Recommendations for neurological, obstetrical and gynaecological care in women with multiple sclerosis: a statement by a working group convened by the Section of Multiple Sclerosis and Neuroimmunology of the Polish Neurological Society

Abstract

Introduction. Multiple sclerosis (MS) is the most common non-traumatic neurological cause of disability in young adults, affecting women 1-3 times more often than men. Several specific challenges arise from the fact that young women diagnosed with MS often have to make decisions related to treatment and family planning at the same time. These issues are connected with fertility, the impact of pregnancy on disease course, the choice of pregnancy timing, and the optimal mode of disease-modifying therapy in the context of a planned pregnancy, contraception, urological complaints, and sexual dysfunction. State of the art. While MS does not in itself adversely affect fertility, pregnancy or childbirth, pregnancy needs to be carefully planned. This requires the interdisciplinary cooperation of a neurologist, gynaecologist and psychologist. Data on the impact of disease-modifying drugs on foetal development are very limited, and none of these drugs is 100% safe during pregnancy. In the second and third trimesters, MS relapse rate decreases. Unfortunately, it increases within the first 3-6 months after delivery. Adequate disease control should be achieved before pregnancy, as relapse rate in the period of two years preceding pregnancy is one of the strongest predictive factors for post-partum relapses. Clinical implications. The following is a statement by a working group of experts in neurology, gynaecology, obstetrics and urology, convened by the Section of Multiple Sclerosis and Neuroimmunology of the Polish Neurological Society, addressing the issues that are specific to the female MS population. The aim of this statement is to provide guidance in pregnancy planning and disease management, both during pregnancy and post-partum. Future directions. This statement reflects expert opinion and is not intended to be read as guidelines. It rather provides up-to-date information on how to optimise care of female MS patients of childbearing age.

The Rate of Hospitalization of Pregnant Women with Multiple Sclerosis in Poland

“…Among women with active disease, the decision to start immunomodulatory therapy should not be delayed, and pregnancy is not recommended during this period. According to the current ECTRIMS/EAN guidelines (2018), when a patient with MS plans to become pregnant, the patient’s clinical status should first be established (i.e., no relapses for at least 1–2 years), and then pregnancy should be attempted [ 26 ]. If there is a high risk of disease reactivation during pregnancy, treatment with IFN beta or GA may be considered until pregnancy is confirmed [ 26 ].…”

“…According to the current ECTRIMS/EAN guidelines (2018), when a patient with MS plans to become pregnant, the patient’s clinical status should first be established (i.e., no relapses for at least 1–2 years), and then pregnancy should be attempted [ 26 ]. If there is a high risk of disease reactivation during pregnancy, treatment with IFN beta or GA may be considered until pregnancy is confirmed [ 26 ]. Continuation of therapy with GA or with beta interferons may be considered in selected cases (in active disease), if the potential benefit outweighs the risk associated with the therapy [ 26 ].…”

“…If there is a high risk of disease reactivation during pregnancy, treatment with IFN beta or GA may be considered until pregnancy is confirmed [ 26 ]. Continuation of therapy with GA or with beta interferons may be considered in selected cases (in active disease), if the potential benefit outweighs the risk associated with the therapy [ 26 ].…”

“…To sum up, in accordance with the Polish guidelines of 2020, the continuation of natalizumab treatment during pregnancy should be considered after careful discussion with patients of the potential implications (e.g., hematological disorders of the newborn) in patients with high disease activity who are treated with natalizumab and intend to become pregnant when stabilization disease is not achieved [ 26 ]. In the aggressive course of the disease, consideration should be given to such therapy, the discontinuation of which will not be associated with the risk of reactivation (cladribine or alemtuzumab).…”

The Potential Preventive Effect of Pregnancy and Breastfeeding on Multiple Sclerosis

“…Results of univariate analysis (only) showed that pregnancy before CIS was protective for CDMS, but pregnancy after CIS was protective in both analyses (univariate and multivariate) D'Hooghe et alThe pregnant group had a significantly shorter time of conversion to the first neurological event 15.3 months(10)(11)(12)(13)(14)(15)(16)(17)(18) than that of the nonpregnant group 35.7 months The pregnant group had significantly higher number (mean±SD) of active lesions on a brain MRI scan (3.2±1.7) than that of the control group(1.8±0.6) …”