Reproductive Decision Making In Women With Multiple Sclerosis
J NeuroSci Nurs 2002 Jun;34(3):145-57
Villanova University College of Nursing, 800 Lancaster, Avenue, Villanova, PA 19085, USA
PMID# 12080870; UI# 22076548
Multiple Sclerosis (MS), the most common acquired Neurological Disorder of young adults, often strikes young women in their childbearing years.
Despite the overlap of MS onset with the childbearing years of women, little is known about how women with MS make decisions about pregnancy and childbearing.
In an effort to understand the process of decision making in these women, an exploratory descriptive qualitative study was undertaken; 15 pregnant women with MS were interviewed about their decisions to become pregnant and the factors that entered into their decision-making processes.
Content analysis was used to identify and describe the fears and concerns of women with MS around the process of making decisions and about how the presence of MS had influenced that process.
The unpredictability of MS and the effect that pregnancy might have on MS was a strong theme that emerged from the analysis.
Although participants in this study had proceeded to become pregnant despite their fears related to the effect of pregnancy on the course of their MS, they continued to perceive their decision as risky.
The diagnosis of MS affected their previous plans for number of children as well as spacing of pregnancies.
Further Experience With IntraVenous ImmunoGlobulin In Women With Recurrent Miscarriage And A Poor Prognosis
Carp HJ, Toder V, Gazit E, Ahiron R, Torchinski A, Mashiach S, Shoenfeld Y
Am J Reprod Immunol 2001 Oct;46(4):268-73
Sheba Medical Center, Department of Obstetrics and Gynecology, Tel Hashomer, Israel
Women with three or more unexplained miscarriages have a 60% chance of a subsequent live birth. IntraVenous ImmunoGlobulin (IVIG) has not been conclusively shown to improve this prognosis.
This study assessed the effect of IVIG in patients expected to have a poor outcome if untreated, i.e. women with five or more abortions, who have aborted after paternal Leukocyte immunization or who continue to abort despite expressing AntiPaternal Complement Dependent AntiBody.
Seventy-six women received IVIG in a dose of 400 mg/kg body weight, in one day (total 30-45 g) in the follicular phase of a cycle in which pregnancy was planned.
A booster dose was administered when pregnancy was diagnosed. Their results were compared to an untreated control group of 74 women.
Thirty-five (49%) pregnancies in treated women have resulted in live births or passed their previous stages of abortion compared to 23 (31%) in control patients (P = 0.04).
These figures indicate that IVIG may prevent further miscarriages in this poor prognosis population.
These figures are especially significant considering the doubt concerning the efficacy of IVIG in patients with three miscarriages and therefore a relatively good prognosis.
Pregnancy And Multiple Sclerosis (The PRIMS Study): Clinical Predictors Of Post-Partum Relapse
The Pregnancy In Multiple Sclerosis Group
Vukusic S, Hutchinson M, Hours M, Moreau T, Cortinovis-Tourniaire P, Adeleine P, Confavreux C
Brain 2004 Jun;127(Pt 6):1353-60
Hopital Neurologique Pierre Wertheimer, Service de Neurologie A, 59 boulevard Pinel, 69394 Lyon cedex 03, France
The influence of pregnancy in Multiple Sclerosis has been a matter of controversy for a long time.
The Pregnancy in Multiple Sclerosis (PRIMS) study was the first large prospective study which aimed to assess the possible influence of pregnancy and delivery on the clinical course of Multiple Sclerosis.
We report here the 2-year post-partum follow-up and an analysis of clinical factors which might predict the likelihood of a relapse in the 3 months after delivery.
The relapse rate in each trimester up to the end of the second year post-partum was compared with that in the pre-pregnancy year. Clinical predictors of the presence or absence of a post-partum relapse were analysed by logistic regression analysis.
Using the best multivariate model, women were classified as having or not having a post-partum relapse predicted, and this was compared with the observed outcome.
The results showed that, compared with the pre-pregnancy year, there was a reduction in the relapse rate during pregnancy, most marked in the third trimester, and a marked increase in the first 3 months after delivery.
Thereafter, from the second trimester onwards and for the following 21 months, the annualized relapse rate fell slightly but did not differ significantly from the relapse rate recorded in the pre-pregnancy year.
Despite the increased risk for the 3 months post-partum, 72% of the women did not experience any relapse during this period. Confirmed disability continued to progress steadily during the study period.
Three indices, an increased relapse rate in the pre-pregnancy year, an increased relapse rate during pregnancy and a higher DSS (Kurtzke's Disability Status Scale) score at pregnancy onset, significantly correlated with the occurrence of a post-partum relapse.
Neither Epidural analgesia nor breast-feeding was predictive. When comparing the predicted and observed status, however, only 72% of the women were correctly classified by the multivariate model.
In conclusion, the results for the second year post-partum confirm that the relapse rate remains similar to that of the pre-pregnancy year, after an increase in the first trimester following delivery.
Women with greater disease activity in the year before pregnancy and during pregnancy have a higher risk of relapse in the post- partum 3 months.
This is, however, not sufficient to identify in advance women with Multiple Sclerosis who are more likely to relapse, especially for planning therapeutic trials aiming to prevent post-partum relapses.
Effect Of IntraVenous ImmunoGlobulin Treatment On Pregnancy And Postpartum-Related Relapses In Multiple Sclerosis
Achiron A, Kishner I, Dolev M, Stern Y, Dulitzky M, Schiff E, Achiron R
J Neurol 2004 Sep;251(9):1133-7
Tel Aviv University, Multiple Sclerosis Center, Sheba Medical Center, Sacker School of Medicine, Tel-Aviv, Israel, Tel-Hashomer 52621, Israel
Acute exacerbations may complicate the course of pregnancy and the postpartum period in patients with Relapsing/Remitting Multiple Sclerosis (RRMS).
To evaluate relapse rate and the effect of immunomodulatory treatment with IntraVenous ImmunoGlobulin (IVIg) during pregnancy and the postpartum period we retrospectively analyzed the data of 108 pregnant RRMS patients.
Group I patients were not treated,
Group II patients were treated with IVIg 0.4 g/kg body weight/day for 5 consecutive days within the first week after delivery with additional booster doses of 0.4 g/kg body weight/day at 6 and 12 weeks postpartum (defined as 12 weeks after labor),
and Group III patients were treated continuously with IVIg during gestation and the postpartum period
(0.4 g/kg body weight/day for 5 consecutive days within the 6-8 weeks of gestation with additional booster doses of 0.4 g/kg body weight/day once every 6 weeks until 12 weeks postpartum).
All patients underwent antenatal care and fetal UltrasonoGraphic surveillance examinations. Relapse rate per woman per year during the pregnancy and the postpartum period as well as neonatal outcome data and IVIg related adverse events were analyzed.
Relapse rate per woman per year for patients treated with IVIg for the whole pregnancy and postpartum period (Group III, N = 28) compared with the untreated Group I patients (N = 39) were as follows:
first trimester 0.43 vs. 0.72, second trimester 0.15 vs. 0.61, third trimester 0.0 vs. 0.41, and postpartum period 0.28 vs.1.33 (p < 0.05).
Patients treated with IVIg only during the postpartum period (Group II, N = 41) also showed a decrease in relapse rate compared with untreated Group I patients, 0.58 vs. 1.33 (p = 0.012).
The mean maternal age, disease duration, gestational age at delivery and fetal delivery weight did not significantly differ between the three groups.
Mode of delivery, Obstetrical complications, the use of Epidural analgesia and breast-feeding, did not affect postpartum relapse rate.
No severe adverse events were associated with IVIg treatment either during the pregnancy or postpartum period for the patients and newborns.
We conclude that in RRMS patients IVIg treatment could be considered as an optional treatment to reduce the incidence of pregnancy and postpartum-related relapses. Further randomized double-blind studies are needed to confirm our findings.
Obstetric Outcomes In Women With Multiple Sclerosis And Epilepsy
Kelly VM, Nelson LM, Chakravarty EF
Stanford University School of Medicine, Division of Epidemiology,
the Department of Medicine, Department of Health Research and Policy, and Division of Immunology and Rheumatology, Stanford, CA
Neurology 2009 Nov 18
To estimate the national occurrence of pregnancies in women with Multiple Sclerosis (MS) and Epilepsy and to compare these pregnancy outcomes cross-sectionally with those in women with pregestational Diabetes Mellitus (DM) and the general obstetric population.
We studied the 2003-2006 Nationwide Inpatient Sample, of the Healthcare Cost and Utilization Project, to estimate the number of deliveries in women with MS, Epilepsy, DM, and the general obstetric population.
Pregnancy outcomes included length of hospital stay, Hypertensive Disorders including Preeclampsia (HTN), Premature Rupture Of Membranes (PROM), Intrauterine Growth Restriction (IUGR), and cesarean delivery.
Multivariable regression analyses used maternal age and race/ethnicity as covariates.
Of an estimated 18.8 million deliveries, 10,055 occurred in women with MS, 4,730 with Epilepsy, and 187,239 with DM.
MS was associated with mildly increased odds of antenatal hospitalization (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.2-1.5),
IUGR (OR 1.7, 95% CI 1.2-2.4), and cesarean delivery (OR 1.3, 95% CI 1.1-1.4).
Similarly, Epilepsy was associated with increased rates of antenatal hospitalization (OR 3.0, 95% CI 2.6-3.5), IUGR (OR 1.9, 95% CI 1.2-3.3), and cesarean delivery (OR 1.5, 95% CI 1.3-1.9).
HTN and PROM were not increased in either group. DM was associated with an increased risk of all adverse outcomes. Length of stay was modestly increased in all groups compared with controls.
In this large national database study of pregnancy outcomes in women with Multiple Sclerosis and Epilepsy.
Rates of intrauterine growth restriction and cesarean delivery were only marginally higher than the general obstetric population without increases in other adverse outcomes.