November 2024

NEUROSCIENCES

EDITH GRAHAM, MD, SHARES BEST PRACTICES FOR MANAGING PREGNANCY IN PATIENTS WITH MS

Selecting MS Treatment

When considering MS treatment, involve patients, their partners (if desired) and clinicians in a shared decision-making process. Discuss family planning regularly, and involve the patient's neurologist, obstetric team and primary physician.

For patients who want to become pregnant, planned pregnancy is recommended to ensure optimal management of MS before conception and optimal adjustment of disease-modifying therapies (DMTs) before pregnancy. Discuss contraception during treatment and washout periods, as some DMTs may need to be discontinued for up to six months before conception.
  • Consider symptomatic treatments for comorbid conditions and make adjustments before conception and/or during pregnancy.
    • Modafinil, used for fatigue, can affect the effectiveness of hormonal contraceptives, so use alternative methods during modafinil treatment and for one month after discontinuation.
  • Follow general guidelines for folic acid and prenatal vitamin supplementation, along with MS-specific considerations such as vitamin D supplementation, smoking cessation and sleep optimization to reduce the risk of disease progression.

More reading on selecting MS treatment:
Practical Considerations for Fertility Treatment
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In counseling for patients with MS and their partners, discuss fertility and the potential risks of infertility treatments. 
  • If a patient has been trying to conceive for more than six months, you can recommend fertility referral and counseling to expedite evaluation while minimizing time off DMTs. 
  • Using DMTs that can be flexibly dosed around IVF procedures may reduce the risk of relapse. 
  • If a patient is undergoing egg cryopreservation, there is no need to discontinue DMT use. 
    • DMT discontinuation is only necessary for egg transfer, following similar timing recommendations as conception.

Practical Considerations for Management

Most DMTs for MS should be stopped before conception or as soon as pregnancy is confirmed. Shared decision-making is crucial, considering the benefit-risk profile of the treatment and the individual's risk aversion and disease course. 
  • Review symptomatic MS treatments for safety during pregnancy. 
  • If accidental exposure to DMT occurs after conception, consider a fetal screening and referring the patient to a maternal-fetal medicine expert. 
  • Avoid IV gadolinium during pregnancy, although MRI is generally safe. 

​Pregnant people with MS should follow the recommended immunization schedule, taking into account their medication regimen and guidance from their obstetrical clinician. 
  • To optimize their immune response, patients should consider getting fully vaccinated at least two weeks before starting S1P receptor modulator treatments. 
  • Live vaccines should be administered at least four weeks before starting B-cell-depleting treatments, while inactivated vaccines should be given at least two weeks before. 
  • Patients with MS, especially those not previously vaccinated, should get a COVID-19 vaccine or modified series if they are on B-cell-depleting treatments or S1P receptor modulators due to the higher risk of severe illness.
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Practical Considerations for Delivery

MS does not contraindicate any obstetric anesthesia, and the choice should be based on obstetric criteria. 

Patients with severe spasticity or weakness in the pelvis and/or legs should be referred to a specialized physiotherapist early in pregnancy. Physiotherapists collaborate with obstetrician-gynecologists to enhance labor and delivery. 

Informing Treatment Decisions

Reassure patients with MS that the condition does not increase the risk of spontaneous abortion or miscarriage. 

There are no specific precautions for drugs or procedures for inducing abortion in patients with MS. Refer those experiencing pregnancy loss for counseling to address grief and stress.

Managing Relapse

During the first few months after childbirth, close monitoring of patients with MS is important. 
  • There is an increased risk of postpartum depression in both mothers and fathers with MS, so ensure the team is aware of this and provides necessary support. 
  • Screen for depressive symptoms using tools like the Edinburgh Postnatal Depression Scale or the Patient Health Questionnaire-2. 
  • Early reintroduction of DMTs after childbirth may be advised to reduce the risk of relapses. However, consider the effects of therapeutic lag, especially in mothers with significant disability or high relapse rates. 
  • There is no data to support the use of IV corticosteroids or IV immunoglobulin to prevent postpartum relapses. 
  • Encourage postpartum physiotherapy, including pelvic floor exercises, particularly for those with MS who experience bladder dysfunction.
  • Infants of mothers exposed to certain anti-CD20 therapies during pregnancy should not receive live vaccines until their B-cell count recovery is confirmed, as recommended by regulatory agencies. Non-live vaccines can be administered, but the vaccine immune response should be assessed.

Practical Considerations for Breastfeeding
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  • Do not delay treatment after childbirth for those with MS who had active disease before pregnancy.
  • Encourage breastfeeding for all MS patients with support from a lactation consultant, if needed. 
  • IV methylprednisolone, IV gadolinium and immunoglobulin G monoclonal antibodies are safe during breastfeeding as they do not transfer into breast milk. 
  • Vaccine recommendations for breastfeeding women with MS should follow standard guidelines. Ensure that patients know that some vaccines can transfer maternal immunity to breastfed infants, such as COVID-19 vaccination.

Supplemental Material
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Edith Graham, MD, Assistant Professor of Multiple Sclerosis (MS)/ Neuroimmunology and Hospital Neurology at Northwestern Medicine

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