Multiple sclerosis (MS) is a chronic, sometimes disabling neurological disease that most often affects young women of childbearing age. However, there are still many questions to be resolved when a woman suffering from this disease decides to become pregnant. We spoke with Dr. Arcaya Navarro, a specialist in Neurology, to clear up some doubts regarding pregnancy in women with multiple sclerosis.
Nowadays we have course-modifying treatments for this disease (MSD) that manage to reduce the frequency of outbreaks and, therefore, their sequelae.
Should the patient communicate her intentions of becoming pregnant?
Dr. Arcaya Navarro advises that you should always inform your doctor of your intentions to become pregnant, since pregnancy planning and the adequacy of the MSD neurological treatment can avoid risky situations for the mother and the fetus.
It is also important to know this fact in order to consider family planning from the onset of the disease, especially because the percentage of accidental pregnancies in women with multiple sclerosis is 40%. For this reason, he insists that neurologists should periodically ask the woman and her partner about their desire to become pregnant.
How does pregnancy affect multiple sclerosis and vice versa?
Pregnancy seems to benefit the course of MS and MS does not affect delivery or fetal development. On the other hand, MS is not a purely inheritable disease for the fetus, but is multifactorial and therefore does not imply that the fetus will inherit it. The doctor points out that compared to healthy women, women with MS are not at greater risk of suffering complications during pregnancy or childbirth. In fact, even the rate of relapses with flares is reduced in the third trimester of pregnancy, although there may be a spike in the first trimester, but postpartum.
What are the risks of stopping treatment?
Dr. Arcaya insists that the drug should not be discontinued without first consulting the neurologist, especially in patients with high disease flare activity. He also points out that the absence of outbreaks in the previous year is related to a lower rate of outbreaks in the postpartum period.
On the other hand, although no drug is recommended in pregnancy, you should not delay the start of EMTs simply because of the desire to become pregnant and what you will have to do is to plan it properly and perform a short washout of the EMT drug if you are already taking it as soon as you have the confirmation of pregnancy.
What type of DMTs are less harmful to the fetus in case of pregnancy?
It will always be preferable not to use any in pregnancy, but in case it is used because it has a high risk of flares, the doctor advises subcutaneous injectable interferons (Betaferon) or glitamatergic acetate (Copaxone).
If the patient is taking other MSD drugs (dimethyl fumarate; alentuzumab; Natalizumab; Ocrelizumab) there is a higher risk of fetal injury and it should be assessed in each individual case whether the benefits to the patient outweigh the risk to the fetus depending on the patient’s degree of MS activity.
Another option would be to switch to interferons during pregnancy and after delivery return to the ones you were taking. Those that would be totally contraindicated during pregnancy are: Oral Cladribine; Fingolimod; Mitoxantrone and Teriflunomide.
In the event that the woman does not wish to become pregnant, the use of contraceptives will be essential, which in no case will worsen the course of MS or the resonance parameters.
What happens if assisted reproduction techniques are used?
Absolutely nothing. There is no contraindication to them and they are effective in about 14% of patients (general population 22-31%), although there is an increased risk of flare-up in the first three months after fertilization if it is not effective.
Childbirth and lactation
From the neurological point of view there is no contraindication for any usual obstetric procedure and there is no contraindication for epidural anesthesia. Multiple sclerosis does not affect childbirth nor is it linked to an increase in obstetric complications, with few exceptions.
Regarding breastfeeding, in patients with low MS activity who have been without MSD treatment during pregnancy, breastfeeding can be given without reintroducing treatment. If they have only been on treatment with beta interferons or glutaramer acetate, such treatment can be maintained even during breastfeeding. In those cases of patients with high activity and other different MSD treatments, they should be reintroduced as soon as possible to avoid flare-ups, which are more frequent after delivery, and breastfeeding should be withdrawn.
However, in addition to these considerations, it will always be the Neurologist managing your disease and the Obstetrician managing your pregnancy who will have the final say.