Multiple Sclerosis

What is multiple sclerosis during pregnancy?

Multiple sclerosis (MS) is a condition that affects the brain, spinal cord, and optic nerves. It is a chronic disease (begins gradually and continues throughout life). It can progress slowly over time, getting worse gradually, or it can occur in flare-ups separated by periods of remission. Either way, it results in increasing disabilities in movement and sensation, as well as problems in balance and urination. MS can occur during pregnancy because often it begins in the middle of life. In many cases, the disease can improve during pregnancy but then returns after the woman gives birth. It is thought that MS is caused by the persons own immune system immune attacking sheaths of fat-like material called myelin that surrounds axons, the long appendages of neurons (nerve cells). Since its the myelin that allows healthy axons to transmit electrical signals rapidly, the destruction of the myelin sheaths interferes with nerve tracts, which are bundles of axons that carry signals through the brain and spinal cord.

How common is multiple sclerosis during pregnancy?

MS typically begins in those aged 20-45 years. Furthermore, the condition is twice as common in females as in males. These two factors mean that a high proportion of patients who develop MS also will have the condition when they are pregnant. Other than age and gender, the following factors increase your risk of developing MS:

• Having a sibling or parent with MS, and especially having an identical twin with MS.
• Being of European (Caucasian) descent
• Living at higher latitude locations (farther from the Equator), especially during the first few years of life
• Higher socioeconomic status
• Possibly, deficiency of vitamin D
• Possibly tobacco use, or secondhand exposure
• Possibly, previous infection with Epstein-Barr virus, the most common cause of mononucleosis

How is multiple sclerosis diagnosed?

Evaluation of possible MS begins with a discussion of the patients history that highlights troubles in movement and vision and also provides your doctor with information about any family member(s) who are known to have had MS, or who may have had the condition. After the history, the physician will move to a physical examination, which will include testing of your vision and muscles that move the eye, tests of your reflexes (including the response of your pupils to light), and evaluation of your ability to think and remember. If suspicion for MS is present following the physical examination, you will be referred to a neurologist, who will do a more thorough physical examination and history, and will them move to laboratory tests and imaging. The laboratory tests will be performed on blood samples and will be chosen so as to identify signs that the immune system has been attacking the nervous system. The actual diagnosis of MS will be made based on imaging, particularly magnetic resonance imaging (MRI), which can identify about 90 percent of cases. The neurologist also may order special electrical tests of your muscles, and whats called a lumbar puncture in which a needle is inserted into the canal that surrounds your lower spinal cord, in order to draw out fluid for additional tests.

Does multiple sclerosis cause problems during pregnancy?

Multiple sclerosis often improves during pregnancy. However, if the disease has already progressed to disabilities involving movement (including walking difficulty), balance, and trouble controlling the bladder, these can get worse as your belly grows.

Does multiple sclerosis during pregnancy cause problems for the baby?

Multiple sclerosis often improves during pregnancy, so usually, the disease does not affect the developing baby directly. However, the treatments usually need to be altered, if possible even before pregnancy begins, because the management depends on medications, several of which may not be safe during pregnancy.

What to consider about taking medications when you are pregnant or breastfeeding:

• The risks to yourself and your baby if you do not treat the multiple sclerosis. These can be significant for those with moderate to severe multiple sclerosis
• The risks and benefits of each medication you use when you are pregnant
• The risks and benefits of each medication you use when you are breastfeeding

What should I know about using medication to treat multiple sclerosis during pregnancy?

An important group of medications used for MS is called immunomodulating agents. Examples are natalizumab, alemtuzumab, ocrelizumab, rituximab, glatiramer acetate, and interferon-beta. The purpose of these agents is to prevent the occurrence of new attacks, but you must stop taking these, and some other MS-fighting agents, during pregnancy, and many of the agents must be washed out of the body before pregnancy even begins. One exception is natalizumab, which may be considered for use in pregnant patients with MS if the disease is extremely severe.

Washout is achieved by having you stop using the agent for a particular amount of time before becoming pregnant. The amount of time needed for washout depends on the drug, but here are the common examples. Fingolimod requires a 2-month washout period before pregnancy. Dimethyl fumarate and natalizumab both require a pre-pregnancy washout period as close to one month as possible. Alemtuzumab requires a 4-month pre-pregnancy washout, whereas Mitoxantrone requires a 6-month washout. Teriflunomide requires a special, accelerated elimination procedure to bring the levels in your blood down below a certain amount (0.02 µg/ml) prior to pregnancy. If MS does flare up during pregnancy, doctors can treat you with a steroid called methylprednisolone, given intravenously.

Who should NOT stop taking medication for multiple sclerosis during pregnancy?

Women with very severe, active MS, may need to continue taking natalizumab. For those who discontinue medications prior to pregnancy but experience a flare-up during pregnancy, treatment with methylprednisolone is necessary.

What should I know about choosing a medication for my multiple sclerosis during pregnancy?

Each class of medications has benefits and drawbacks, but multiple sclerosis often improves during pregnancy, thereby compensating for the withdrawal of medications. Otherwise, MS can be a clinical dilemma. Whenever possible, your doctor will try to control MS flare-ups with methylprednisolone.

You may find Pregistrys expert reports about the individual medications used to treat this condition here. Additional information can also be found in the sources listed at the end of this report.

What should I know about taking a medication for my multiple sclerosis when I am breastfeeding?

A high degree of uncertainty surrounds the question of MS treatment safety in connection with breastfeeding. Many women with MS tend to relapse following delivery, putting them into a situation in which immunomodulators and other agents may need to be restarted. Information from studies is limited. For each patient, her physician will offer a recommendation on whether it would be prudent to breastfeed or to withhold breastfeeding and use infant formula. In some cases, it may be possible to time things so that the woman can br
eastfeed and pump and store breastmilk for a short period after delivery, then resume treatments for MS and stop breastfeeding. 

What alternative therapies besides medications can I use to treat my multiple sclerosis during pregnancy?

Physical therapy, assistive devices, and exercise can be helpful.

What can I do for myself and my baby when I have multiple sclerosis during pregnancy?

Work with your doctors to find an optimal balance between medications and symptom severity. In most cases, all medications can be stopped, or washed out, prior to pregnancy, and the patient can get through pregnancy without a flare-up. Otherwise, flare-ups can be managed with short bouts of methylprednisolone.

Resources for multiple sclerosis in pregnancy:

For more information about multiple sclerosis during and after pregnancy, contact http://www.womenshealth.gov/ (800-994-9662 [TDD: 888-220-5446]) or check the following links:

• National Multiple Sclerosis Society: Pregnancy and Reproduction Issues
• March of Dimes: Multiple Sclerosis and Pregnancy