The most common age for a multiple sclerosis diagnosis is late 20s to early 30s. The ratio of women to men is almost 3:1, therefore the issue of pregnancy and multiple sclerosis is not an uncommon circumstance and yet there is considerable doubt, lack of clarity and questions around this very important matter in women of child-bearing age with MS. There can be conflicting information making it difficult for both patients and providers.
Fertility
While some studies suggest that issues with fertility might be slightly more common in women with MS, and patients with MS have higher rates of assisted reproductive technology (ART) use to have children, one also needs to keep in mind that many women with MS delay pregnancy due to any number of concerns and this in turn may contribute to problems with fertility. With regard to fertility treatments, while earlier studies suggested that they might be associated with a higher risk of relapses, newer, larger studies have not found this to be true. The kind of fertility treatment could also have an impact on this. Therapies have to be catered to paitent needs and has to be individualized after disucussions between the provider and patient.
Pregnancy and Lactation
Pregnancy itself, especially the latter part, seems to be a relatively “protected “ state as the high estrogen levels confer an immune-modulating effect with a decrease in the the risk of having a relapse. Conversely the post-partum period has a higher risk of a relapse once the hormonal levels drop. Exclusive breast feeding appears to be protective. However decisions about re-starting DMT after pregnacy has to be made after taking into consideration the level of disease activity from MS and patient preferences.
For obvious ethical considerations, pregnant and lactating women are excluded from clinical trials of disease modifying treatment ( DMT) for MS. So data about safety in these scenarios may not be easily available. However post-approval data can be obtained through patient registries and insurance claims databases.
It is generally recommended that patients discontinue their DMT while trying to conceive. There is also a certain wash-out period, the length of which depends on the specifc medication. Decisions about which specific DMT to start in a patient of childbearing age must be made after discussions with patients about pregnancy and the timing of it. For example, if a patient is intending on trying to conceive in the near future, it would be best to avoid medications that can cause a disease recurrence or rebound on treatment cessation especially within a short period of initiation. In patients with high disease activity it is worthwhile starting a high efficacy DMT with durable effect. In other words, treatments that offer extended periods of effectiveness even after the medication is discontinued and elimated from the body. Examples are cladribine and B cell targeted therapies like ocrelizumab.
Vitamin D- Women are advised to supplement vitamin D and have not have deficient serum levels during pregnancy. Low vitamin D is associated with more disease activity in MS and studies have also shown higher risk of ms in children associated with low maternal vitamin D levels during pregnancy.
MRIs do not involve radiation so they are generally safe dring pregnancy, but contrast administration is not recommended during pregnancy or nursing. Its advised that MRIs be done only if urgently needed and routine surveilance scans delayed until after delivery.
If relapses occur during pregnancy, they can be treated with steroids if needed. The decision to use steroids has to made depending on the symptoms and severity of the relapse.
Most DMTs are not recommended to be taken during lactation as they can be secreted in breast milk. Monoclonal antibodies, which are a class of DMTs used in MS, may have negligent levels in breast milk and appear to be safe to use during nursing.
Post-Partum Symptoms
During the post-partum period , patients are particularly vulnerable to worsening symptoms even in the absence of a relapse. Many of the typical triggers for making symptoms more prominent are present during this period, including lack of sleep,fatigue/exhaustion and stress. There is also higher risk of post-partum depression in women with MS. Patients, their families and providers have to be mindful of these and address them as necessary.
In conclusion women with multiple sclerosis can have safe pregnancies and healthy babies. With adequate support, counseling, awareness and planning we can manage this successfully without any detriment to the patient’s health.