Pregnancy Management in Multiple Sclerosis and Other Demyelinating Diseases.
Journal
Continuum (Minneapolis, Minn.)
ISSN: 1538-6899
Titre abrégé: Continuum (Minneap Minn)
Pays: United States
ID NLM: 9509333
Informations de publication
Date de publication:
01 02 2022
01 02 2022
Historique:
entrez:
8
2
2022
pubmed:
9
2
2022
medline:
3
3
2022
Statut:
ppublish
Résumé
Multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSDs) are chronic autoimmune demyelinating conditions of the central nervous system often diagnosed in women of childbearing age. Therefore, safe family planning, pregnancy, and postpartum management are important considerations for many patients with MS or NMOSD. Many patients with MS can safely become pregnant and remain well throughout pregnancy and the postpartum period with guidance from specialists on treatment planning. During pregnancy, women with NMOSD may face some increased risk of both neurologic and obstetric complications. Recent attention has focused on evaluating the safety of pharmacologic agents during pregnancy and breastfeeding. Unfortunately, care disparities remain common in both MS and NMOSD, and recovery of function is often not optimally managed in the postpartum period. This article reviews the current state of knowledge on peripartum management in these neurologic conditions and offers practical considerations and case studies. When caring for women with MS and NMOSD of childbearing potential, treatment planning is important to optimize outcomes in both patient and newborn.
Identifiants
pubmed: 35133309
doi: 10.1212/CON.0000000000001108
pii: 00132979-202202000-00004
doi:
Types de publication
Journal Article
Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
12-33Informations de copyright
Copyright © 2022 American Academy of Neurology.
Références
Compston A, Confavreaux C, Lassmann H, et al. The natural history of multiple sclerosis. In: Compston A, McDonald I, Noseworthy J, editors. McAlpine's multiple sclerosis. 4th ed. Churchill Livingstone Elsevier; 2006:183–272.
Wallin MT, Culpepper WJ, Campbell JD, et al. The prevalence of MS in the United States: a population-based estimate using health claims data. Neurology 2019;92(10):e1029–e1040. doi:10.1212/WNL.0000000000007035
doi: 10.1212/WNL.0000000000007035
Ysrraelit MC, Correale J. Impact of sex hormones on immune function and multiple sclerosis development. Immunology 2019;156(1):9–22. doi:10.1111/imm.13004
doi: 10.1111/imm.13004
World Health Organization. Neurological disorders: public health challenges. Published 2006. Accessed December 7, 2021. who.int/mental_health/neurology/neurological_disorders_report_web.pdf
Weinshenker BG, Hader W, Carriere W, et al. The influence of pregnancy on disability from multiple sclerosis: a population-based study in Middlesex County, Ontario. Neurology 1989;39(11):1438–1440. doi:10.1212/wnl.39.11.1438
doi: 10.1212/wnl.39.11.1438
Houtchens MK, Edwards NC, Schneider G, et al. Pregnancy rates and outcomes in women with and without MS in the United States. Neurology 2018;91(17):e1559–e1569. doi:10.1212/WNL.0000000000006384
doi: 10.1212/WNL.0000000000006384
Langer-Gould A, Smith JB, Albers KB, et al. Pregnancy-related relapses and breastfeeding in a contemporary multiple sclerosis cohort. Neurology 2020;94(18):e1939–e1949. doi:10.1212/WNL.0000000000009374
doi: 10.1212/WNL.0000000000009374
Shimizu Y, Fujihara K, Ohashi T, et al. Pregnancy-related relapse risk factors in women with anti-AQP4 antibody positivity and neuromyelitis optica spectrum disorder. Mult Scler 2016;22(11):1413–1420. doi:10.1177/1352458515583376
doi: 10.1177/1352458515583376
Mao-Draayer Y, Thiel S, Mills EA, et al. Neuromyelitis optica spectrum disorders and pregnancy: therapeutic considerations. Nat Rev Neurol 2020;16(3):154–170. doi:10.1038/s41582-020-0313-y
doi: 10.1038/s41582-020-0313-y
Deng S, Qiu K, Tu R, et al. Relationship between pregnancy and acute disseminated encephalomyelitis: a single-case study. Front Immunol 2020;11:609476. doi:10.3389/fimmu.2020.609476
doi: 10.3389/fimmu.2020.609476
Shah AK, Tselis A, Mason B. Acute disseminated encephalomyelitis in a pregnant woman successfully treated with plasmapheresis. J Neurol Sci 2000;174(2):147–151. doi:10.1016/s0022-510x(00)00260-4
doi: 10.1016/s0022-510x(00)00260-4
Ramos-Ruperto L, Martínez-Sánchez N, Bartha-Rasero JL, et al. Susac syndrome and pregnancy: a relationship to clarify. About two cases and review of the literature. J Matern Fetal Neonatal Med 2020;1–6. doi:10.1080/14767058.2020.1712712
doi: 10.1080/14767058.2020.1712712
Antulov R, Holjar Erlić I, Perković O, et al. Susac's syndrome during pregnancy—the first Croatian case. J Neurol Sci 2014;341(1-2):162–164. doi:10.1016/j.jns.2014.04.010
doi: 10.1016/j.jns.2014.04.010
Qiu J, Riminton DS, Reddel SW, Hardy TA. Pregnancy without relapse following treated Susac syndrome. Mult Scler Relat Disord 2020;45:102357. doi:10.1016/j.msard.2020.102357
doi: 10.1016/j.msard.2020.102357
Willekens B, Kleffner I. Susac syndrome and pregnancy: a review of published cases and considerations for patient management. Ther Adv Neurol Disord 2021;14:1756286420981352. doi:10.1177/1756286420981352
doi: 10.1177/1756286420981352
Iskender C, Yasar O, Kaymak O, et al. Behçet's disease and pregnancy: a retrospective analysis of course of disease and pregnancy outcome. J Obstet Gynaecol Res 2014;40(6):1598–1602. doi:10.1111/jog.12386
doi: 10.1111/jog.12386
Orgul G, Aktoz F, Beksac MS. Behcet's disease and pregnancy: what to expect?J Obstet Gynaecol 2018;38(2):185–188. doi:10.1080/01443615.2017.1336614
doi: 10.1080/01443615.2017.1336614
Uzun S, Alpsoy E, Durdu M, Akman A. The clinical course of Behçet's disease in pregnancy: a retrospective analysis and review of the literature. J Dermatol 2003;30(7):499–502. doi:10.1111/j.1346-8138.2003.tb00423.x
doi: 10.1111/j.1346-8138.2003.tb00423.x
Dahl J, Myhr K-M, Daltveit AK, et al. Pregnancy, delivery, and birth outcome in women with multiple sclerosis. Neurology 2005;65(12):1961–1963. doi:10.1212/01.wnl.0000188898.02018.95
doi: 10.1212/01.wnl.0000188898.02018.95
Chen YH, Lin HL, Lin HC. Does multiple sclerosis increase risk of adverse pregnancy outcomes? A population-based study. Mult Scler 2009;15(5):606–612. doi:10.1177/1352458508101937
doi: 10.1177/1352458508101937
Martin JA, Hamilton BE, Osterman MJK, et al. Births: final data for 2016. Natl Vital Stat Rep 2018;67(1):1–55.
Andersen JB, Kopp TI, Sellebjerg F, Magyari M. Pregnancy-related and perinatal outcomes in women with multiple sclerosis: a nationwide Danish cross-sectional study. Neurol Clin Pract 2021;11(4):280–290. doi:10.1212/CPJ.0000000000001035
doi: 10.1212/CPJ.0000000000001035
Mahlanza I, Manieri MC, Houtchens MH. Fertility, maternal and pediatric development outcomes: interim report from the PREG-MS Registry. ECTRIMS Online Library. Published October 25, 2017. Accessed December 7, 2021. onlinelibrary.ectrims-congress.eu/ectrims/2017/ACTRIMS-ECTRIMS2017/199378/tatenda.d.mahlanza.fertility.maternal.and.pediatric.development.outcomes.html.
Amezcua L, McCauley JL. Race and ethnicity on MS presentation and disease course. Mult Scler 2020;26(5):561–567. doi:10.1177/1352458519887328
doi: 10.1177/1352458519887328
Amezcua L, Rivas E, Joseph S, et al. Multiple sclerosis mortality by race/ethnicity, age, sex, and time period in the United States, 1999-2015. Neuroepidemiology 2018;50(1-2):35–40. doi:10.1159/000484213
doi: 10.1159/000484213
Khan O, Williams MJ, Amezcua L, et al. Multiple sclerosis in US minority populations: clinical practice insights. Neurol Clin Pract 2015;5(2):132–142. doi:10.1212/CPJ.0000000000000112
doi: 10.1212/CPJ.0000000000000112
Amezcua L, Oksenberg JR, McCauley JL. MS in self-identified Hispanic/Latino individuals living in the US. Mult Scler J Exp Transl Clin 2017;3(3):2055217317725103. doi:10.1177/2055217317725103
doi: 10.1177/2055217317725103
Vukusic S, Hutchinson M, Hours M, et al. Pregnancy and multiple sclerosis (the PRIMS study): clinical predictors of post-partum relapse. Brain 2004;127(Pt 6):1353–1360. doi:10.1093/brain/awh152
doi: 10.1093/brain/awh152
Confavreux C, Hutchinson M, Hours MM, et al. Rate of pregnancy-related relapse in multiple sclerosis. Pregnancy in Multiple Sclerosis Group. N Engl J Med 1998;339(5):285–291. doi:10.1056/NEJM199807303390501
doi: 10.1056/NEJM199807303390501
Lehmann H, Zveik O, Levin N, et al. Brain MRI activity during the year before pregnancy can predict post-partum clinical relapses. Mult Scler 2021;13524585211002719. doi:10.1177/13524585211002719
doi: 10.1177/13524585211002719
Houtchens M, Bove R, Healy B, et al. MRI activity in MS and completed pregnancy: data from a tertiary academic center. Neurol Neuroimmunol Neuroinflamm 2020;7(6):e890. doi:10.1212/NXI.0000000000000890
doi: 10.1212/NXI.0000000000000890
Anderson A, Krysko KM, Rutatangwa A, et al. Clinical and radiologic disease activity in pregnancy and postpartum in MS. Neurol Neuroimmunol Neuroinflamm 2021;8(2):e959. doi:10.1212/NXI.0000000000000959
doi: 10.1212/NXI.0000000000000959
D'Souza R, Wuebbolt D, Andrejevic K, et al. Pregnancy and neuromyelitis optica spectrum disorder—reciprocal effects and practical recommendations: a systematic review. Front Neurol 2020;11:544434. doi:10.3389/fneur.2020.544434
doi: 10.3389/fneur.2020.544434
Kim W, Kim S-H, Nakashima I, et al. Influence of pregnancy on neuromyelitis optica spectrum disorder. Neurology 2012;78(16):1264–1267. doi:10.1212/WNL.0b013e318250d812
doi: 10.1212/WNL.0b013e318250d812
Nour MM, Nakashima I, Coutinho E, et al. Pregnancy outcomes in aquaporin-4–positive neuromyelitis optica spectrum disorder. Neurology 2016;86(1):79–87. doi:10.1212/WNL.0000000000002208
doi: 10.1212/WNL.0000000000002208
Huda S, Whittam D, Bhojak M, et al. Neuromyelitis optica spectrum disorders. Clin Med (Lond) 2019;19(2):169–176. doi:10.7861/clinmedicine.19-2-169
doi: 10.7861/clinmedicine.19-2-169
Soares-Dos-Reis R, Tsz-Ching JL, Kim SH, et al. Asian and African/Caribbean AQP4-NMOSD patient outcomes according to self-identified race and place of residence. Mult Scler Relat Disord 2021;53:103080. doi:10.1016/j.msard.2021.103080
doi: 10.1016/j.msard.2021.103080
Stratos K, Lee L, Dai D, et al. Evaluation of ethnicity as a predictor of diagnostic phenotype and prognosis in neuromyelitis optica spectrum disorder in Toronto, Canada. Mult Scler Relat Disord 2020;40:101950. doi:10.1016/j.msard.2020.101950
doi: 10.1016/j.msard.2020.101950
Sepúlveda M, Armangué T, Sola-Valls N, et al. Neuromyelitis optica spectrum disorders: comparison according to the phenotype and serostatus. Neurol Neuroimmunol Neuroinflamm 2016;3(3):225. doi:10.1212/NXI.0000000000000225
doi: 10.1212/NXI.0000000000000225
Das G, Damotte V, Gelfand JM, et al. Rituximab before and during pregnancy: a systematic review, and a case series in MS and NMOSD. Neurol Neuroimmunol Neuroinflamm 2018;5(3):e453. doi:10.1212/NXI.0000000000000453
doi: 10.1212/NXI.0000000000000453
Smith JB, Hellwig K, Fink K, et al. Rituximab, MS, and pregnancy. Neurol Neuroimmunol Neuroinflamm 2020;7(4):e734. doi:10.1212/NXI.0000000000000734
doi: 10.1212/NXI.0000000000000734
Langer-Gould AM. Pregnancy and family planning in multiple sclerosis. Continuum (Minneap Minn) 2019;25(3):773–792. doi:10.1212/CON.0000000000000745
doi: 10.1212/CON.0000000000000745
Houtchens M. Multiple sclerosis and pregnancy. Clin Obstet Gynecol 2013;56(2):342–349. doi:10.1097/GRF.0b013e31828f272b
doi: 10.1097/GRF.0b013e31828f272b
Lu G, Beadnall HN, Barton J, et al. The evolution of “No Evidence of Disease Activity” in multiple sclerosis. Mult Scler Relat Disord 2018;20:231–238. doi:10.1016/j.msard.2017.12.016
doi: 10.1016/j.msard.2017.12.016
The American College of Obstetricians and Gynecologists. Vitamin D: screening and supplementation during pregnancy. Committee Opinion Number 495. Published July 2011. Reaffirmed 2021. Accessed December 21, 2021. acog.org/clinical/clinical-guidance/committee-opinion/articles/2011/07/vitamin-d-screening-and-supplementation-during-pregnancy
Allen D, Hunter MS, Wood S, Beeson T. One key question. Matern Child Health J 2017;21(3):387–392. doi:10.1007/s10995-017-2283-2
doi: 10.1007/s10995-017-2283-2
Houtchens MK, Zapata LB, Curtis KM, Whiteman MK. Contraception for women with multiple sclerosis: guidance for healthcare providers. Mult Scler 2017;23(6):757–764. doi:10.1177/1352458517701314
doi: 10.1177/1352458517701314
Sadeghpour N, Mirmosayyeb O, Bjørklund G, Shaygannejad V. Is fertility affected in women of childbearing age with multiple sclerosis or neuromyelitis optica spectrum disorder?J Mol Neurosci 2020;70(11):1829–1835. doi:10.1007/s12031-020-01576-x
doi: 10.1007/s12031-020-01576-x
Thöne J, Lichtenberg S, Stahl A, et al. Ovarian reserve in women with neuromyelitis optica spectrum disorder. Front Neurol 2018;9:446. doi:10.3389/fneur.2018.00446
doi: 10.3389/fneur.2018.00446
Hellwig K, Correale J. Artificial reproductive techniques in multiple sclerosis. Clin Immunol 2013;149(2):219–224. doi:10.1016/j.clim.2013.02.001
doi: 10.1016/j.clim.2013.02.001
Massarotti C, Inglese M, Anserini P. Fertility in multiple sclerosis patients: still many unanswered questions. Reprod Biomed Online 2020;41(3):567. doi:10.1016/j.rbmo.2020.06.003
doi: 10.1016/j.rbmo.2020.06.003
McCombe PA, Stenager E. Female infertility and multiple sclerosis: is this an issue?Mult Scler 2015;21(1):5–7. doi:10.1177/1352458514549406
doi: 10.1177/1352458514549406
McCombe PA, Greer JM. Female reproductive issues in multiple sclerosis. Mult Scler 2013;19(4):392–402. doi:10.1177/1352458512452331
doi: 10.1177/1352458512452331
Houtchens MK, Edwards NC, Hayward B, et al. Live birth rates, infertility diagnosis, and infertility treatment in women with and without multiple sclerosis: data from an administrative claims database. Mult Scler Relat Disord 2020;46:102541. doi:10.1016/j.msard.2020.102541
doi: 10.1016/j.msard.2020.102541
Bove R, Rankin K, Lin C, et al. Effect of assisted reproductive technology on multiple sclerosis relapses: case series and meta-analysis. Mult Scler 2020;26(11):1410–1419. doi:10.1177/1352458519865118
doi: 10.1177/1352458519865118
Wallach AI, Tremblay M, Kister I. Advances in the treatment of neuromyelitis optica spectrum disorder. Neurol Clin 2021;39(1):35–49. doi:10.1016/j.ncl.2020.09.003
doi: 10.1016/j.ncl.2020.09.003
Hoeltzenbein M, Beck E, Rajwanshi R, et al. Tocilizumab use in pregnancy: analysis of a global safety database including data from clinical trials and post-marketing data. Semin Arthritis Rheum 2016;46(2):238–245. doi:10.1016/j.semarthrit.2016.05.004
doi: 10.1016/j.semarthrit.2016.05.004
Kelly RJ, Höchsmann B, Szer J, et al. Eculizumab in pregnant patients with paroxysmal nocturnal hemoglobinuria. N Engl J Med 2015;373(11):1032–1039. doi:10.1056/NEJMoa1502950
doi: 10.1056/NEJMoa1502950
Sanofi Genzyme. Aubagio drug elimination guide. Published 2021. Accessed December 7, 2021. aubagiohcp.com/content/pdf/drug_elimination_guide.pdf
Landi D, Marfia GA. Exposure to natalizumab during pregnancy and lactation is safe – yes. Mult Scler 2020;26(8):887–889. doi:10.1177/1352458520915814
doi: 10.1177/1352458520915814
Tysabri. Prescribing information. Biogen Inc; 2020. Accessed December 7, 2021. tysabri.com/content/dam/commercial/tysabri/pat/en_us/pdf/tysabri_prescribing_information.pdf
Friend S, Richman S, Bloomgren G, et al. Evaluation of pregnancy outcomes from the Tysabri® (natalizumab) pregnancy exposure registry: a global, observational, follow-up study. BMC Neurol 2016;16(1):150. doi:10.1186/s12883-016-0674-4
doi: 10.1186/s12883-016-0674-4
Portaccio E, Annovazzi P, Ghezzi A, et al. Pregnancy decision-making in women with multiple sclerosis treated with natalizumab: I: fetal risks. Neurology 2018;90(10):e823–e831. doi:10.1212/WNL.0000000000005067
doi: 10.1212/WNL.0000000000005067
Yeh WZ, Widyastuti PA, Van der Walt A, et al. Natalizumab, fingolimod and dimethyl fumarate use and pregnancy-related relapse and disability in women with multiple sclerosis. Neurology 2021;96(24):e2989–e3002. doi:10.1212/WNL.0000000000012084
doi: 10.1212/WNL.0000000000012084
Alroughani R, Alowayesh MS, Ahmed SF, et al. Relapse occurrence in women with multiple sclerosis during pregnancy in the new treatment era. Neurology 2018;90(10):e840–e846. doi:10.1212/WNL.0000000000005065
doi: 10.1212/WNL.0000000000005065
Anderson A, Singh J, Bove R. Neuroimaging and radiation exposure in pregnancy. Handb Clin Neurol 2020;171:179–191. doi:10.1016/B978-0-444-64239-4.00009-6
doi: 10.1016/B978-0-444-64239-4.00009-6
ACOG Committee Opinion No. 776 Summary: immune modulating therapies in pregnancy and lactation. Obstet Gynecol 2019;133(4):846–849. doi:10.1097/AOG.0000000000003177
doi: 10.1097/AOG.0000000000003177
Gur C, Diav-Citrin O, Shechtman S, et al. Pregnancy outcome after first trimester exposure to corticosteroids: a prospective controlled study. Reprod Toxicol 2004;18(1):93–101. doi:10.1016/j.reprotox.2003.10.007
doi: 10.1016/j.reprotox.2003.10.007
Galati A, Brown ES, Bove R, et al. Glucocorticoids for therapeutic immunosuppression: clinical pearls for the practicing neurologist. J Neurol Sci 2021;430:120004. doi:10.1016/j.jns.2021.120004
doi: 10.1016/j.jns.2021.120004
Carmichael S, Shaw GM, Ma C, et al. Maternal corticosteroid use and orofacial clefts. Am J Obstet Gynecol 2007;197(6):585.e1–e7. doi:10.1016/j.ajog.2007.05.046
doi: 10.1016/j.ajog.2007.05.046
Källén B. Maternal drug use and infant cleft lip/palate with special reference to corticoids. Cleft Palate Craniofac J 2003;40(6):624–628. doi:10.1597/02-077
doi: 10.1597/02-077
Mariotti V, Marconi AM, Pardi G. Undesired effects of steroids during pregnancy. J Matern Fetal Med 2004;16suppl 2:5–7. doi:10.1080/14767050410001727099
doi: 10.1080/14767050410001727099
Kemp MW, Newnham JP, Challis JG, et al. The clinical use of corticosteroids in pregnancy. Hum Reprod Update 2016;22(2):240–259. doi:10.1093/humupd/dmv047
doi: 10.1093/humupd/dmv047
Laskin CA, Bombardier C, Hannah ME, et al. Prednisone and aspirin in women with autoantibodies and unexplained recurrent fetal loss. N Engl J Med 1997;337(3):148–153. doi:10.1056/NEJM199707173370302
doi: 10.1056/NEJM199707173370302
Battin M, Bevan C, Harding J. Growth in the neonatal period after repeat courses of antenatal corticosteroids: data from the ACTORDS randomized trial. Arch Dis Child Neonatal Ed 2012;97(2):F99–F105. doi:10.1136/adc.2011.211318
doi: 10.1136/adc.2011.211318
Wind M, Gaasbeek AGA, Oosten LEM, et al. Therapeutic plasma exchange in pregnancy: a literature review. Eur J Obstet Gynecol Reprod Biol 2021;260:29–36. doi:10.1016/j.ejogrb.2021.02.027
doi: 10.1016/j.ejogrb.2021.02.027
de Sèze M, Gamé X. Multiple sclerosis and pelviperineology: urinary and sexual dysfunctions and pregnancy [in French]. Prog Urol 2014;24(8):483–494. doi:10.1016/j.purol.2014.02.006
doi: 10.1016/j.purol.2014.02.006
Durufle A, Petrilli S, Nicolas B, et al. Effects of pregnancy and child birth on urinary symptoms and urodynamics in women with multiple sclerosis. Int Urogynecol J Pelvic Floor Dysfunct 2006;17(4):352–355. doi:10.1007/s00192-005-0012-7
doi: 10.1007/s00192-005-0012-7
de Sèze M, Ruffion A, Denys P, et al. The neurogenic bladder in multiple sclerosis: review of the literature and proposal of management guidelines. Mult Scler 2007;13(7):915–928. doi:10.1177/1352458506075651
doi: 10.1177/1352458506075651
Block VJ, Mestas O, Anderson A, et al. Underutilization of physical therapy for symptomatic women with MS during and following pregnancy. Mult Scler Relat Disord 2021;48:102703. doi:10.1016/j.msard.2020.102703
doi: 10.1016/j.msard.2020.102703
Razaz N, Tremlett H, Marrie RA, Joseph KS. Peripartum depression in parents with multiple sclerosis and psychiatric disorders in children. Mult Scler 2016;22(14):1830–1840. doi:10.1177/1352458516631037
doi: 10.1177/1352458516631037
Krysko KM, Anderson A, Singh J, et al. Risk factors for peripartum depression in women with multiple sclerosis. Mult Scler 2021:13524585211041108. doi:10.1177/13524585211041108
doi: 10.1177/13524585211041108
Williams KE, Koleva H. Identification and treatment of peripartum anxiety disorders. Obstet Gynecol Clin North Am 2018;45(3):469–481. doi:10.1016/j.ogc.2018.04.001
doi: 10.1016/j.ogc.2018.04.001
Langan R, Goodbred AJ. Identification and management of peripartum depression. Am Fam Physician 2016;93(10):852–858.
Physical Activity and Exercise During Pregnancy and the Postpartum Period: ACOG Committee Opinion, Number 804. Obstet Gynecol 2020;135(4):e178–e188. doi:10.1097/AOG.0000000000003772
doi: 10.1097/AOG.0000000000003772
Krysko KM, Rutatangwa A, Graves J, et al. Association between breastfeeding and postpartum multiple sclerosis relapses: a systematic review and meta-analysis. JAMA Neurol 2020;77(3):327–338. doi:10.1001/jamaneurol.2019.4173
doi: 10.1001/jamaneurol.2019.4173
LaHue SC, Gelfand AA, Bove RM. Navigating monoclonal antibody use in breastfeeding women: do no harm or do little good?Neurology 2019;93(15):668–672. doi:10.1212/WNL.0000000000008213
doi: 10.1212/WNL.0000000000008213
Zengin Karahan S, Boz C, Terzi M, et al. Methylprednisolone concentrations in breast milk and serum of patients with multiple sclerosis treated with IV pulse methylprednisolone. Clin Neurol Neurosurg 2020;197:106118. doi:10.1016/j.clineuro.2020.106118
doi: 10.1016/j.clineuro.2020.106118