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Multiple sclerosis and pregnancy

Multiple Sclerosis and Related Disorders, Volume 3, Issue 6, November 2014, Pages 770

Multiple sclerosis (MS) is a chronic, neurodegenerative disease that has a high impact on patients׳ quality of life. The majority of diagnosed patients are women of childbearing age, making pregnancy-related issues (conception, contraception, childbirth, lactation) a key concern. MS typically stabilizes during pregnancy, particularly in the last trimester. Evidence suggests that the disease does not affect fertility, delivery, fetal health or pregnancy itself and does not cause birth defects. There is no increase in spontaneous abortions although a decreased birth weight has been reported. Epidural analgesia is safe in women with MS and hasn´t worsened disability in the postpartum period. Small differences in MS risk according to month of birth have been reported (higher in spring, lower in autumn). MS risk is lower among women born to mothers with high vitamin D intake during pregnancy, supplementing vitamin D-deficient mothers could be useful. No single gene produces MS . The risk for MS is about 2% for a child with one MS parent, and 6–12% for children where both parents have MS.

Regarding the course of the disease, pregnancy had no effect on disability and no negative long-term impact. It seems that pregnancy could accelerate disease in RIS patients.

High relapse rate or disability before pregnancy as well as relapse during pregnancy, have been associated with increased risk for postpartum attacks. An increase in new or enlarging MRI lesions post-partum was reported in several studies.MS itself does not pose any obstacles to breastfeeding and there is no risk of disease transmission through breast milk. Conflicting data indicate either no effect from breast-feeding or a positive benefit in reducing MS activity.

The FDA has said that DMTs should not be used in MS patients who are pregnant, trying to become pregnant, or breast-feeding. Even though studies which have considered this aspect have found no effect of glatiramer acetate and only minor adverse effects of interferons. Glatiramer acetate has the most favorable pregnancy rating (class B). Natalizumab, fingolimod and BG12 have been given a pregnancy category C rating by the FDA based on results of animal studies and teriflunomide has been designated pregnancy category X. It is also recommended to discontinue symptomatic therapies prior to conception if they are not absolutely necessary. A short course of high-dose corticosteroids to hasten recovery from disabling relapses appears relatively safe during pregnancy, but there is a possible increased risk of fetal cleft palate associated with their use in the first trimester. There is little information regarding effects of MS disease modifying treatments on human male fertility or pregnancy outcomes in fathers receiving treatment.

Footnotes

Consultant Neurologist, University Hospital San Carlos, Madrid, Spain