Pregnancy: Effect on Multiple Sclerosis, Treatment Considerations, and Breastfeeding

Abstract

Multiple sclerosis (MS) commonly affects women in childbearing years making pregnancy issues important for patients with MS and their families. Pregnancy is a naturally occurring disease modifier of MS associated with a 70% reduction in relapse rates in the third trimester. This relapse rate reduction during the last trimester is roughly equal to the most effective disease-modifying treatments for MS. Given this efficacy, various pregnancy factors have been tested to determine which play a part in pregnancy's protection, and some have been translated to completed and ongoing phase II clinical trials. In contrast to protective effects during pregnancy, the postpartum period entails increased relapse risk, which may be due to either abrupt removal of protective pregnancy factors after delivery or to unique deleterious factors inherent to the postpartum period. The effect of breastfeeding on MS remains unclear. The best predictor for whether a patient will have a postpartum relapse is the incidence of her having active relapsing MS prior to pregnancy. The medical management of MS during pregnancy and the postpartum period is challenging given the risks of medication exposure to the fetus in utero and to the infant through breast milk. This review will focus on clinical aspects of pregnancy, including the effects of pregnancy on MS disease activity, as well as the medical management of MS during pregnancy and postpartum.

Pregnancy outcomes in Portuguese women with multiple sclerosis: The PREGNIMS study

“…Multiple sclerosis (MS) usually affects women in childbearing age, making the effect of pregnancy on the disease (and vice versa) an important clinical issue (Voskuhl and Momtazee, 2017). It is now well established that the risk of relapse significantly declines during pregnancy, particularly during the third trimester, only to increase threefold in the first three-to-four months postpartum, compared with the pre-pregnancy period (Nelson et al, 1988;Confavreux et al, 1998).…”

The Potential of Computational Modeling to Predict Disease Course and Treatment Response in Patients with Relapsing Multiple Sclerosis

“…Another aspect that we took into account was the pregnancy condition of some female patients. Several findings report that pregnancy ameliorates MS and other cell-mediated autoimmune conditions like psoriasis and rheumatoid arthritis through a temporary status of enhanced immunomodulation [54,55]. In this case, during the pregnancy period, we simulated an increased activity of the central and peripheral mechanisms of immune tolerance, leading to a lesser activation of auto-reactive T and B clones directed against ODC.…”

Pregnancy and Multiple Sclerosis: An Update on the Disease Modifying Treatment Strategy and a Review of Pregnancy’s Impact on Disease Activity

“…For the most part, for patients who are not pregnant or breastfeeding, MS relapses are treated by administering methylprednisolone intravenously or its analog orally [6]. Following the FDA pregnancy risk classification, corticosteroids are labeled in the pregnancy risk category C. Use of corticosteroids during the first trimester of pregnancy should be avoided as these drugs have been linked to fetal malformations, such as orofacial clefts among women using corticosteroids early in pregnancy [48].…”

“…The increasing number of MS among women of reproductive age remains a clinical issue, as the variety of disease modifying therapies (DMTs) holds possible side effects for the fetus and the woman before or after conceiving. Through the pre-conception, pregnancy and post-partum periods there is a need for disease control management to decrease chances of MS relapses while avoiding the potential risks to the mother and the fetus [6].…”