Pregnancy and multiple sclerosis (the PRIMS study): clinical predictors of post‐partum relapse

Abstract

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.

The Role of Postpartum Intravenous Corticosteroids in the Prevention of Relapses in Multiple Sclerosis

“…8 Breastfeeding was also not shown to affect postpartum relapse activity in PRIMS. 4 Data published by Oliveri et al 9 showed that intravenous methylprednisolone (IVMP) reduced magnetic resonance imaging (MRI) activity, defined as the number of contrast-enhancing lesions over a 2-month period. Therefore, we hypothesized that a dose of IVMP in the immediate postpartum period might reduce the risk of relapse.…”

Obstetric anesthesia/analgesia does not affect disease course in multiple sclerosis: 10‐year retrospective cohort study

“…There was also no impact of epidural analgesia on relapse. This corresponds with the outcome of the PRIMS study (254 women with MS, C‐sections 43, EOA 42) (Confavreux et al., 1998; Vukusic et al., 2004) showing no significant difference in the rate of relapse between women who underwent epidural analgesia and those who did not. However, this was a secondary outcome of the study and no detailed analysis was provided (Confavreux et al., 1998).…”

“…Our study results of postpartum relapses are consistent with data in other studies (Finkelsztejn, Brooks, Paschoal, & Fragoso, 2011; Vukusic et al., 2004) showing the largest number of relapses in the first trimester postpartum.…”

“…In the past, pregnancy was discouraged in women with MS; however recent studies have shown pregnancy as having a potentially beneficial role on MS relapse rates with no effects on long‐term progression of the disease (Confavreux, Hutchinson, Hours, Cortinovis‐Tourniaire, & Moreau, 1998; Koch, Uyttenboogaart, Heersema, Steen, & De Keyser, 2009; Vukusic et al., 2004). …”

“…Despite initial concerns that pain management techniques could worsen the short (or long) term course of MS, existing studies have shown no effect on overall MS disability (Confavreux et al., 1998; Pasto et al., 2012) or the precipitation of MS relapse (Confavreux et al., 1998; Dalmas, Texier, Ducloy‐Bouthors, & Krivosic‐Horber, 2003; Pasto et al., 2012; Vukusic et al., 2004). …”