title: Postpartum relapses increase the risk of disability progression in multiple sclerosis: the role of disease modifying drugs.
abstract: OBJECTIVE
  To assess relapses, disability progression and the role of disease modifying drugs (DMDs) in the year after delivery in women with multiple sclerosis (MS).
  
  
  METHODS
  We prospectively followed-up pregnancies occurring between 2002 and 2008 in women with MS, recruited from 21 Italian MS centres. The risk of relapses and disability progression in the year after delivery was assessed using time-dependent Cox regression analysis.
  
  
  RESULTS
  350 out of 423 pregnancies were assessed (pregnancies not resulting in live birth and with a postpartum follow-up period shorter than 1 year were excluded from the analysis). 148 patients (42.3%) had at least one relapse in the year after delivery. An Expanded Disability Status Scale (EDSS) score at conception ≥2.0 (HR=1.4; 95% CI 1.1 to 2.0; p=0.046) and a higher number of relapses before (HR=1.5; 95% CI 1.2 to 1.8; p<0.001) and during pregnancy (HR=2.3; 95% CI 1.6 to 3.4; p<0.001) were related to a higher risk of postpartum relapses. On the contrary, early DMD resumption after delivery marginally reduced the risk of postpartum relapses (HR=0.7, 95% CI 0.4 to 1.0; p=0.079). Moreover, 44/338 women progressed by at least one point on the EDSS. Disability progression was associated with a higher number of relapses before (HR=1.4, 95% CI 1.1 to 1.9; p=0.047) and after delivery (HR=2.7, 95% CI 1.4 to 5.2; p=0.002).
  
  
  CONCLUSIONS
  Our findings show an increased risk of postpartum relapses and disability accrual in women with higher disease activity before and during pregnancy. Since it may reduce the risk of postpartum relapses, early DMD resumption should be encouraged, particularly in patients with more active disease.
authors.affiliation: Department of NEUROFARBA, University of Florence, Florence, Italy.
authors.forename: Emilio
authors.identifier: http://orcid.org/0000-0002-9662-1762
authors.initials: E
authors.lastname: Portaccio
authors.affiliation: Hospital of Gallarate, Gallarate (VA), Italy.
authors.forename: Angelo
authors.initials: A
authors.lastname: Ghezzi
authors.affiliation: Department of NEUROFARBA, University of Florence, Florence, Italy.
authors.forename: Bahia
authors.initials: B
authors.lastname: Hakiki
authors.affiliation: Department of NEUROFARBA, University of Florence, Florence, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Sturchio
authors.affiliation: Scientific Institute University Vita-Salute San Raffaele, Milan, Italy.
authors.forename: Vittorio
authors.initials: V
authors.lastname: Martinelli
authors.affiliation: Scientific Institute University Vita-Salute San Raffaele, Milan, Italy.
authors.forename: Lucia
authors.initials: L
authors.lastname: Moiola
authors.affiliation: Department of Neurology, University of Catania, Catania, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Patti
authors.affiliation: Department of Neurology, University of Genova, Genova, Italy.
authors.forename: Gian Luigi
authors.initials: GL
authors.lastname: Mancardi
authors.affiliation: Department of Neurology, ASL3 Genovese, Genova, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Solaro
authors.affiliation: Department of Neurology, University of Ferrara, Ferrara, Italy.
authors.forename: Maria Rosaria
authors.initials: MR
authors.lastname: Tola
authors.affiliation: Department of Neurology and Psychiatry, "La Sapienza" University, Rome, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Pozzilli
authors.affiliation: Department of Neurology and Psychiatry, "La Sapienza" University, Rome, Italy.
authors.forename: Laura
authors.initials: L
authors.lastname: De Giglio
authors.affiliation: Department of Neurology, University of L'Aquila, L'Aquila, Italy.
authors.forename: Rocco
authors.initials: R
authors.lastname: Totaro
authors.affiliation: Department of Neuroscience and Imaging, University "G. d'Annunzio" of Chieti, Chieti, Italy.
authors.forename: Alessandra
authors.initials: A
authors.lastname: Lugaresi
authors.affiliation: Department of Neuroscience and Imaging, University "G. d'Annunzio" of Chieti, Chieti, Italy.
authors.forename: Giovanna
authors.initials: G
authors.lastname: De Luca
authors.affiliation: Department of Neurology, University of Bari, Bari, Italy.
authors.forename: Damiano
authors.initials: D
authors.lastname: Paolicelli
authors.affiliation: Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy.
authors.forename: Maria Giovanna
authors.initials: MG
authors.lastname: Marrosu
authors.affiliation: Scientific Institute University Vita-Salute San Raffaele, Milan, Italy.
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Comi
authors.affiliation: Department of Neurology, University of Bari, Bari, Italy.
authors.forename: Maria
authors.initials: M
authors.lastname: Trojano
authors.affiliation: Department of NEUROFARBA, University of Florence, Florence, Italy.
authors.forename: Maria Pia
authors.initials: MP
authors.lastname: Amato
mesh_terms: D000328:Adult; D017668:Age of Onset; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D016208:Databases, Factual; D004185:Disability Evaluation; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016899:Interferon-beta / Q000627:therapeutic use; D007558:Italy; D008775:Methylprednisolone / Q000627:therapeutic use; D009103:Multiple Sclerosis / Q000188:drug therapy* / Q000503:physiopathology*; D049590:Postpartum Period; D011247:Pregnancy; D011256:Pregnancy Outcome; D011446:Prospective Studies; D012008:Recurrence; D018570:Risk Assessment; D012307:Risk Factors
chemical_list: D000893:Anti-Inflammatory Agents; D016899:Interferon-beta; D008775:Methylprednisolone