The PRegnancy In Multiple Sclerosis-PlMS-study was a European prospective multicenter study in which 254 pregnancies were described (Vukusic, 2006). Relapse risk was reduced 70 percent during pregnancy, but with a significantly greater relapse rate postpartum. This may be related to higher pregnancy-induced numbers of T-helper lymphocytes and an increased T2/Tl ratio (Airas, 2008). In a metaanalysis of women with more than 1200 pregnancies complicated by lvIS, their relapse rate was 0.4 per year before pregnancy; 0.26 per year during pregnancy; and this increased to 0.7 per year
FIGURE 60-4 Magnetic resonance cranial images from a woman with mUltiple sclerosis. A.T2-weighted axial image shows bright signal abnormalities in white matter, typical for multiple sclerosis. B. Sagittal T2-FLAIR image shows hyperintense areas within the corpus callosum that are representative of demyelination in multiple sclerosis. (Reproduced with permission from Hauser SL, Goodin DS: Multiple Sclerosis and other demyelinating diseases. In Kasper DL, Fauci AS, Hauser SL, et al (eds): Harrison's Principles of Internal Medicine, 19th ed. McGraw-Hili,
New York, 201o5b.) after delivery (Finkelsztejn, 2011). Bove and associates (2014) reached similar conclusions after a systematic review. Factors associated with postpartum relapse include a high relapse rate before pregnancy, relapses during pregnancy, and a high MS disability score (Portaccio, 2014; Vukusic, 2006). Breastfeeding has no apparent efect on postpartum relapses (Hellwig, 2015; Portaccio, 2011).
Efects of Multiple Sclerosis on Pregnancy
With uncomplicated disease, there are usually no adverse efects on pregnancy ourcome (Bove, 2014). Some women may become fatigued more easily, those with bladder dysfunction are predisposed to urinary infection, and women with spinal lesions at or above T 6 are at risk for autonomic dysrelexia. In one study of 449 pregnancies in afected women, the labor induction rate was higher, and second-stage labor was longer (Dahl, 2006). he greater induction rate and elective operations contributed to the overall higher cesarean delivery rate. In an analysis of 649 afected women, the mean birthweight was lower but the perinatal mortality rate was similar compared with that of controls (Dahl, 2005). Other studies have corroborated that MS does not significantly afect obstetrical and neonatal outcomes (Finkelsztejn, 2011; Fong, 2018).
Goals are to arrest acute or initial attacks, employ diseasemodiying agents, and provide symptomatic relief. Some treatments may need to be modiied during pregnancy. Acute or initial attacks are treated with high-dose intravenous methylprednisolone-500 to 1000 mg daily for 3 to 5 days, followed by oral prednisone for 2 weeks. Plasma exchange may be considered. Symptomatic relief can be provided by analgesics; carbamazepine, phenytoin, or amitriptyline for neurogenic pain; baclofen for spasticity; :Tadrenergic blockade for bladder neck relaxation; and cholinergic and anticholinergic drugs to stimulate or inhibit bladder contractions.