title: Epidural analgesia and cesarean delivery in multiple sclerosis post-partum relapses: the Italian cohort study.
abstract: BACKGROUND
  Few 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.
  
  
  METHODS
  In 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.
  
  
  RESULTS
  We 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).
  
  
  CONCLUSIONS
  Our 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.
authors.affiliation: Department of Neurology, University of Florence, Viale Morgagni 85, 50134, Florence, Italy.
authors.forename: Luisa
authors.initials: L
authors.lastname: Pastò
authors.forename: Emilio
authors.initials: E
authors.lastname: Portaccio
authors.forename: Angelo
authors.initials: A
authors.lastname: Ghezzi
authors.forename: Bahia
authors.initials: B
authors.lastname: Hakiki
authors.forename: Marta
authors.initials: M
authors.lastname: Giannini
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Razzolini
authors.forename: Elisa
authors.initials: E
authors.lastname: Piscolla
authors.forename: Laura
authors.initials: L
authors.lastname: De Giglio
authors.forename: Carlo
authors.initials: C
authors.lastname: Pozzilli
authors.forename: Damiano
authors.initials: D
authors.lastname: Paolicelli
authors.forename: Maria
authors.initials: M
authors.lastname: Trojano
authors.forename: Maria Giovanna
authors.initials: MG
authors.lastname: Marrosu
authors.forename: Francesco
authors.initials: F
authors.lastname: Patti
authors.forename: Loredana
authors.initials: L
authors.lastname: La Mantia
authors.forename: Gian Luigi
authors.initials: GL
authors.lastname: Mancardi
authors.forename: Claudio
authors.initials: C
authors.lastname: Solaro
authors.forename: Rocco
authors.initials: R
authors.lastname: Totaro
authors.forename: Maria Rosaria
authors.initials: MR
authors.lastname: Tola
authors.forename: Valeria
authors.initials: V
authors.lastname: Di Tommaso
authors.forename: Alessandra
authors.initials: A
authors.lastname: Lugaresi
authors.forename: Lucia
authors.initials: L
authors.lastname: Moiola
authors.forename: Vittorio
authors.initials: V
authors.lastname: Martinelli
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Comi
authors.forename: Maria Pia
authors.initials: MP
authors.lastname: Amato
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural / Q000009:adverse effects*; D002585:Cesarean Section / Q000009:adverse effects*; D015331:Cohort Studies; D004185:Disability Evaluation; D018450:Disease Progression; D005260:Female; D006801:Humans; D009103:Multiple Sclerosis / Q000209:etiology*; D049590:Postpartum Period; D011247:Pregnancy