Abstract
Objective To review the current evidence regarding pregnancy-related issues in multiple sclerosis (MS) and to provide recommendations specific for each of them. Research design and methods A systematic review was performed based on a comprehensive literature search. Results MS has no effect on fertility, pregnancy or fetal outcomes, and pregnancies do not affect the long-term disease course and accumulation of disability. There is a potential risk for relapse after use of gonadotropin-releasing hormone agonists during assisted reproduction techniques. At short-term, pregnancy leads to a reduction of relapses during the third trimester, followed by an increased risk of relapses during the first three months postpartum. Pregnancies in MS are not per se high risk pregnancies, and MS does not influence the mode of delivery or anesthesia unless in the presence of significant disability. MRI is not contraindicated during pregnancy; however, gadolinium contrast media should be avoided whenever possible. It is safe to use pulse dose methylprednisolone infusions to manage acute disabling relapses during pregnancy and breastfeeding. However, its use during the first trimester of pregnancy is still controversial. Women with MS should be encouraged to breastfeed with a possible favorable effect of exclusive breastfeeding. Disease-modifying drugs can be classified according to their potential for pregnancy-associated risk and impact on fetal outcome. Interferon beta (IFNβ) and glatiramer acetate (GA) may be continued until pregnancy is confirmed and, after consideration of the individual risk-benefit if continued, during pregnancy. The benefit of continuing natalizumab during the entire pregnancy may outweigh the risk of recurring disease activity, particularly in women with highly active MS. GA and IFNβ are considered safe during breastfeeding. The use of natalizumab during pregnancy or lactation requires monitoring of the newborn. Conclusions This review provides current evidence and recommendations for counseling and management of women with MS preconception, during pregnancy and postpartum.
Highlights
Multiple sclerosis (MS) is a chronic autoimmune condition affecting the central nervous system (CNS)
The findings revealed that: (1) the annualized relapse rate (ARR) during pregnancy decreased during the third trimester of pregnancy to 0.2; (2) there was an increased ARR (1.2 during the first 3 months postpartum, in which nearly 30% of patients experienced relapses; (3) the overall ARR in the pregnancy year (9 months of pregnancy and 3 months postpartum) was similar to the antepartum rate; (4) the disease activity steadily returned to levels observed preconception[50,51,52]; (5) no change in disability progression was observed during the study period
MS has no effect on fertility, pregnancy and fetal outcomes, and pregnancies do not have a negative impact on the longterm disease course and accumulation of disability
Summary
Multiple sclerosis (MS) is a chronic autoimmune condition affecting the central nervous system (CNS). Relapses being the clinical expression of the acute inflammatory process, and progression being related to chronic diffuse axonal and neuronal degeneration[1]. A recent study in female patients with MS, revealed that 47% of patients felt inadequately informed about their disease-modifying therapy (DMT) use during pregnancy[5]. This highlights the importance of discussing with the patient reproductive and pregnancy related-issues including impact of MS on fertility and fetal development; MS medications before, during and after pregnancy; effect of pregnancy on the MS prognosis in short- and long-term; DMT use and recommended washout periods, monitoring of relapses and disease activity during pregnancy, delivery and anesthetic choice, postpartum disease activity and breastfeeding. The objective of this review is to assess the current evidence regarding the short-term effects of pregnancy on MS and provide evidence- and experience-based practical guidance for the treatment of MS in women of childbearing age before conception, during pregnancy and lactation
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