Severe Neuroinammatory Relapse After Extrauterine Pregnancy and Abortion: A Case Report on a Patient With Heterogenic Ms Phenotype Carrying Myelin Oligodendrocyte Glycoprotein Autoantibodies

Background. Pregnancy has disease-modifying effects in MS. First trimester abortion might be followed by increased MS activity. MS with myelin oligodendrocyte glycoprotein (MOG) autoantibodies is a rare and agressive disease variant. Results. and Conclusions. Pregnancy in combination with MOG antibody carriership and termination of dimethyl fumarate just of MS.


Background
In women with multiple sclerosis (MS), relapse frequency declines during pregnancy, particularly during the third trimester. After delivery, the relapse rate is higher than before pregnancy in the rst three months, and eventually decreases to the baseline level . (1) The effects of abortion on MS are not completely understood. A recent study by Landi et al. showed that abortion was associated with a clinical and radiological rebound effect 12 months post-event. (2) Here, we review a case of a 43-year-old woman who developed a drastic neuroin ammatory rebound after an extrauterine pregnancy and a laparoscopic abortion.

Materials And Methods
A woman born in 1976 in the Middle East and moved to Sweden in 2007 was diagnosed with MS in 2010.
Patient was enrolled in to STOPMS-II study. Study was approved by Regional Ethical Committee in Stockholm ethical permit DNr 2009/2017-31/2 "STOPMS-II". Patient signed informed concent to participate in thie studyand patient provided written informed consent for clinical information and images to be published. In her medical history, she had a conservatively treated meningioma, hypertension and gastroesophageal re ux disease. She had no known heredity for neurological diseases. She rst presented with optic neuritis in 2008, during her rst pregnancy. McDonalds diagnostic criteria 2005 were ful lled.(3) A myelin oligodendrocyte glycoprotein (MOG) antibody test was not available at that time.
Brain MRI just prior to MS diagnosis showed nine T2 lesions and MRI of the spinal cord showed 2 short myelitis lesions. At 2013 brain and spinal cord MRI showed pictures typical for MS with multiple short myelitis lesions. Until 2015, no radiological ndings supported a diagnosis other than MS, as no longitudinally extensive myelitees were found.
During the period 2011-2014 patient was treated with interferon beta-1a, Expanded disability status scale (EDSS) was 4.0 (2011). The treatment was changed to dimethyl fumarate (DMF) in 2014, due to relapses and new MRI lesions. MRI of brain and spinal cord showed no new lesions, while treated with half dose of DMF during the period January 2015 -April 2019. The DMF treatment was discontinued in August 2019, as the MRI had not shown any new lesions between April 2018 and April 2019, and the patient was considered to have a secondary-progressive disease course with EDSS 7.5. In addition to impaired gait, she also had urinary incontinence, dysphagia and reduced vision, as well as pseudobulbar affects.
In August 2019, the patient sought emergency care for lower abdominal pain and vaginal bleeding. She was diagnosed with tubal pregnancy, with increased levels of serum chorionic gonadotropin 7600 IE/L, indicating pregnancy at week 6. A salpingectomy was performed with no gynaecological complications.
A month before the abortion, the patient had experienced a worsening of her gait: she could no longer take any steps or stand up without falling. The EDSS was 8.0.   Brain MRI sequences prior and post abortion. Images 1a, 1b. Brain MRI, 3D T2-weighted FLAIR sequences, sagittal image 73 (out of 176) demonstrating radical increase in brain contrast number of T2 lesions between April (1a) and November 2019 (1b, bright arrows). 1c, 1d: 3D T2-weighted FLAIR sequences, sagittal image 109 (out of 176) demonstrating radical increase in brain contrast number of T2 lesions between April (1c) and November 2019 (1d, bright arrows). 1e: 3D T1 weighted sequences with