Clinical Neuroimmunology by Unknown

Author:Unknown
Language: eng
Format: epub
ISBN: 9783030244361
Publisher: Springer International Publishing

Managing Postpartum Relapse

Although MS relapse rates are known to decrease during pregnancy, numerous studies have shown higher rates of relapse in the 3 months postpartum [109, 110]. Acute disease exacerbation during this period has the potential to worsen postpartum depression or can interfere with the developing bond between both mother and child [110]. Three variables correlate with increased postpartum relapse: increased relapse rate in the year prior to pregnancy, increased relapse rate during pregnancy, and a higher Expanded Disability Status Scale score at pregnancy onset [109, 114]. In turn, women on DMT prior to or during conception and throughout pregnancy have shown lower relapse rates than those not on therapy [109]. Acute exacerbation in the postpartum period can effectively be treated with intravenous methylprednisolone [110, 123]. This is considered safe when breastfeeding as only small concentrations pass into milk from mother to child [123]. Based on retrospective studies, intravenous immunoglobulin can also be administered postpartum with no adverse effects and the ability to reduce relapse rates by about 50% [110, 124].

Limited evidence and no clear consensus exist on how to prevent postpartum relapse [109, 110]. After delivery, many practitioners decide to resume DMT; however, the optimal time to restart these agents remains unclear [109]. As discussed earlier, many maintenance therapies are contraindicated during breastfeeding. Although it is generally recommended to resume DMT in patients with highly active disease prepregnancy, there is evidence that exclusive breastfeeding reduces MS relapse [108, 125, 126]. A prospective study showed fivefold relapse rate reduction in patients who exclusively breastfed in the 2-month postpartum period [108, 110, 126]. However, earlier studies suggested no effect on postpartum relapse rates during lactation. Although this is still an area of controversy, the decision regarding breastfeeding versus reinitiation of DMT should be tailored to the individual and thoroughly discussed between patient and provider [108, 110].

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