Letters to the editor
Pregnancy in multiple sclerosis Bernardi et al. have published a very interesting paper entitled: Influence of pregnancy on relapses in multiple sclerosis: a cohort study (Acta Neurol Scand 1991: 84:403-6). They found that 33% ofthe women in the study had clinical onset of disease during pregnancy or during post partum. Furthermore, no relapses were observed in the last trimester of pregnancy, while an increase in relapses was detected in the first and second trimester of puerperium, though only the number of relapses in the former period reached a statistically significant level. Bernardi et a1 recommended that physicians could provide reassuring counselling about pregnancy to MS women. The results of the study are in accordance with those of most other studies (1-3). However, the authors do not take into consideration the problem of how pregnancy and childbirth influence the course of the disease. In a previous study (3), based on a representative sample of women with MS, we found that women with disease onset before or in relation to pregnancy or childbirth were significantly more handicapped than women without children and women with disease onset after pregnancy. Before reassuring women with MS who want to have children, it is necessary to take the problems involved into consideration. Furthermore, the high percentage of women (33%) who have onset of the disease in relation to pregnancy and childbirth is worrying, and gives rise to the question, whether pregnancy or childbirth can trigger the development of MS in predisposed persons (4). As physicians counselling MS-patients, we must be aware of the numerous problems involved, e.g., taking care of a child, keeping a job, economic and social problems and the sexual problems MS patients have to deal with when deciding whether or not to have children (5). References 1. POSERS, POSERW. Multiple sclerosis and gestation. Neurology 1983: 33: 1422-1427. 2. BIRKK, RUDICK R. Pregnancy and multiple sclerosis. Neurol 1986: 43: 119-126. 3. STENAGER EN, STENAGER E, JENSEN K. Graviditet og disseminere sklerose. En retrospektiv undersergelse. Ugeskr laege 1989: 151: 1744-1746. 4. STENAGER E, STENAGER EN, JENSEN K. Pregnancy, birth, gynecologic operations and multiple sclerosis. Acta Obst Gyn Scand (in press). 5. STENAGER E, STENAGER EN, JENSEN K. Sexual aspects of multiple sclerosis. Sem Neurol (in press).
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E . S . Stenager, E. Stenager, K . Jensen Department of Neurology Odense Hospital Denmark Reply
We thank Dr Stenager and colleagues for their observations on our study. Actually, our data would seem to exclude pregnancy influencing the course of the disease, at least in the period during which we followed the patients. In fact, after a 3-year followup the Kurtzke Expanded Disability Status Scale (EDSS) did not statistically differ between the groups of women we studied. In particular, the 52 women who had a pregnancy after the onset of the disease presented a mean final EDSS of 3.2 & 2.5. Of them, the 17 women who had onset during the “year of pregnancy” (i.e. gestation plus puerperium) had a mean final EDSS of 3.1 & 3.0. The 84 women without pregnancy showed a mean EDSS of 4.0 & 2.9 and the 46 women with pregnancy before the onset of disease had a mean final EDSS of 3.8k2.7. (p < .98). However, we cannot exclude that longer follow-up could allow the observation of different scores. Our data are in agreement with those of Poser & Poser (1) who found that women with pregnancies after onset of disease tended to be less disabled than the patients with pregnancies only before onset or without pregnancy. Ghezzi & Caputo (2) indicated that the comparison of 119 patients with pregnancy during the disease with a control group did not show significant differences with regard to invalidity. Finally, more recently, Weisnshenker et al. found no association in 185 subjects between disability and total number of pregnancies, timing of pregnancy relative to onset of MS, or either onset or worsening of MS in relation to a pregnancy (3). As to their second comment, it is well known that pregnancy is a risk factor triggering the onset of the disease. However, at present, it is impossible to define the subgroup of asymptomatic women at risk of developing MS in order to discourage pregnancy in these subjects. Although our data showed no effect of pregnancy on the course of MS in a short-term follow-up, we believe that when counselling MS women willing to conceive, an attending physician should take into account all the concomitant medical and social factors which could influence the development of the disease.
Pregnancy in multiple sclerosis Bernardi et al. have published a very interesting paper entitled: Influence of pregnancy on relapses in multiple sclerosis: a cohort study (Acta Neurol Scand 1991: 84:403-6). They found that 33% ofthe women in the study had clinical onset of disease during pregnancy or during post partum. Furthermore, no relapses were observed in the last trimester of pregnancy, while an increase in relapses was detected in the first and second trimester of puerperium, though only the number of relapses in the former period reached a statistically significant level. Bernardi et a1 recommended that physicians could provide reassuring counselling about pregnancy to MS women. The results of the study are in accordance with those of most other studies (1-3). However, the authors do not take into consideration the problem of how pregnancy and childbirth influence the course of the disease. In a previous study (3), based on a representative sample of women with MS, we found that women with disease onset before or in relation to pregnancy or childbirth were significantly more handicapped than women without children and women with disease onset after pregnancy. Before reassuring women with MS who want to have children, it is necessary to take the problems involved into consideration. Furthermore, the high percentage of women (33%) who have onset of the disease in relation to pregnancy and childbirth is worrying, and gives rise to the question, whether pregnancy or childbirth can trigger the development of MS in predisposed persons (4). As physicians counselling MS-patients, we must be aware of the numerous problems involved, e.g., taking care of a child, keeping a job, economic and social problems and the sexual problems MS patients have to deal with when deciding whether or not to have children (5). References 1. POSERS, POSERW. Multiple sclerosis and gestation. Neurology 1983: 33: 1422-1427. 2. BIRKK, RUDICK R. Pregnancy and multiple sclerosis. Neurol 1986: 43: 119-126. 3. STENAGER EN, STENAGER E, JENSEN K. Graviditet og disseminere sklerose. En retrospektiv undersergelse. Ugeskr laege 1989: 151: 1744-1746. 4. STENAGER E, STENAGER EN, JENSEN K. Pregnancy, birth, gynecologic operations and multiple sclerosis. Acta Obst Gyn Scand (in press). 5. STENAGER E, STENAGER EN, JENSEN K. Sexual aspects of multiple sclerosis. Sem Neurol (in press).
222
E . S . Stenager, E. Stenager, K . Jensen Department of Neurology Odense Hospital Denmark Reply
We thank Dr Stenager and colleagues for their observations on our study. Actually, our data would seem to exclude pregnancy influencing the course of the disease, at least in the period during which we followed the patients. In fact, after a 3-year followup the Kurtzke Expanded Disability Status Scale (EDSS) did not statistically differ between the groups of women we studied. In particular, the 52 women who had a pregnancy after the onset of the disease presented a mean final EDSS of 3.2 & 2.5. Of them, the 17 women who had onset during the “year of pregnancy” (i.e. gestation plus puerperium) had a mean final EDSS of 3.1 & 3.0. The 84 women without pregnancy showed a mean EDSS of 4.0 & 2.9 and the 46 women with pregnancy before the onset of disease had a mean final EDSS of 3.8k2.7. (p < .98). However, we cannot exclude that longer follow-up could allow the observation of different scores. Our data are in agreement with those of Poser & Poser (1) who found that women with pregnancies after onset of disease tended to be less disabled than the patients with pregnancies only before onset or without pregnancy. Ghezzi & Caputo (2) indicated that the comparison of 119 patients with pregnancy during the disease with a control group did not show significant differences with regard to invalidity. Finally, more recently, Weisnshenker et al. found no association in 185 subjects between disability and total number of pregnancies, timing of pregnancy relative to onset of MS, or either onset or worsening of MS in relation to a pregnancy (3). As to their second comment, it is well known that pregnancy is a risk factor triggering the onset of the disease. However, at present, it is impossible to define the subgroup of asymptomatic women at risk of developing MS in order to discourage pregnancy in these subjects. Although our data showed no effect of pregnancy on the course of MS in a short-term follow-up, we believe that when counselling MS women willing to conceive, an attending physician should take into account all the concomitant medical and social factors which could influence the development of the disease.
