Epidural analgesia and cesarean delivery in multiple sclerosis post-partum relapses: the Italian cohort study

Abstract

BackgroundFew studies have systematically addressed the role of epidural analgesia and caesarean delivery in predicting the post-partum disease activity in women with Multiple Sclerosis (MS).The objective of this study was to assess the impact of epidural analgesia (EA) and caesarean delivery (CD) on the risk of post-partum relapses and disability in women with MS.MethodsIn the context of an Italian prospective study on the safety of immunomodulators in pregnancy, we included pregnancies occurred between 2002 and 2008 in women with MS regularly followed-up in 21 Italian MS centers. Data were gathered through a standardized, semi-structured interview, dealing with pregnancy outcomes, breastfeeding, type of delivery (vaginal or caesarean) and EA. The risk of post-partum relapses and disability progression (1 point on the Expanded Disability Status Sclae, EDSS, point, confirmed after six months) was assessed through a logistic multivariate regression analysis.ResultsWe collected data on 423 pregnancies in 415 women. Among these, 349 pregnancies resulted in full term deliveries, with a post-partum follow-up of at least one year (mean follow-up period 5.5±3.1 years). One hundred and fifty-five patients (44.4%) underwent CD and 65 (18.5%) EA. In the multivariate analysis neither CD, nor EA were associated with a higher risk of post-partum relapses. Post-partum relapses were related to a higher EDSS score at conception (OR=1.42; 95% CI 1.11-1.82; p=0.005), a higher number of relapses in the year before pregnancy (OR=1.62; 95% CI 1.15-2.29; p=0.006) and during pregnancy (OR=3.07; 95% CI 1.40-6.72; p=0.005). Likewise, CD and EA were not associated with disability progression on the EDSS after delivery. The only significant predictor of disability progression was the occurrence of relapses in the year after delivery (disability progression in the year after delivery: OR= 4.00; 95% CI 2.0-8.2; p<0.001; disability progression over the whole follow-up period: OR= 2.0; 95% CI 1.2-3.3; p=0.005).ConclusionsOur findings, show no correlation between EA, CD and postpartum relapses and disability. Therefore these procedures can safely be applied in MS patients. On the other hand, post-partum relapses are significantly associated with increased disability, which calls for the need of preventive therapies after delivery.

Management of women with multiple sclerosis through pregnancy and after childbirth

“…Any anesthetic choice or delivery method is acceptable [Pastò et al 2012]. These are purely obstetric decisions.…”

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

“…However, this was a secondary outcome of the study and no detailed analysis was provided (Confavreux et al., 1998). Another analysis of a cohort used to determine pregnancy and fetal outcomes in MS patients with interferone (CS 155, EA 65) also showed no correlation between EOA, CS and postpartum relapse (Pasto et al., 2012). One small prospective study of 19 women (EOA 10, CS 1) concluded that EOA was innocuous in the context of MS patients (Dalmas et al., 2003).…”

“…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). …”

Relapse in multiple sclerosis

“…Although self reported stress may be a prodrome of relapses, 24 external threat increases the risk of relapse, suggesting a causal association. 25 Physical trauma, 26 vaccinations, 27 and epidural analgesia 28 are not associated with relapses. No controlled studies have examined the effect of surgical operations.…”