Updated Perspectives on the Challenges of Managing Multiple Sclerosis During Pregnancy

Abstract

Multiple sclerosis (MS) is a chronic immune-mediated, inflammatory, and degenerative disease that is up to three times more frequent in young women. MS does not alter fertility and has no impact on fetal development, the course of pregnancy, or childbirth. The Pregnancy in Multiple Sclerosis Study in 1998 showed that pregnancy, mostly in untreated women, did not adversely affect MS, as disease activity decreased during pregnancy (although it significantly increased in the first trimester postpartum). These findings, together with the limited information available on the potential risks of fetal exposure to disease modifying treatments (DMTs), meant that women were advised to delay the onset of DMTs, stop them prior to conception, or, in case of unplanned pregnancy, discontinue them when pregnancy was confirmed. Now, many women with MS receive DMTs before pregnancy and, despite being considered a period of MS stability, up to 30% of patients could relapse in the first trimester postpartum. Factors associated with an increased risk of relapse and disability during pregnancy and postpartum include relapses before and during pregnancy, a greater disability at the time of conception, the occurrence of relapses after DMT cessation before conception, and the use of high-efficacy DMTs before conception, especially natalizumab or fingolimod. Strategies to prevent postpartum activity are needed in some patients, but consensus is lacking regarding the therapeutic strategies for women with MS of a fertile age. This, along with the increasing number of DMTs, means that the decision-making processes in aspects related to family planning and therapeutic strategies before, during, and after pregnancy are increasingly more complex. The purpose of this review is to provide an update on pregnancy-related issues in women with MS, including recommendations for counseling, general management, use of DMTs in pre-pregnancy, pregnancy, and postpartum periods, and breastfeeding-related aspects of DMTs.

Pregnancy and reproductive health in women with multiple sclerosis: an update

“…Nonetheless, the trend of increased ARR postpartum, even considering the lower baseline ARR in a variety of modern cohorts, has persisted. Relapse activity in the year before pregnancy is the strongest predictor of intrapartum, and postpartum relapses in WwMS [5,56,[60][61][62].…”

“…The sensitivity and specificity of the revised MS diagnostic criteria also helped contribute to earlier and more accurate diagnosis, and to the increasing proportion of women who become pregnant after an MS diagnosis [4]. Up to 50% of couples who have not had children before MS diagnosis want to start a family in the future, and up to 25% of women plan a pregnancy in the 2 years following their diagnosis [5]. It has been estimated that 20-30% of women with MS will deliver a child after disease onset, but these numbers are increasing [6].…”

Insights for Healthcare Providers on Shared Decision-Making in Multiple Sclerosis: A Narrative Review

“…MS affects more women than men, at a ratio of approximately 3:1; it is also on the rise among young women [ 21 ]. For women with MS in their child-bearing years and couples planning a pregnancy, SDM is a critical aspect of selecting a DMT because treatment selection must balance the benefit to the patient against potential risk to the fetus [ 22 ]. Additionally, many DMTs, including alemtuzumab, natalizumab, ocrelizumab, cladribine, teriflunomide, fingolimod, siponimod, ozanimod, and ponesimod, are contraindicated or not recommended during breastfeeding, or only recommended if the benefit justifies the risk to the infant [ 22 ].…”

Disparities by Race in Pregnancy Care and Clinical Outcomes in Women With Multiple Sclerosis

“…Women represent three-quarters of people with multiple sclerosis (MS) and are most often diagnosed during their reproductive years. 1 After the immunotolerant state of pregnancy, postpartum MS relapse risk 2 is influenced by both disease-related factors (disability before pregnancy and relapse rate) 3 and treatment-related 3 , 4 and breastfeeding 5 practices. Therefore, quality and type of care could influence MS outcomes.…”