Top

Published in:

01-10-2017 | Original Article

Management of pregnancy-related issues in multiple sclerosis patients: the need for an interdisciplinary approach

Authors: Maria Pia Amato, Antonio Bertolotto, Roberto Brunelli, Paola Cavalla, Benedetta Goretti, Maria Giovanna Marrosu, Francesco Patti, Carlo Pozzilli, Leandro Provinciali, Nicola Rizzo, Nicola Strobelt, Gioacchino Tedeschi, Maria Trojano, Giancarlo Comi

Published in: Neurological Sciences | Issue 10/2017

Abstract

Multiple sclerosis (MS) is a demyelinating and neurodegenerative disease of the central nervous system (CNS), most probably autoimmune in origin, usually occurring in young adults with a female/male prevalence of approximately 3:1. Women with MS in the reproductive age may face challenging issues in reconciling the desire for parenthood with their condition, owing to the possible influence both on the ongoing or planned treatment with the possible consequences on the disease course and on the potential negative effects of treatments on foetal and pregnancy outcomes. At MS diagnosis, timely counselling should promote informed parenthood, while disease evolution should be assessed before making therapeutic decisions. Current guidelines advise the discontinuation of any treatment during pregnancy, with possible exceptions for some treatments in patients with very active disease. Relapses decline during pregnancy but are more frequent during puerperium, when MS therapy should be promptly resumed in most of the cases. First-line immunomodulatory agents, such as interferon-β (IFN-β) and glatiramer acetate (GA), significantly reduce the post-partum risk of relapse. Due to substantial evidence of safety with the use of GA during pregnancy, a recent change in European marketing authorization removed the pregnancy contraindication for GA. This paper reports a consensus of Italian experts involved in MS management, including neurologists, gynaecologists and psychologists. This consensus, based on a review of the available scientific evidence, promoted an interdisciplinary approach to the management of pregnancy in MS women.

Compston A, Coles A (2008) Multiple sclerosis. Lancet 372(9648):1502–1517. doi:10.1016/S0140-6736(08)61620-7 CrossRefPubMed

Bove R, Chitnis T (2014) The role of gender and sex hormones in determining the onset and outcome of multiple sclerosis. Mult Scler 20(5):520–526. doi:10.1177/1352458513519181 CrossRefPubMed

Miller DH, Fazekas F, Montalban X, Reingold SC, Trojano M (2014) Pregnancy, sex and hormonal factors in multiple sclerosis. Mult Scler 20(5):527–536. doi:10.1177/1352458513519840 CrossRefPubMedPubMedCentral

Pozzilli C, Pugliatti M, Paradig M. S. Group (2015) An overview of pregnancy-related issues in patients with multiple sclerosis. Eur J Neurol 22(Suppl 2):34–39. doi:10.1111/ene.12797 CrossRefPubMed

Confavreux C, Hutchinson M, Hours MM, Cortinovis-Tourniaire P, Moreau T (1998) Rate of pregnancy-related relapse in multiple sclerosis. Pregnancy in Multiple Sclerosis Group. N Engl J Med 339(5):285–291. doi:10.1056/NEJM199807303390501 CrossRefPubMed

Vukusic S, Hutchinson M, Hours M, Moreau T, Cortinovis-Tourniaire P, Adeleine P, Confavreux C, Pregnancy In Multiple Sclerosis Group (2004) Pregnancy and multiple sclerosis (the PRIMS study): clinical predictors of post-partum relapse. Brain 127(Pt 6):1353–1360. doi:10.1093/brain/awh152 CrossRefPubMed

Karp I, Manganas A, Sylvestre MP, Ho A, Roger E, Duquette P (2014) Does pregnancy alter the long-term course of multiple sclerosis? Ann Epidemiol 24(7):504–508 e502. doi:10.1016/j.annepidem.2014.04.007 CrossRefPubMed

Masera S, Cavalla P, Prosperini L, Mattioda A, Mancinelli CR, Superti G, Chiavazza C, Vercellino M, Pinessi L, Pozzilli C (2015) Parity is associated with a longer time to reach irreversible disability milestones in women with multiple sclerosis. Mult Scler 21(10):1291–1297. doi:10.1177/1352458514561907 CrossRefPubMed

Jokubaitis VG, Spelman T, Kalincik T, Lorscheider J, Havrdova E, Horakova D, Duquette P, Girard M, Prat A, Izquierdo G, Grammond P, Van Pesch V, Pucci E, Grand'Maison F, Hupperts R, Granella F, Sola P, Bergamaschi R, Iuliano G, Spitaleri D, Boz C, Hodgkinson S, Olascoaga J, Verheul F, McCombe P, Petersen T, Rozsa C, Lechner-Scott J, Saladino ML, Farina D, Iaffaldano P, Paolicelli D, Butzkueven H, Lugaresi A, Trojano M, Group MSS (2016) Predictors of long-term disability accrual in relapse-onset multiple sclerosis. Ann Neurol 80(1):89–100. doi:10.1002/ana.24682 CrossRefPubMed

10.

Bove R, Alwan S, Friedman JM, Hellwig K, Houtchens M, Koren G, Lu E, McElrath TF, Smyth P, Tremlett H, Sadovnick AD (2014) Management of multiple sclerosis during pregnancy and the reproductive years: a systematic review. Obstet Gynecol 124(6):1157–1168. doi:10.1097/AOG.0000000000000541 CrossRefPubMed

11.

Vukusic S, Marignier R (2015) Multiple sclerosis and pregnancy in the 'treatment era'. Nat Rev Neurol 11(5):280–289. doi:10.1038/nrneurol.2015.53 CrossRefPubMed

12.

McCombe PA, Greer JM (2013) Female reproductive issues in multiple sclerosis. Mult Scler 19(4):392–402. doi:10.1177/1352458512452331 CrossRefPubMed

13.

Pozzilli C, De Giglio L, Barletta VT, Marinelli F, Angelis FD, Gallo V, Pagano VA, Marini S, Piattella MC, Tomassini V, Pantano P (2015) Oral contraceptives combined with interferon beta in multiple sclerosis. Neurol Neuroimmunol Neuroinflamm 2(4):e120. doi:10.1212/NXI.0000000000000120 CrossRefPubMedPubMedCentral

14.

Payne D, McPherson KM (2010) Becoming mothers. Multiple sclerosis and motherhood: a qualitative study. Disabil Rehabil 32(8):629–638. doi:10.3109/09638280903204708 CrossRefPubMed

15.

Coyle PK (2016) Management of women with multiple sclerosis through pregnancy and after childbirth. Ther Adv Neurol Disord 9(3):198–210. doi:10.1177/1756285616631897 CrossRefPubMedPubMedCentral

16.

Ristori G, Cannoni S, Stazi MA, Vanacore N, Cotichini R, Alfo M, Pugliatti M, Sotgiu S, Solaro C, Bomprezzi R, Di Giovanni S, Figa Talamanca L, Nistico L, Fagnani C, Neale MC, Cascino I, Giorgi G, Battaglia MA, Buttinelli C, Tosi R, Salvetti M (2006) Multiple sclerosis in twins from continental Italy and Sardinia: a nationwide study. Ann Neurol 59(1):27–34. doi:10.1002/ana.20683 CrossRefPubMed

17.

Sadovnick AD, Macleod PM (1981) The familial nature of multiple sclerosis: empiric recurrence risks for first, second-, and third-degree relatives of patients. Neurology 31(8):1039–1041CrossRefPubMed

18.

Coyle PK (2014) Multiple sclerosis and pregnancy prescriptions. Expert Opin Drug Saf 13(12):1565–1568. doi:10.1517/14740338.2014.973848 CrossRefPubMed

19.

Ferrero S, Pretta S, Ragni N (2004) Multiple sclerosis: management issues during pregnancy. Eur J Obstet Gynecol Reprod Biol 115(1):3–9. doi:10.1016/j.ejogrb.2003.10.020 CrossRefPubMed

20.

Culpepper WJ 2nd (2015) The incidence and prevalence of comorbidity in multiple sclerosis. Mult Scler 21(3):261–262. doi:10.1177/1352458515574151 CrossRefPubMed

21.

Food and Drug Administration (FDA) (2014) Content and format of labeling for human prescription drug and biological products; requirements for pregnancy and lactation labeling. Available from: http://www.federalregister.gov/a/2014-28241. Accessed 26 November, 2016

22.

European Medicines Agency (EMA) (2016) Quality review of documents human product-information annotated template (English) version 9. Available from: http://www.ema.europa.eu/docs/en_GB/document_library/Template_or_form/2009/10/WC500004368.pdf. Accessed 26 November, 2016

23.

National Institute for Health Care and Excellence (NICE) (2014) Multiple sclerosis in adults: management. Clinical guideline. Available from: https://www.nice.org.uk/guidance/cg186. Accessed 26 November 2016

24.

Cavalla P, Rovei V, Masera S, Vercellino M, Massobrio M, Mutani R, Revelli A (2006) Fertility in patients with multiple sclerosis: current knowledge and future perspectives. Neurol Sci 27(4):231–239. doi:10.1007/s10072-006-0676-x CrossRefPubMed

25.

Michel L, Foucher Y, Vukusic S, Confavreux C, de Seze J, Brassat D, Clanet M, Clavelou P, Ouallet JC, Brochet B, Pelletier J, Labauge P, Lebrun C, Lepage E, Le Frere F, Jacq-Foucher M, Barriere P, Wiertlewski S, Laplaud DA, Club Francophone de la Sclerose En Plaques (2012) Increased risk of multiple sclerosis relapse after in vitro fertilisation. J Neurol Neurosurg Psychiatry 83(8):796–802. doi:10.1136/jnnp-2012-302235 CrossRefPubMed

26.

Amato MP, Derfuss T, Hemmer B, Liblau R, Montalban X, Soelberg Sørensen P, Miller DH, for the 2016 ECTRIMS Focused Workshop Group (2017) Environmental modifiable risk factors for multiple sclerosis: report from the 2016 ECTRIMS focused workshop [epub ahead of print]. Multiple Sclerosis Journal:135245851668684. doi:10.1177/1352458516686847

27.

Jalkanen A, Kauko T, Turpeinen U, Hamalainen E, Airas L (2015) Multiple sclerosis and vitamin D during pregnancy and lactation. Acta Neurol Scand 131(1):64–67. doi:10.1111/ane.12306 CrossRefPubMed

28.

Munger KL, Aivo J, Hongell K, Soilu-Hanninen M, Surcel HM, Ascherio A (2016) Vitamin D status during pregnancy and risk of multiple sclerosis in offspring of women in the Finnish Maternity Cohort. JAMA Neurol 73(5):515–519. doi:10.1001/jamaneurol.2015.4800 CrossRefPubMedPubMedCentral

29.

ACOG American College of Obstetricians and Gynecologists (2011) Committee opinion no. 495: vitamin D: screening and supplementation during pregnancy. Obstet Gynecol 118(1):197–198CrossRef

30.

Greenberg JA, Bell SJ, Ausdal WV (2008) Omega-3 fatty acid supplementation during pregnancy. Rev Obstet Gynecol 1(4):162–169PubMedPubMedCentral

31.

Mueller BA, Zhang J, Critchlow CW (2002) Birth outcomes and need for hospitalization after delivery among women with multiple sclerosis. Am J Obstet Gynecol 186(3):446–452CrossRefPubMed

32.

Ponsonby AL, Lucas RM, van der Mei IA, Dear K, Valery PC, Pender MP, Taylor BV, Kilpatrick TJ, Coulthard A, Chapman C, Williams D, McMichael AJ, Dwyer T (2012) Offspring number, pregnancy, and risk of a first clinical demyelinating event: the AusImmune Study. Neurology 78(12):867–874. doi:10.1212/WNL.0b013e31824c4648 CrossRefPubMed

33.

Pasto 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, M. S. Study Group of the Italian Neurological Society (2012) Epidural analgesia and cesarean delivery in multiple sclerosis post-partum relapses: the Italian cohort study. BMC Neurol 12:165. doi:10.1186/1471-2377-12-165 CrossRefPubMedPubMedCentral

34.

Kelly VM, Nelson LM, Chakravarty EF (2009) Obstetric outcomes in women with multiple sclerosis and epilepsy. Neurology 73(22):1831–1836. doi:10.1212/WNL.0b013e3181c3f27d CrossRefPubMed

35.

Banwell B, Giovannoni G, Hawkes C, Lublin F (2013) Editors' welcome and a working definition for a multiple sclerosis cure. Mult Scler Relat Disord 2(2):65–67. doi:10.1016/j.msard.2012.12.001 CrossRefPubMed

36.

Kappos L, De Stefano N, Freedman MS, Cree BA, Radue EW, Sprenger T, Sormani MP, Smith T, Haring DA, Piani Meier D, Tomic D (2016) Inclusion of brain volume loss in a revised measure of 'no evidence of disease activity' (NEDA-4) in relapsing-remitting multiple sclerosis. Mult Scler 22(10):1297–1305. doi:10.1177/1352458515616701 CrossRefPubMed

37.

Baroncini D, Ghezzi A, Annovazzi PO, Colombo B, Martinelli V, Minonzio G, Moiola L, Rodegher M, Zaffaroni M, Comi G (2016) Natalizumab versus fingolimod in patients with relapsing-remitting multiple sclerosis non-responding to first-line injectable therapies. Mult Scler 22(10):1315–1326. doi:10.1177/1352458516650736 CrossRefPubMed

38.

Sellebjerg F, Barnes D, Filippini G, Midgard R, Montalban X, Rieckmann P, Selmaj K, Visser LH, Sorensen PS, Relapses ETFoToMS (2005) EFNS guideline on treatment of multiple sclerosis relapses: report of an EFNS task force on treatment of multiple sclerosis relapses. Eur J Neurol 12(12):939–946. doi:10.1111/j.1468-1331.2005.01352.x CrossRefPubMed

39.

Otero-Romero S, Amato MP, Chandraratna D, Clanet M, Comi G, Derfuss T, Fazekas F, Hemmer B, Hartung HP, Havrdova E, Kappos L, Liblau R, Lubetzki C, Miller DH, Olsson T, Selmaj C, Siva A, Sorensen PS, Thalheim C, Wiendl H, Zipp F, Thompson AJ, Gold R, Montalban X (2016) ECTRIMS-EAN clinical practice guideline on pharmacological management of multiple sclerosis [abstract] . Multiple sclerosis journal 22(abstract 255):834

40.

Leone MA, Keindl M, Schapira AH, Deuschl G, Federico A (2015) Practical recommendations for the process of proposing, planning and writing a neurological management guideline by EAN task forces. Eur J Neurol 22(12):1505–1510. doi:10.1111/ene.12818 CrossRefPubMed

41.

Amato MP, Portaccio E, Ghezzi A, Hakiki B, Zipoli V, Martinelli V, Moiola L, Patti F, La Mantia L, Mancardi GL, Solaro C, Tola MR, Pozzilli C, De Giglio L, Totaro R, Lugaresi A, Di Tommaso V, Paolicelli D, Marrosu MG, Comi G, Pellegrini F, Trojano M, Society MSSGotIN (2010) Pregnancy and fetal outcomes after interferon-beta exposure in multiple sclerosis. Neurology 75(20):1794–1802. doi:10.1212/WNL.0b013e3181fd62bb CrossRefPubMed

42.

De Giglio L, Gasperini C, Tortorella C, Trojano M, Pozzilli C (2015) Natalizumab discontinuation and disease restart in pregnancy: a case series. Acta Neurol Scand 131(5):336–340. doi:10.1111/ane.12364 CrossRefPubMed

43.

Giannini M, Portaccio E, Ghezzi A, Hakiki B, Pasto L, Razzolini L, Piscolla E, De Giglio L, Pozzilli C, Paolicelli D, Trojano M, Marrosu MG, Patti F, La Mantia L, Mancardi G, Solaro C, Totaro R, Tola MR, De Luca G, Lugaresi A, Moiola L, Martinelli V, Comi G, Amato MP (2012) Pregnancy and fetal outcomes after glatiramer acetate exposure in patients with multiple sclerosis: a prospective observational multicentric study. BMC Neurol 12:124. doi:10.1186/1471-2377-12-124 CrossRefPubMedPubMedCentral

44.

Pecori C, Giannini M, Portaccio E, Ghezzi A, Hakiki B, Pasto L, Razzolini L, Sturchio A, De Giglio L, Pozzilli C, Paolicelli D, Trojano M, Marrosu MG, Patti F, Mancardi GL, Solaro C, Totaro R, Tola MR, De Luca G, Lugaresi A, Moiola L, Martinelli V, Comi G, Amato MP, Society MSSGotIN (2014) Paternal therapy with disease modifying drugs in multiple sclerosis and pregnancy outcomes: a prospective observational multicentric study. BMC Neurol 14:114. doi:10.1186/1471-2377-14-114 CrossRef

45.

Lu E, Wang BW, Guimond C, Synnes A, Sadovnick D, Tremlett H (2012) Disease-modifying drugs for multiple sclerosis in pregnancy: a systematic review. Neurology 79(11):1130–1135. doi:10.1212/WNL.0b013e3182698c64 CrossRefPubMedPubMedCentral

46.

MHRA-Medicine & Health products Regulatory Agency (2016) Summary of product characteristics, Copaxone 20 mg/ml solution for injection, pre-filled syringe, revision 02/12/2016. Available from: http://www.mhra.gov.uk/. Accessed 31 January, 2017

47.

MHRA-Medicine & Health products Regulatory Agency (2017) Summary of product characteristics, Copaxone 40 mg/ml solution for injection, pre-filled syringe, revision 30/03/2017. Available from: http://www.mhra.gov.uk/. Accessed 04 April, 2017

48.

Vukusic S, Durand-Dubief F, Benoit A, Marignier R, Frangoulis B, Confavreux C (2015) Natalizumab for the prevention of post-partum relapses in women with multiple sclerosis. Mult Scler 21(7):953–955. doi:10.1177/1352458514554056 CrossRefPubMed

49.

Haghikia A, Langer-Gould A, Rellensmann G, Schneider H, Tenenbaum T, Elias-Hamp B, Menck S, Zimmermann J, Herbstritt S, Marziniak M, Kumpfel T, Meinl I, Plavina T, Gold R, Hellwig K (2014) Natalizumab use during the third trimester of pregnancy. JAMA Neurol 71(7):891–895. doi:10.1001/jamaneurol.2014.209 CrossRefPubMed

50.

Gandhi S, Jakimovski D, Ahmed R, Hojnacki D, Kolb C, Weinstock-Guttman B, Zivadinov R (2016) Use of natalizumab in multiple sclerosis: current perspectives. Expert Opin Biol Ther 16(9):1151–1162. doi:10.1080/14712598.2016.1213810 CrossRefPubMed

51.

Friend S, Richman S, Bloomgren G, Cristiano LM, Wenten M (2016) Evaluation of pregnancy outcomes from the Tysabri(R) (natalizumab) pregnancy exposure registry: a global, observational, follow-up study. BMC Neurol 16(1):150. doi:10.1186/s12883-016-0674-4 CrossRefPubMedPubMedCentral

52.

Thiel S, Langer-Gould A, Rockhoff M, Haghikia A, Queisser-Wahrendorf A, Gold R, Hellwig K (2016) Interferon-beta exposure during first trimester is safe in women with multiple sclerosis—a prospective cohort study from the German Multiple Sclerosis and Pregnancy Registry. Mult Scler 22(6):801–809. doi:10.1177/1352458516634872 CrossRefPubMed

53.

Comi G, Amato MP, Bertolotto A, Centonze D, De Stefano N, Farina C, Gallo P, Ghezzi A, Grimaldi LM, Mancardi G, Marrosu MG, Montanari E, Patti F, Pozzilli C, Provinciali L, Salvetti M, Tedeschi G, Trojano M (2016) The heritage of glatiramer acetate and its use in multiple sclerosis. Multiple Sclerosis and Demyelinating Disorders 1(1):6. doi:10.1186/s40893-016-0010-2 CrossRef

54.

Martinelli V, Colombo B, Dalla Costa G, Dalla Libera D, Moiola L, Falini A, Comi G, Filippi M (2016) Recurrent disease-activity rebound in a patient with multiple sclerosis after natalizumab discontinuations for pregnancy planning. Mult Scler 22(11):1506–1508. doi:10.1177/1352458513492246 CrossRefPubMed

55.

Houtchens MK, Kolb CM (2013) Multiple sclerosis and pregnancy: therapeutic considerations. J Neurol 260(5):1202–1214. doi:10.1007/s00415-012-6653-9 CrossRefPubMed

56.

Carmichael SL, Shaw GM, Ma C, Werler MM, Rasmussen SA, Lammer EJ, National Birth Defects Prevention Study (2007) Maternal corticosteroid use and orofacial clefts. Am J Obstet Gynecol 197(6):585 e581–585 e587. doi:10.1016/j.ajog.2007.05.046 CrossRef

57.

Simon JH, Li D, Traboulsee A, Coyle PK, Arnold DL, Barkhof F, Frank JA, Grossman R, Paty DW, Radue EW, Wolinsky JS (2006) Standardized MR imaging protocol for multiple sclerosis: Consortium of MS Centers consensus guidelines. AJNR Am J Neuroradiol 27(2):455–461PubMed

58.

World Health Organization (2006) Pregnancy, childbirth, postpartum and newborn care. A guide for essential practice, World Health Organization (WHO) Department of Making Pregnancy Safer Geneva, Switzerland

59.

Finkelsztejn A, Brooks JB, Paschoal FM Jr, Fragoso YD (2011) What can we really tell women with multiple sclerosis regarding pregnancy? A systematic review and meta-analysis of the literature. BJOG 118(7):790–797. doi:10.1111/j.1471-0528.2011.02931.x CrossRefPubMed

60.

Pakpoor J, Disanto G, Lacey MV, Hellwig K, Giovannoni G, Ramagopalan SV (2012) Breastfeeding and multiple sclerosis relapses: a meta-analysis. J Neurol 259(10):2246–2248. doi:10.1007/s00415-012-6553-z CrossRefPubMed

61.

Conradi S, Malzahn U, Paul F, Quill S, Harms L, Then Bergh F, Ditzenbach A, Georgi T, Heuschmann P, Rosche B (2013) Breastfeeding is associated with lower risk for multiple sclerosis. Mult Scler 19(5):553–558. doi:10.1177/1352458512459683 CrossRefPubMed

62.

Fares J, Nassar AH, Gebeily S, Kobeissy F, Fares Y (2016) Pregnancy outcomes in Lebanese women with multiple sclerosis (the LeMS study): a prospective multicentre study. BMJ Open 6(5):e011210. doi:10.1136/bmjopen-2016-011210 CrossRefPubMedPubMedCentral

63.

Hellwig K, Rockhoff M, Herbstritt S, Borisow N, Haghikia A, Elias-Hamp B, Menck S, Gold R, Langer-Gould A (2015) Exclusive breastfeeding and the effect on postpartum multiple sclerosis relapses. JAMA Neurol 72(10):1132–1138. doi:10.1001/jamaneurol.2015.1806 CrossRefPubMed

64.

Ragnedda G, Leoni S, Parpinel M, Casetta I, Riise T, Myhr KM, Wolfson C, Pugliatti M (2015) Reduced duration of breastfeeding is associated with a higher risk of multiple sclerosis in both Italian and Norwegian adult males: the EnvIMS study. J Neurol 262(5):1271–1277. doi:10.1007/s00415-015-7704-9 CrossRefPubMed

65.

Amato MP, Portaccio E (2015) Fertility, pregnancy and childbirth in patients with multiple sclerosis: impact of disease-modifying drugs. CNS Drugs 29(3):207–220. doi:10.1007/s40263-015-0238-y CrossRefPubMed

66.

Ford CC, Johnson KP, Lisak RP, Panitch HS, Shifronis G, Wolinsky JS, Copaxone Study Group (2006) A prospective open-label study of glatiramer acetate: over a decade of continuous use in multiple sclerosis patients. Mult Scler 12(3):309–320. doi:10.1191/135248506ms1318oa CrossRefPubMed

67.

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, M. S. Study Group of the Italian Neurological Society (2014) Postpartum relapses increase the risk of disability progression in multiple sclerosis: the role of disease modifying drugs. J Neurol Neurosurg Psychiatry 85(8):845–850. doi:10.1136/jnnp-2013-306054 CrossRefPubMed

68.

Alwan S, Yee IM, Dybalski M, Guimond C, Dwosh E, Greenwood TM, Butler R, Sadovnick AD (2013) Reproductive decision making after the diagnosis of multiple sclerosis (MS). Mult Scler 19(3):351–358. doi:10.1177/1352458512452920 CrossRefPubMed

69.

Ferraro D, Simone AM, Adani G, Vitetta F, Mauri C, Strumia S, Senesi C, Curti E, Baldi E, Santangelo M, Montepietra S, Immovilli P, Guareschi A, Neri W, Granella F, Caniatti L, Tola MR, Motti L, Pesci I, Montanari E, Sola P (2017) Definitive childlessness in women with multiple sclerosis: a multicenter study. Neurol Sci. doi:10.1007/s10072-017-2999-1

Title: Management of pregnancy-related issues in multiple sclerosis patients: the need for an interdisciplinary approach
Authors: Maria Pia Amato
Antonio Bertolotto
Roberto Brunelli
Paola Cavalla
Benedetta Goretti
Maria Giovanna Marrosu
Francesco Patti
Carlo Pozzilli
Leandro Provinciali
Nicola Rizzo
Nicola Strobelt
Gioacchino Tedeschi
Maria Trojano
Giancarlo Comi
Publication date: 01-10-2017
Publisher: Springer Milan
Published in: Neurological Sciences / Issue 10/2017
Print ISSN: 1590-1874
Electronic ISSN: 1590-3478
DOI: https://doi.org/10.1007/s10072-017-3081-8

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Management of pregnancy-related issues in multiple sclerosis patients: the need for an interdisciplinary approach

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 10/2017

Camptocormia as presenting in lower motor neuron disease with TARDBP mutation: case report

Mesencephalic astrocyte-derived neurotrophic factor and its role in nervous system disease

Pure motor monoparesis due to infarction of the "hand knob" area: radiological and morphological features

Dramatic improvement of impulsive aggressive behaviour following shunt surgery in a patient with idiopathic normal pressure hydrocephalus

Extra central nervous system metastases from glioblastoma: a new possible trigger event?

Thymectomy is a beneficial therapy for patients with non-thymomatous ocular myasthenia gravis: a systematic review and meta-analysis