Multiple Sclerosis in Pregnant and Postpartum Women

Abstract

This case study involves a patient with multiple sclerosis (MS) and her care during the postpartum period. MS is a chronic disease of the central nervous system. A common feature is that the body’s immune system starts attacking healthy tissue by mistake. Specifically, the body attacks the myelin sheath that protects nerve cells. In 2017, a 29-year-old gravida 5, para 5 woman, while participating in a MS medication trial, was found to be pregnant. During her stay in the hospital, she received gabapentin for MS and was scheduled to have a rituximab infusion before discharge. Many women with MS will have an exacerbation of symptoms during the postpartum period. In this case, after coordinating care among postpartum, neurology, management, obstetric providers, and staff, we were able to transport the patient to our high-risk unit on Postpartum Day 4 for rituximab infusion. A neurological assessment, mobility, and pain assessment were performed by nursing and neurology staff on arrival in the unit. The woman was alert and knew who she was, where she was, and the approximate time (i.e., oriented ×3); a 10/10 headache was noted, and decreased strength–sensation was noted in the extremities. The patient was placed on cardiac monitoring and premedicated 30 min before the administration of rituximab. A hydrocortisone injection was ordered to have at bedside in case of an adverse reaction. Medication titration was based on the patient’s toleration to treatment. The infusion rate was started at 50 mg/hr and increased by 50 mg/hr every 30 min. The patient started to feel “flu like” symptoms at a rate of 100 mg/hr, so dosing was held there. When infusion completed, the patient reported increased mobility and decreased pain. She was transferred back to the postpartum unit for discharge to home. The patient was educated on hand washing and infection prevention, advised to avoid walking while holding her newborn when she felt unsteady, and informed of the need of assistive devices for walking at home if need be. Contact information for neurology and transfusion center follow-up information were provided.