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A systematic literature review to examine the considerations around pregnancy in women of child-bearing age with myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) or aquaporin 4 neuromyelitis optica spectrum disorder (AQP4+ NMOSD)
This is the first systematic review to look at both women of child-bearing age with AQP4+ NMOSD and women of child-bearing age with MOGAD.
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AQP4+ NMOSD may be associated with risks to healthy delivery and with a rise in annualised relapse rate postpartum, which may have implications for management.
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Limited data availability emphasises the need for novel research in these important patient groups, particularly for MOGAD.
Abstract
Background
Aquaporin-4 antibody positive (AQP4+) neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) are rare autoimmune diseases with overlapping phenotypes. Understanding their clinical manifestation prior to, during and after pregnancy may influence the management of women of child-bearing age (WOCBA) with these diseases.
Methods
This systematic review identified relevant MEDLINE-indexed publications dated between 01 January 2011 and 01 November 2021, and congress materials from key conferences between 01 January 2019 and 01 November 2021. These were manually assessed for relevance to AQP4+ NMOSD and/or MOGAD in WOCBA, with selected data extracted and considered.
Results
In total, 107 articles were retrieved and reviewed for relevancy, including 65 clinical studies. Limited evidence was found regarding a conclusive impact of either disease on female fertility, sexual function or menarche, and impact on maternal outcomes requires further investigation in both conditions to establish risk for pre-eclampsia, gestational diabetes and other complications relative to the general population. Collated data for pregnancy outcomes show clear risks in AQP4+ NMOSD to healthy delivery and a rise in annualised relapse rate postpartum that may require adaptation of treatment regimens. Disease activity appears to be attenuated during pregnancy in MOGAD patients with an increased risk of relapse during the postpartum months, but strong conclusions cannot be made due to a paucity of available data.
Conclusions
This review brings together the literature on AQP4+ NMOSD and MOGAD in WOCBA. The potential impact of pregnancy and the postpartum period on disease activity suggest a proactive management strategy early on may improve maternal and infant outcomes, but more clinical data are needed, particularly for MOGAD.
Aquaporin-4 antibody positive (AQP4+) neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) are rare, demyelinating, antibody-mediated autoimmune diseases; in both cases, the antibodies cause inflammation of the central nervous system (CNS). Although the conditions are distinct, they have overlapping phenotypes (
). Both diseases can affect women of child-bearing age (WOCBA). Understanding the impact of the diseases and their treatments is particularly important for WOCBA, whose choices regarding family planning may be profoundly affected by a diagnosis of either condition.
In the adult population, both AQP4+ NMOSD and MOGAD are more likely to affect women than men. The differential is more substantial in AQP4+ NMOSD populations, which are typically up to 90% female (seronegative cases show an equal distribution between genders) (
Prognostic factors and disease course in aquaporin-4 antibody-positive patients with neuromyelitis optica spectrum disorder from the United Kingdom and Japan.
Prognostic factors and disease course in aquaporin-4 antibody-positive patients with neuromyelitis optica spectrum disorder from the United Kingdom and Japan.
). This brings a need for awareness of future family planning issues, particularly in females. MOGAD typically presents in adults in their early thirties, although a significant proportion of patients develop the condition in childhood (
Neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein associated disorder-optic neuritis: a comprehensive review of diagnosis and treatment.
). Given the paediatric population, it is important – as in other areas of medicine – that paediatricians managing MOGAD are aware of the potential future impact of both the condition and the treatments they are using so that they can plan for a smooth adolescent-to-adult transition (
). Although not all women will seek to become pregnant, many will want the reassurance that their medical care is not foreclosing the possibility and can facilitate it safely, without incurring a health risk that might prompt consideration of termination.
Other demographic factors can also impact pregnancy and may differ between the two diseases. Ethnicity is known to be correlated with pregnancy outcomes, due to various factors including complex sociodemographic (
Gestational weight gain across continents and ethnicity: systematic review and meta-analysis of maternal and infant outcomes in more than one million women.
). Differences in the prevalence of NMOSD have been observed across ethnic groups. In the United States and Europe, NMOSD accounts for 1–2% of all CNS inflammatory demyelinating diseases, whereas it accounts for a third or more cases in Asian and other non-White groups (
). Studies reporting incidence and/or prevalence estimates of NMOSD and AQP4+ NMOSD suggest that African ethnicity is associated with the highest incidence and prevalence, and White ethnicity with the lowest (
Prevalence and incidence of neuromyelitis optica spectrum disorder, aquaporin-4 antibody-positive NMOSD and MOG antibody-positive disease in Oxfordshire, UK.
Prognostic factors and disease course in aquaporin-4 antibody-positive patients with neuromyelitis optica spectrum disorder from the United Kingdom and Japan.
). Although data for MOGAD are limited, analysis of UK cohorts has suggested that predisposition to and outcome of MOGAD are not influenced by ethnicity (
). For example, systemic lupus erythematosus, antiphospholipid syndrome and myasthenia gravis (MG) have all been associated with NMOSD and can be a particular risk to the mother and foetus. However, there is no clear evidence linking MOGAD with other autoimmune diseases (
). In terms of risk of relapse, data vary, but both have a relatively high risk of attacks in the absence of immunosuppressive treatment: AQP4+ NMOSD tends to have a greater mean annualised relapse rate (ARR) at 0.82 vs 0.2 for MOGAD (
Prognostic factors and disease course in aquaporin-4 antibody-positive patients with neuromyelitis optica spectrum disorder from the United Kingdom and Japan.
). Consideration of how pregnancy impacts relapse risk is unclear, and patients with AQP4+ NMOSD may show a different (and higher risk) profile compared with seronegative patients within the NMOSD population, and compared with patients with MOGAD; however, data are limited (
Disease management raises common questions about how the disease, or its treatment, might affect a woman's potential for pregnancy, the course of pregnancy and its outcomes for both woman and child. For young female patients, this process should include future fertility considerations and an awareness that pregnancy may interact with their condition and/or treatments, with potentially adverse effects (
). In pregnancy, B-cell depleting therapies may be generally well tolerated, but may require any vaccinations to be given prior to therapy initiation to mitigate the effects of reduced immune response; these vaccinations may not always be suitable for pregnant women and, conversely, immunosuppression may undermine the effect of vaccines recommended during pregnancy (
N-MOmentum study investigators Inebilizumab for the treatment of neuromyelitis optica spectrum disorder (N-MOmentum): a double-blind, randomised placebo-controlled phase 2/3 trial.
Safety and efficacy of satralizumab monotherapy in neuromyelitis optica spectrum disorder: a randomised, double-blind, multicentre, placebo-controlled phase 3 trial.
), there are no currently approved treatments available for MOGAD. Of the currently available preventative medications that comprise standard treatment (prednisone, azathioprine, mycophenolate mofetil, rituximab, eculizumab, inebilizumab, satralizumab and tocilizumab (
); whilst azathioprine, rituximab, eculizumab and glucocorticoids are considered to be relatively safe in pregnancy and the treatments of choice for NMOSD during this period, in cases of relapse, consideration of non-fluorinated glucocorticoid treatment, plasma exchange or immunoadsorption is recommended (
Studies focused on pregnancy in NMOSD or MOGAD patients may provide insight into the management of the disease and the pregnancy. We have conducted the first systematic review to include evidence relating to either NMOSD or MOGAD in pregnancy and the postpartum period, to assess outcomes and potential management strategies for WOCBA and female adolescent patients with one of these diseases.
2. Methods
Literature searches of MEDLINE (accessed through PubMed) included citations published between January 2011 and November 2021. Searches were limited to studies performed in humans and all relevant article types were reviewed, including case reports, clinical studies and earlier reviews. Results in languages other than English were excluded after retrieval. Searches included “NMOSD” or “MOGAD” as well as expansions or similar descriptive terms that would allow us to capture patients retrospectively diagnosed with MOGAD given the recent changes in classification.
We also searched for terms relating to WOCBA, including disease course during pregnancy, treatment during pregnancy, effects on menstrual cycle and fertility, impact on the foetus and newborn, impact on lactation, treatment during lactation, and any treatment of WOCBA. Full listings of our search terms and strings are provided in supplementary table 1. Searches of the annual meeting archives (published abstract books) from the American Academy of Neurology, the European Academy of Neurology, the Americas Committee for Treatment and Research in Multiple Sclerosis, and the European Committee for Treatment and Research in Multiple Sclerosis from January 2019 to November 2021 for NMOSD or MOGAD were carried out in December 2021. Bibliographies of reviews were scanned, and authorial knowledge of the literature was used to supplement these searches and provide contextual citations, including those relating to the use of the immune treatments used in pregnancy in other diseases and which are commonly used in AQP4+ NMOSD or MOGAD.
Given the comparative paucity of studies in rare diseases, qualitative descriptions of key clinical findings were made where outcomes and endpoints differed too starkly for direct comparison and tabulation. Where endpoint definitions varied, notes and clarifications were made to ensure that the maximum data were captured. Studies were qualitatively assessed by the authors for reporting bias, heterogeneity of population and methodological robustness.
3. Results
The results of the systematic literature review are shown in Fig. 1. In total, 107 articles were reviewed, including 65 clinical studies, 30 case reports and 12 reviews. No previous systematic reviews included both NMOSD and MOGAD and there were few congress materials of relevance. In our searches, 84 articles were relevant to NMOSD only, 13 articles were relevant to MOGAD only and 10 were relevant to both. Moreover, only a subset of studies assessed disease activity before pregnancy, during pregnancy and postpartum, or the impact on pregnancy outcomes; this subset is summarised in Fig. 2.
) and a small cohort study found that, after diagnosis, women with NMOSD experienced more irregularities in their menstrual cycles than healthy controls (
). Data directly assessing fertility outcomes in NMOSD were limited. No studies or case reports identified in our review discussed the effect of MOGAD on fertility.
Sixteen retrospective studies and one prospective study provided data relating to WOCBA with NMOSD (
Influence of pregnancy on disease progression and activity of neuromyelitis optica spectrum disorder (NMOSD) among seropositive female patients In Isfahan, Iran.
Of 11 NMOSD studies that tracked ARR during pregnancy, one study showed an increase in ARR during the first trimester of pregnancy, compared with the pre-pregnancy period; patients were recruited to this retrospective study from 2011 to 2013, and most did not receive immunosuppressive treatment prior to or during pregnancy (
). Nine of the 11 NMOSD studies that tracked ARR postpartum described an increased ARR during the postpartum period compared to pre-pregnancy, particularly in the first trimester postpartum (P = 0.037–P<0.001) (
). Additionally, one study showed a significant increase in ARR during pregnancy and the first trimester after (most often elective) abortion, compared with before pregnancy (P = 0.008 and P = 0.019, respectively) (
). One of two MOGAD studies reported a lower ARR during pregnancy compared with pre-pregnancy levels, whereas the other reported no significant change; however, both found an increase in ARR relative to the pregnancy during the postpartum period (
Several studies identified an association in patients with NMOSD between continued/adequate immunosuppressive therapy and a lower risk of attacks during pregnancy (
). A further study found that pregnancy-related attacks (occurring in pregnancy or postpartum) were negatively associated with use of rituximab before pregnancy (
A summary of studies assessing pregnancy outcomes is shown in Fig. 4 and supplementary table 3. We identified 17 retrospective studies and one prospective study providing data relating to WOCBA with NMOSD (
Influence of pregnancy on disease progression and activity of neuromyelitis optica spectrum disorder (NMOSD) among seropositive female patients In Isfahan, Iran.
Data for mothers on outcomes such as pre-eclampsia, gestational diabetes and other complications were limited; only seven studies in total reported any such information and, of those, six reported occurrences of pre-eclampsia only. Rates of pre-eclampsia appeared to be in line with prevalence estimates for women without NMOSD or MOGAD (approximately 2–5% of pregnancies are affected, with variation between studies) (
The international federation of gynecology and obstetrics (FIGO) initiative on pre-eclampsia: a pragmatic guide for first-trimester screening and prevention.
) although interpretation should be cautious given the small number of pregnancies with these rare conditions considered. One study reported rates of pre-eclampsia in NMOSD that were comparatively high (>11%) relative to the general population. These were obtained from patients both before and after their diagnosis of NMOSD – which may indicate that rates were associated with autoimmune disorders that are themselves associated with NMOSD or may be a statistical artefact given the relatively small sample size (
) reporting rates of 56% and 62%, respectively. Higher rates of spontaneous abortion and stillbirths were observed for AQP4+ NMOSD compared with the general population (where data were available) (
). An overview of these core findings is presented in Fig. 4. Four studies reported mean birth weight, which ranged from 2444 g (in a cohort of untreated patients) to 3263 g; premature births were excluded from these data (
In pregnant women with MOGAD, only one study reported the proportion of healthy deliveries (given as 86%); malformations or neonatal complications were either stated as no cases observed or they were not reported (
). No study formally calculated the relative risk of spontaneous abortion. A case report described the occurrence 6 months postpartum of a severe and abrupt relapse with progression to respiratory failure; the patient was treated successfully with plasmapheresis with no further relapses on immunosuppression (
Table 1 complements the systematic review by summarising treatments commonly used in the studies we identified that are available for treatment of AQP4+ NMOSD and/or MOGAD, as informed by relevant guidelines from other neurological conditions (MG) in pregnancy and long-term use (
Note, indications listed are those considered relevant and not fully comprehensive. Table based on MG guidelines (Narayanaswami et al., 2021; Norwood et al., 2014).
This is the first systematic review to assess both the impact of AQP4+ NMOSD in WOCBA and the impact of MOGAD in WOCBA, and to assess each condition's trajectory through pregnancy and the postpartum period. The increasing recognition of MOGAD as an immunologically and clinically distinct disease from NMOSD and multiple sclerosis (MS) (
) represent an important milestone for patients, their carers and physicians. Our review contributes to discussions of these conditions as separate entities, while raising awareness of risks that may help to direct the treatment and monitoring of patients both during and after pregnancy (
It is generally accepted that pregnancy has an impact on autoimmune diseases – probably due to the effects of sex hormones on immune function – and can therefore alter the course of the disease (
). Our findings showed that pregnancy can alter the course of NMOSD, particularly in the postpartum period, but does not always do so; this is broadly consistent with a previous review describing pregnancy-related NMOSD attacks, which showed, in the studies reviewed, a consistent increase in relapse rates postpartum but variation across studies in relapse rates during pregnancy, compared with pre-pregnancy (
). For AQP4+ NMOSD, a marked increase in relapse risk occurs during the postpartum period, particularly in the first three months, compared with the pre-pregnancy period (
). For MOGAD, insufficient evidence exists to establish a strong conclusion, but it appears that a lower rate during pregnancy is followed by a rebound effect after birth (
). A retrospective analysis of a multicentre French MOGAD cohort, in which 25 pregnancies occurred post disease onset, identified no relapses during pregnancy and a slight increase in disease activity in the first 3 months postpartum (
A postpartum increase in relapse risk may result from changes in immune tolerance during pregnancy that are reversed after childbirth. It also seems plausible that discontinued or insufficient immunosuppression may be a risk factor for postpartum attacks in both conditions, suggesting that this period may require clinicians to act pre-emptively after childbirth to restore adequate suppression of the auto-immune response through intensive treatment. Data specifying which subsets of patients were off treatment during and after their pregnancies were limited by small sample size but were consistent with this observation. This represents a confounding effect in the data (some publications did not specify treatment state and others included patients who were diagnosed during pregnancy). Of note, among 144 WOCBA in the French MOGAD cohort, 12.5% experienced their first symptoms during pregnancy or the first year (primarily the first 3 months) postpartum, contrasting with the relatively low relapse rate in pregnancy and postpartum of women with prior-onset MOGAD; the authors suggest that this may partly relate to treatments received before and during pregnancy (
). More studies are needed to assess the relative risk of ceasing or reducing immunosuppression during and after pregnancy and to further characterise patient subsets.
Conversely, the issue of how these diseases affect pregnancy must also be considered. In terms of maternal complications (for example, pre-eclampsia or gestational diabetes) and neonatal malformations, frequency data were rarely presented with comparable, controlled background rates from an appropriately matched population. However, the data as a whole indicate a risk to healthy delivery among women with AQP4+ NMOSD. This is consistent with a preliminary analysis of the Collaborative International Research in Clinical and Longitudinal Experience Studies (CIRCLES) registry, in which prior-onset NMOSD was associated with a lower frequency of good pregnancy outcome (defined as live birth without pregnancy problems) and vaginal delivery, relative to pregnancies in women who developed NMOSD after pregnancy; NMOSD relapse in the year before delivery was also negatively associated with good pregnancy outcome (
). Placental AQP4 expression is high during mid-gestation, which could lead to activation of the classical complement pathway; while such pathway activation has not been demonstrated in NMOSD, AQP4 autoantibodies are implicated in other autoimmune diseases, including systemic lupus erythematosus, and in this context are known to be associated with higher rates of spontaneous abortion (
). Data on pregnancy outcomes in patients with MOGAD were limited, although risks appear to be lower than for patients with AQP4+ NMOSD. A recent analysis of 25 pregnancies occurring after onset of MOGAD identified one miscarriage and two preterm births (frequencies similar to those observed in the general population (
Given not only an absence of extensive data, but also comprehensive guidelines for managing pregnancy in women with AQP4+ NMOSD or MOGAD, clinicians have needed to rely on existing data on the diseases outside pregnancy to assess risk of relapse and respective severity, on their own observations of disease in individual patients, and on adapting relevant guidelines from other rare neurological diseases. Critical decisions include whether to sustain or change an established regimen in light of a pregnancy (or if planning for pregnancy). A national UK workshop exploring best practice guidelines for MG in pregnancy identified strategies that, from our review, appear relevant for AQP4+ NMOSD and MOGAD as another autoimmune disorder: optimising a regimen prior to conception with a view to ensuring stable control throughout the pregnancy (
). The guidelines further indicated that pyridostigmine, prednisolone, azathioprine and ciclosporin/tacrolimus are supported, but mycophenolate mofetil and methotrexate should be stopped pre-pregnancy due to their teratogenic effects (
). The French MS Society has recently developed 66 evidence-based recommendations for pregnancy in women with NMOSD, covering topics including pregnancy planning, pregnancy and postpartum follow-up, delivery routes, relapse prevention and management, and disease-modifying treatments (
). In relation to preventative treatment, the guidelines recommend that mycophenolate mofetil is discontinued pre-pregnancy; rituximab and tocilizumab should be used during pregnancy only in exceptional cases (and following group discussion) where there may be no satisfactory alternative; continuation of eculizumab in pregnancy should be subject to group discussion, owing to insufficient evidence; and azathioprine can be continued before and during pregnancy if disease activity requires it. Where treatment has been stopped, early resumption following childbirth is recommended to reduce the risk of postpartum relapses (
Although no treatments have been specifically validated for pregnant women with AQP4+ NMOSD and MOGAD, safety data from other patient populations may be relevant. In particular, data are available for eculizumab and rituximab, summarised in recent guidelines for MG (
). The use of eculizumab during pregnancy (which has been trialled in AQP4+ NMOSD) is supported by data from a 10-year paroxysmal nocturnal haemoglobinuria cohort: of 260 cases of eculizumab exposure in pregnant women, 70% resulted in live births, with no new safety signals (
). An analysis of rituximab use before and during pregnancy included a case study series of 11 pregnancies (one ongoing) comprising seven patients with MS and three with NMOSD, all of which resulted in full-term live births of healthy newborns (one lost to follow-up); conception occurred within 6 months of exposure to rituximab, but no patient in the case series received rituximab while pregnant. The authors also observed from a systematic review of 102 pregnancies that rituximab use within 6 months prior to conception did not identify any major safety concerns (
). Similarly, a recent cohort study in 81 women, including 10 with NMOSD, found that pregnancy outcomes following anti-CD20 therapy (rituximab or ocrelizumab) in the year before pregnancy were within the expected range for the population; however, when treatment was given during pregnancy, an increase in preterm births was observed and two cases of major congenital abnormality, both in patients with relapsing-remitting multiple sclerosis who had received ocrelizumab, occurred (
). Preliminary analysis of data from the CIRCLES registry associated rituximab treatment in the year before delivery to be negatively associated with good pregnancy outcomes in patients with prior-onset NMOSD (
). Our findings, considering the limitations of the level of evidence, may support use during pregnancy of both rituximab and eculizumab as potential treatment options where other drugs more conventionally used in pregnancy are not appropriate.
The anti-CD19 antibody inebilizumab is indicated for treatment of AQP4+ NMOSD. Like rituximab (an anti-CD20 antibody), it is a B-cell-depleting therapy, and additionally targets CD19-positive plasmablasts and plasma cells (
). Product information advises that, as a precautionary measure, it is preferable to avoid inebilizumab use during pregnancy and in WOCBA not using contraception (
). Satralizumab, an anti-IL-6R antibody, is also indicated in AQP4+ NMOSD. Teratogenic effects are not expected because of its similarity to tocilizumab (which lacks an NMOSD indication), but pregnancy risks require investigation (
). Product information advises against tocilizumab use in pregnancy unless clearly necessary, and that it is preferable to avoid satralizumab use in pregnancy as a precautionary measure (
Different risk–benefit calculations for MOGAD support divergent choices in regimen prior to pregnancy, given that it can be considered a less disabling condition than NMOSD (
). Prednisolone is not contraindicated and can be maintained during pregnancy. Regular IVIg may incur a potential risk of maternal hypovolemia and hyperviscosity, leading to a subsequent risk of thromboembolism; this requires monitoring, but IVIg is generally considered safe based on its use in pregnancy in other conditions (
Our conclusions are necessarily provisional given a paucity of data – particularly for MOGAD – and a secondary outcome of this review is a mapping of current gaps in the literature which may help to identify avenues for future research. No studies were found assessing the impact of MOGAD on fertility, and while no significant effects were identified for AQP4+ NMOSD, data are currently limited. It is known that AQP4 is expressed in the female reproductive tract (
), theoretically indicating a potential for AQP4 autoantibodies to affect reproductive function, and so the relationship between these conditions and reproductive potential may require further elucidation. Conversely, data on the potential impact of current treatments on fertility were minimal, yet greatly needed if clinicians are to support not only the choices of WOCBA, but also the future and transitional needs of female adolescent patients. Choosing the safest possible treatment that preserves the health of the mother is essential for those seeking to get pregnant (
). Of currently used treatments, corticosteroids, azathioprine and IVIg are not contraindicated when breastfeeding, although mycophenolate mofetil or methotrexate are advised against (
While clinical studies on pregnancy and the postpartum period in both conditions were found, this systematic review has limitations. Some are noted in passing above; many relate to variability in reporting. For instance, the choice of endpoints varied substantially, and no studies reported the reasons for elective abortion; we note that some patients may have been reluctant to volunteer this information. The number of stillbirths was not reported or could not be calculated for five studies. Other limitations are consistent with the challenges of recruiting pregnant patients with rare diseases, notably heterogeneous patient populations and retrospective study designs. There have been three recent therapies approved in AQP4+ NMOSD that are not represented in the studies we identified. In MOGAD, randomised clinical studies are underway to investigate potential new therapies: NCT05063162 (cosMOG; (
) will investigate the IL-6 inhibitor satralizumab. As with many investigational clinical studies, however, pregnancy is an exclusion criterion. The French RESPONSE registry (NCT03900221 (
)) may complement these data as an initiative designed to monitor pregnancy in neurological disorders, and is currently recruiting women with MS, NMOSD or MOGAD who will be followed through pregnancy and up to 6 years postpartum.
5. Conclusions
Our review provides an overview of the evidence base relating to AQP4+ NMOSD and MOGAD disease and treatment outcomes during pregnancy and the postpartum period. There is a rise in annualised relapse rate postpartum that may require adaptation of treatment regimens; increased risk of relapse in MOGAD is suggested, but strong conclusions cannot be made due to a paucity of available data. The observation in AQP4+ NMOSD and suggestion in MOGAD that the postpartum period is associated with a greater risk of relapse and so should trigger careful management and treatment adjustment is consistent with existing literature. To further substantiate and extend these findings, there is a need for further clinical research on the management, course and outcomes of AQP4+ NMOSD and particularly MOGAD in WOCBA. Notable gaps to be addressed in future research include greater consideration of the impact of disease and treatment on fertility, the long-term impacts of treatments started during childhood, the impacts of these diseases on pregnancy outcomes on the infant in addition to the mother and a greater understanding of the impacts of these diseases on lactation and sexual function.
Jacqueline Palace has received support for scientific meetings and honorariums for advisory work from Merck Serono, Novartis, Chugai, Alexion, Roche, Medimmune, argenx, Sanofi, UCB Pharma, Mitsubishi, Amplo Biotechnology and Janssen. She has received grants from Alexion, Roche, Medimmune and Amplo Biotechnology. She holds patent ref. P37347WO and licence agreement with numares multi-marker MS diagnostics. She has shares in AstraZeneca. Her NMO service is funded by Highly Specialised Services NHS England.
Zoya Panahloo is an employee and stockholder of UCB Pharma.
Niall Harrison was an employee of Ogilvy Health UK at the time of the study.
M Isabel Leite has received funding from the NHS (Myasthenia and Related Disorders Service and National Specialised Commissioning Group for Neuromyelitis Optica, UK) and the University of Oxford, UK. She has been awarded research grants from the UK association for patients with myasthenia (The Myaware) and the University of Oxford. She has received speaker honoraria or travel grants from Biogen Idec, Novartis, UCB Pharma and the Guthy-Jackson Charitable Foundation. She also serves on scientific or educational advisory boards for UCB Pharma, argenx and Viela/Horizon.
Role of the funding source
This literature review was conducted by Ogilvy Health on behalf of the authors and funded by UCB Pharma. One of the authors (ZP) is an employee of UCB Pharma. Other than ZP, the funder had no role in study design, data collection or data analysis. Other employees at UCB and professional medical writers provided publication support, as detailed in the Acknowledgements.
Acknowledgments
This research was funded by UCB Pharma. Medical writing support was provided by Charlotte Mulcare and Mary Berrington for Ogilvy Health UK, funded by UCB Pharma, in accordance with Good Publication Practice 3 guidelines (http://www.ismpp.org/gpp3). The authors thank Margarita Lens, CMPP, of UCB Pharma for publication and editorial support.
Influence of pregnancy on disease progression and activity of neuromyelitis optica spectrum disorder (NMOSD) among seropositive female patients In Isfahan, Iran.
Gestational weight gain across continents and ethnicity: systematic review and meta-analysis of maternal and infant outcomes in more than one million women.
Neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein associated disorder-optic neuritis: a comprehensive review of diagnosis and treatment.
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Note, indications listed are those considered relevant and not fully comprehensive. Table based on MG guidelines (