, Martinelli V, Comi G, Amato MP. Epidural analgesia and cesarean delivery in multiple sclerosis post-partum relapses: the Italian cohort study. BMC Neurol 2012; 12:165. [PMID: 23276328 PMCID: PMC3544735 DOI: 10.1186/1471-2377-12-165] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 12/19/2012] [Indexed: 11/10/2022] Open
Abstract
Background Few studies have systematically addressed the role of epidural analgesia and caesarean delivery in predicting the post-partum disease activity in women with Multiple Sclerosis (MS). The objective of this study was to assess the impact of epidural analgesia (EA) and caesarean delivery (CD) on the risk of post-partum relapses and disability in women with MS. Methods In the context of an Italian prospective study on the safety of immunomodulators in pregnancy, we included pregnancies occurred between 2002 and 2008 in women with MS regularly followed-up in 21 Italian MS centers. Data were gathered through a standardized, semi-structured interview, dealing with pregnancy outcomes, breastfeeding, type of delivery (vaginal or caesarean) and EA. The risk of post-partum relapses and disability progression (1 point on the Expanded Disability Status Sclae, EDSS, point, confirmed after six months) was assessed through a logistic multivariate regression analysis. Results We collected data on 423 pregnancies in 415 women. Among these, 349 pregnancies resulted in full term deliveries, with a post-partum follow-up of at least one year (mean follow-up period 5.5±3.1 years). One hundred and fifty-five patients (44.4%) underwent CD and 65 (18.5%) EA. In the multivariate analysis neither CD, nor EA were associated with a higher risk of post-partum relapses. Post-partum relapses were related to a higher EDSS score at conception (OR=1.42; 95% CI 1.11-1.82; p=0.005), a higher number of relapses in the year before pregnancy (OR=1.62; 95% CI 1.15-2.29; p=0.006) and during pregnancy (OR=3.07; 95% CI 1.40-6.72; p=0.005). Likewise, CD and EA were not associated with disability progression on the EDSS after delivery. The only significant predictor of disability progression was the occurrence of relapses in the year after delivery (disability progression in the year after delivery: OR= 4.00; 95% CI 2.0-8.2; p<0.001; disability progression over the whole follow-up period: OR= 2.0; 95% CI 1.2-3.3; p=0.005). Conclusions Our findings, show no correlation between EA, CD and postpartum relapses and disability. Therefore these procedures can safely be applied in MS patients. On the other hand, post-partum relapses are significantly associated with increased disability, which calls for the need of preventive therapies after delivery.
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Affiliation(s)
- Luisa Pastò
- Department of Neurology, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
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Alwan S, Sadovnick AD. Multiple sclerosis and pregnancy: maternal considerations. ACTA ACUST UNITED AC 2012; 8:399-414. [PMID: 22757731 DOI: 10.2217/whe.12.33] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Multiple sclerosis (MS) is the most commonly acquired neurological disorder affecting young adults of reproductive age with approximately a 3:1 female-to-male ratio. Pregnancy is not contraindicated in MS but remains to be an issue that raises many questions. Although relapse rates tend to increase in the first 3 months postpartum, pregnancy does not seem to be a detriment to the long-term progression of MS and has a protective effect on reducing relapses, especially during the third trimester. MS does not appear to affect fertility or increase the risk of congenital anomalies or pregnancy complications. There has been some evidence that maternal treatment with β interferons, the most commonly used disease-modifying therapies in MS, may cause adverse reproductive outcomes, prompting the US FDA to issue warnings about their use at conception and during pregnancy.
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Affiliation(s)
- Sura Alwan
- Department of Medical Genetics, University of British Columbia, and Vancouver Coastal Health Authority-UBC Hospital, Vancouver, BC, Canada.
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Hellwig K, Haghikia A, Rockhoff M, Gold R. Multiple sclerosis and pregnancy: experience from a nationwide database in Germany. Ther Adv Neurol Disord 2012; 5:247-53. [PMID: 22973421 DOI: 10.1177/1756285612453192] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate exposure to disease-modifying therapies (DMTs) during pregnancy in 335 pregnancies of multiple sclerosis (MS) patients and to further determine whether exclusive breastfeeding of MS mothers has any relevant influence on postpartum relapse rate. BACKGROUND Only limited data are available on whether DMT exposure during pregnancy affects relapse rate during pregnancy or after birth. Currently, findings on beneficial effect of exclusive breastfeeding on MS disease course are controversially discussed. METHODS We enrolled pregnant women with MS who contacted us directly or via their treating physicians to be included in our nationwide MS and pregnancy database. RESULTS We identified 78 pregnancies under interferon-beta (IFNβ) preparations, 41 under glatiramer acetate (GLAT), and 216 pregnancies without DMT exposure during pregnancy. As expected, annualized relapse rate (ARR) decreased continuously during pregnancy in nonexposed mothers (p < 0.001) to then increase after birth. In IFNβ- or GLAT-exposed women this typical pattern was not as obvious. Congenital anomalies were within normal ranges in exposed pregnancies. In total, 170 women were identified who exclusively breastfed (EBF). Significantly reduced postpartum relapse rate during the first 3 months after birth were registered in the EBF group as compared with nonexclusively breastfeeding (NEBF) or nonbreastfeeding women (NBF) women with MS (p < 0.0001). Relapse rate (RR) in the year before pregnancy had been similar throughout all groups. We did not observe any significant differences in RR of NEBF and NBF women. CONCLUSION Exclusive breastfeeding showed some beneficial effects on postpartum relapse rate in our cohort. Our data support that IFNβ and GLAT do not seem to represent a major teratogenic risk in pregnancy.
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Affiliation(s)
- Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
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Abstract
Multiple sclerosis (MS) is more common in females than males and frequently affects women during their reproductive years. Thus, issues surrounding pregnancy and reproduction are of concern to women with MS. This review documents studies that shed light on reproductive issues in women with MS. The available literature was searched for papers relating to pregnancy and MS. Pregnancy is protective in MS in the short term, perhaps due to modulation of the immune system in pregnancy. It also possible that changes in the brain in pregnancy could protect against the effects of inflammation. The long-term effects of pregnancy also seem to be beneficial to MS, perhaps due to long-term epigenetic changes or possibly due to the effects of fetal microchimerism. Obstetric outcomes in women with MS are similar to those in the general population. In addition, there have been no reports of severe fetal abnormalities in babies exposed to first-line MS therapies. There is no good evidence that breast-feeding is protective in MS. There is no evidence that oral contraceptive pill use predisposes to MS, nor influences the clinical course of MS. After menopause, there is possible deterioration of MS, but it’s difficult to disentangle this from the effects of aging and the natural progressive history of MS. The strong biological effect of pregnancy on MS deserves further study, so that these mechanisms can possibly be replicated as therapies for MS.
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Borisow N, Döring A, Pfueller CF, Paul F, Dörr J, Hellwig K. Expert recommendations to personalization of medical approaches in treatment of multiple sclerosis: an overview of family planning and pregnancy. EPMA J 2012; 3:9. [PMID: 22738272 PMCID: PMC3464716 DOI: 10.1186/1878-5085-3-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 06/22/2012] [Indexed: 12/18/2022]
Abstract
Multiple sclerosis is the most common chronic autoimmune disease of the central nervous system which preferentially affects females at childbearing age. For this reason, patients and treating physicians were frequently confronted with questions concerning family planning, pregnancy and birth. Preventive and personalized treatment approaches are considered, because topics as heredity, risk of congenital malformations, influence of pregnancy on MS and aspects of drug therapy during the period of conception, pregnancy, puerperium and lactation have to be discussed. Here, we provide an overview about the current state of knowledge regarding these issues.
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Affiliation(s)
- Nadja Borisow
- NeuroCure Clinical Research Center and Clinical and Experimental Research Center for Multiple Sclerosis, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
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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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49
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Breastfeeding and multiple sclerosis relapses: a meta-analysis. J Neurol 2012; 259:2246-8. [DOI: 10.1007/s00415-012-6553-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 05/02/2012] [Accepted: 05/08/2012] [Indexed: 12/01/2022]
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50
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Voskuhl RR, Gold SM. Sex-related factors in multiple sclerosis susceptibility and progression. Nat Rev Neurol 2012; 8:255-63. [PMID: 22450508 DOI: 10.1038/nrneurol.2012.43] [Citation(s) in RCA: 173] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The pathogenesis of multiple sclerosis (MS) involves complex interactions between genetic susceptibility and environmental triggers. Clinical observations suggest that the study of sex differences might provide important insight into mechanisms of pathogenesis and progression of the disease in patients. MS occurs more frequently in women than in men, indicating that sex-related factors have an effect on an individual's susceptibility to developing the condition. These factors include hormonal, genetic and environmental influences, as well as gene-environment interactions and epigenetic mechanisms. Interestingly, women do not have a poorer prognosis than men with MS despite a higher incidence of the disease and more-robust immune responses, which suggests a mechanism of resilience. Furthermore, the state of pregnancy has a substantial effect on disease activity, characterized by a reduction in relapse rates during the third trimester but an increased relapse rate in the postpartum period. However, pregnancy has little effect on long-term disability in women with MS. The unravelling of the mechanisms underlying these clinical observations in the laboratory and application of the results to the clinical setting is a unique and potentially fruitful strategy to develop novel therapeutic approaches for MS.
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Affiliation(s)
- Rhonda R Voskuhl
- Department of Neurology, University of California Los Angeles, Neuroscience Research Building 1, Room 475D, 635 Charles Young Drive South, Los Angeles, CA 90095, USA.
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