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Multiple sclerosis and pregnancy in the 'treatment era'

Key Points

  • Pregnancies in women with MS are normal pregnancies: the disease itself does not pose a particular risk to the fetus

  • Relapses decrease during pregnancy, but rebound in the first 3 months postpartum, with an overall neutral effect in terms of relapses and disability in the pregnancy year

  • Epidural analgesia and breastfeeding are possible in women with MS

  • Disease-modifying treatments might be harmful to the fetus, and discontinuation before conception may be warranted; however, stopping treatment might be harmful to the mother

  • There is currently no treatment to prevent post-partum relapses

  • Pregnancy is possible in neuromyelitis optica; considering the potential severity of any attack and the high risk of a postpartum relapse to the mother, maintenance of immunoactive treatment should be discussed

Abstract

The influence of pregnancy on the course of multiple sclerosis (MS) has long been controversial; until the end of 1990s, women with MS were discouraged from having children owing to a biased belief that pregnancy would worsen the disease course. Since the first large prospective study in 1998, counselling of women with MS has changed radically, and many patients have attained their desire of motherhood. Although many disease-modifying drugs have come to market in the past two decades, when used during pregnancy and lactation, their beneficial effects on the course of MS have to be balanced with fears concerning potential risks to the fetus or child. The wealth of treatment options and the various associated risks have created a growing need for counselling on family planning for women with MS. Most importantly, such counselling should address the concerns that women with MS might have regarding pregnancy. Second, as soon as a woman starts considering pregnancy, a treatment plan should be established. This plan needs to weigh the risk posed to the fetus by potentially harmful drug exposure, and the risk to the mother from a reappearance of disease activity. Finally, breastfeeding and treatment options after delivery should be discussed to outline the options for prevention of postpartum relapses, and the possible resumption of disease-modifying drugs.

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Figure 1: Risk of multiple sclerosis (MS) among family members of affected individuals.
Figure 2: EMA Pregnancy Classification.

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The authors contributed equally to the article.

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Correspondence to Sandra Vukusic.

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Competing interests

S.V. has received consulting and lecture fees, travel grants and research support from Bayer-Schering, Biogen Idec, Genzyme, Novartis, Merck Serono, Sanofi Aventis and Teva Pharma. R.M. has received consulting and lecture fees, travel grants and research support from Bayer-Schering, Biogen Idec, Genzyme, Novartis, Merck Serono, Sanofi Aventis and Teva Pharma, and serves in the advisory board of MedImmune.

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Supplementary Table 1

Use of first-line, second-line and off-label disease-modifying treatment in pregnancy (DOC 92 kb)

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Vukusic, S., Marignier, R. Multiple sclerosis and pregnancy in the 'treatment era'. Nat Rev Neurol 11, 280–289 (2015). https://doi.org/10.1038/nrneurol.2015.53

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