Pregnancy and multiple sclerosis: What to be aware of?

A few years ago, MS patients were advised not to become pregnant. From a medical point of view, there are rarely reasons to avoid pregnancy, but a few things should be considered.

Pregnancy with MS: favourable influence on the disease

For women with MS, there are generally no medical objections to pregnancy. However, there are many special considerations that need to be taken into account. How does the pregnancy progress? Which medication can be continued? How often do relapses occur during pregnancy, and how are they treated?

It is reassuring to know that, according to the results of studies to date, pregnancy tends to have a favourable effect on the disease.1 The natural immunosuppression during pregnancy not only protects the foetus, but also the mother from new relapses. Most pregnant women with MS feel fit and able-bodied.

Pregnancy planning

Pregnancy should be planned more carefully for women with MS who wish to have children in order to avoid complications. It has been shown that the likelihood of a relapse during pregnancy is significantly increased if the woman already had a high frequency of relapses before the pregnancy.2 It is therefore recommended that women with high disease activity first change their drug therapy in order to regulate the frequency of relapses. 

In addition, some immunomodulators must be discontinued some time before the planned pregnancy, as they can lead to miscarriages and damage the unborn child.3 However, if the pregnancy occurs spontaneously, the use of immunomodulators is not a reason to terminate the pregnancy. Individual decisions must be made in consultation with the treating neurologist, taking into account the type of medication being taken.

MS relapses during pregnancy

As most immunomodulators can have an embryotoxic effect, they should be discontinued before pregnancy. During pregnancy, however, the body produces hormones and antibodies that can favourably influence the immune system and thus the course of MS. This makes relapses less likely, especially in the last trimester of pregnancy.

However, around a third of pregnant women with MS still experience a flare-up, usually in the first few months of pregnancy.4 If a flare-up occurs, it is treated with high doses of glucocorticoids or plasmapheresis. Cortisone therapy is safe and effective for both the pregnant woman and the child.  

Birth and postpartum

A delay in the labour process is only to be expected if there is a relevant physical obstruction. In these cases, a caesarean section can be planned. However, women with MS are advised not to have a home birth. 

Hormonal changes after the birth can lead to new relapses. This appears to be the case regardless of whether the child was born by caesarean section or vaginally. In the first three months after giving birth, around 30 per cent of women have a flare-up.3 In most cases, the disease status soon returns to its pre-pregnancy level.  

Breastfeeding may also have a protective effect on the mother - it can prevent new flare-ups. If new relapses occur despite breastfeeding, breastfeeding can be discontinued and immunomodulatory therapy can be initiated. As these active substances pass into breast milk, women who are being treated with these active substances must not continue breastfeeding.

Key take-away for medical practice: pregnancy is also possible with MS 

Pregnancy in MS patients is possible, but requires multidisciplinary and close monitoring to ensure the health of both the mother and the foetus. Future research is needed to deepen the understanding of the interactions between pregnancy and MS and to further optimise management.

Sources
  1. Krysko KM, Bove R, Dobson R, Jokubaitis V, Hellwig K. Treatment of Women with Multiple Sclerosis Planning Pregnancy. Curr Treat Options Neurol. 2021;23(4):11. doi: 10.1007/s11940-021-00666-4. Epub 2021 Mar 30. PMID: 33814892; PMCID: PMC8008016.
  2. Varytė G, Zakarevičienė J, Ramašauskaitė D, Laužikienė D, Arlauskienė A. Pregnancy and Multiple Sclerosis: An Update on the Disease Modifying Treatment Strategy and a Review of Pregnancy's Impact on Disease Activity. Medicina (Kaunas). 2020 Jan 21;56(2):49. doi: 10.3390/medicina56020049. PMID: 31973138; PMCID: PMC7074401.
  3. Voskuhl R, Momtazee C. Pregnancy: Effect on Multiple Sclerosis, Treatment Considerations, and Breastfeeding. Neurotherapeutics. 2017 Oct;14(4):974-984. doi: 10.1007/s13311-017-0562-7. PMID: 28766273; PMCID: PMC5722767.
  4. Gajofatto A, Benedetti MD. Treatment strategies for multiple sclerosis: When to start, when to change, when to stop? World J Clin Cases. 2015 Jul 16;3(7):545-55. doi: 10.12998/wjcc.v3.i7.545. PMID: 26244148; PMCID: PMC4517331.