© Borgis - Postępy Nauk Medycznych 7/2016, s. 490-493
*Beata Rebizant, Elżbieta Narojczyk-Świeściak
Multiple sclerosis and pregnancy
Stwardnienie rozsiane a ciąża
2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Father Jerzy Popiełuszko “Bielański” Hospital, Independent Public Health Care Institution in Warsaw
Head of Department: Associate Professor Romuald Dębski, MD, PhD
Streszczenie
Stwardnienie rozsiane (łac. sclerosis multiplex – SM), jest najczęstszą chorobą demielinizacyjną ośrodkowego układu nerwowego. Według Towarzystwa Stwardnienia Rozsianego jest to najczęstsza przyczyna (z wyjątkiem urazów) niepełnosprawności młodych dorosłych. Etiopatogeneza choroby jest złożona i może się wiązać z wieloma różnymi czynnikami działającymi jednocześnie lub kaskadowo, prowadząc do rozwoju choroby. Pod uwagę brane są czynniki genetyczne, środowiskowe oraz infekcyjne. Pomimo intensywnych badań prowadzonych na całym świecie dotychczas nie udało się opracować terapii pozwalającej całkowicie zatrzymać postęp choroby i uchronić pacjentów przed wynikającą z niej niepełnosprawnością. Wiele nieznanych jeszcze przyczyn związanych z SM i jego przebiegiem było przyczyną negatywnego nastawienia lekarzy do planów prokreacyjnych chorych pacjentek. Doniesienia z wielośrodkowego prospektywnego badania PRIMS (ang. pregnancy in multiple sclerosis) całkowicie zmieniły zapatrywanie na ciążę u kobiet z SM. Ponad wszelką wątpliwość wykazano, że ciąża zmniejsza ryzyko rzutów i postępu choroby w trakcie jej trwania, zaś zwiększone ryzyko rzutu w pierwszych trzech miesiącach po porodzie nie wpływa negatywnie na stopień niepełnosprawności w porównaniu do kobiet, które nigdy nie były w ciąży. Analiza przyczyn takiego stanu jest przedmiotem wielu badań i nowych koncepcji na sposób leczenia SM.
Summary
Multiple sclerosis (MS) is the most common demyelinating condition of the central nervous system. According to the Polish Association for Multiple Sclerosis, MS is the most common cause (excluding injuries) of disability in young adults. Its etiopathogenesis is complex and can be associated with multiple factors acting together or in a cascading manner, leading to the development of the disease. Genetic, environmental and infectious factors are taken into account. Despite intensive worldwide research attempts to develop treatment that would completely halt the progression of MS and prevent disability have not succeeded. Multiple unknowns about the MS and its course were probably the main reason behind healthcare professionals’ negative attitude towards female MS patients planning to become parents. The PRIMS (Pregnancy In Multiple Sclerosis) multicenter prospective clinical study has completely changed the views on pregnancy in female MS patients. The research clearly demonstrated that pregnancy decreases the risk of relapse and progression during its course, while the increased risk of relapse during the first three months after delivery has no negative impact on the degree of disability compared to women who have never been pregnant. The analysis of this phenomenon is the subject of extensive research and new concepts in the field of MS treatment.
Introduction
Multiple sclerosis is a multifactorial disease characterised by inflammatory, neurodegenerative lesions as well as impaired repair mechanisms in the central nervous system. The aetiology of MS is complex and probably involves a number of different factors acting together or in a cascading manner, leading to the development of the disease (1).
The disease usually manifests in individuals between 20 and 40 years of age, however, MS symptoms can develop in people of all ages. MS is more common in women. It seems that there has been a continuous rise in the female-to-male MS ratio (2, 3), which is estimated to be approximately 2.67:1 (3). The neuromodulatory role of sex hormones is probably the reason for this disproportion. Also, a relationship is observed between gender and age of onset. The onset of symptoms usually occurs between 18 and 30 years of age in women and between 30 and 40 years of age in men.
The prevalence of MS varies in different latitudes. MS is more common in regions with lower sunlight exposure, and thus higher vitamin D deficiency (1, 4). The role of sunlight exposure has been confirmed in studies in monozygotic twins, comparing the incidence of MS in siblings (5). It was found that low vitamin D levels (hypovitaminosis D) are related to increased MS incidence (6). Studies on serum vitamin D levels in MS patients demonstrated that vitamin D deficiency occurs in most patients, even in the earliest stages of the disease (7). Furthermore, it seems that appropriate vitamin D supplementation can alleviate the disease (8).
Genetic factors also play a role in MS aetiology. The causes of the disease are also sought among HLA factors, genes for T cell receptors and endogenous viruses contained in the human genome (1).
The impact of Chronic Cerebrospinal Venous Insufficiency (CCSVI) is also contemplated (9). This theory seems to be most controversial due to different views on MS pathogenesis, and thus a different approach to MS treatment. As a result of this controversy, the FDA published an official statement warning patients against the risks involved in the invasive treatment of unconfirmed efficacy (10).
Symptoms
MS symptomatology can vary considerably. Periodic neurologic symptom recurrence or increase (i.e. relapses) is a constant characteristic of the disease. Periods of complete or partial remission are observed between relapses. The most common symptoms include visual disorders (including optic neuritis, diplopia, nystagmus), autonomic disorders (bladder dysfunction affects 80% of patients) (11), impaired sensation (paraesthesia, heat intolerance) as well as motor, cerebellar, cognitive and mental disorders.
Diagnosis
The initial diagnosis is usually based on the characteristic clinical picture, i.e. manifestation of symptoms in the form of relapses and remissions. First MS signs are often ignored by patients. A thorough medical history allows to identify relapses long before the diagnosis.
Additional tests help confirm the initial diagnosis. MRI of the central nervous system reveals typical multifocal demyelination of the white matter. Oligoclonal proteins are found in the cerebrospinal fluid in approximately 80% of MS patients (12, 13). Prolonged latencies in the evoked potential (EP) tests can indicate demyelination even in asymptomatic patients (14).
Treatment
There is no effective treatment for MS. Intravenous corticosteroids are usually administered during exacerbations. If their efficacy is insufficient, plasmapheresis and intravenous immunoglobulins can be considered. Although there are a number of disease modifying treatments available, none of these is able to completely halt the progression of the disease. It should also be noted that none of these preparations is approved for safe use in pregnant or breastfeeding patients.
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