Pregnancy and Multiple Sclerosis
Ruisheng Duan, Shandong Province Qianfo Mountain Hospital
Many patients with multiple sclerosis (MS) are women of maternal age who are faced with the problem of pregnancy. Overall, pregnancy has no effect on the long-term prognosis (level of disability) of MS patients; pregnancy does not reduce the risk of MS onset; the relapse rate of MS during pregnancy is reduced; women with MS do not have more complications in childbirth than women without the disease; and most studies conclude that MS itself does not cause preterm delivery, low birth mass, infant mortality, or teratogenic risk (except for drug-induced). The high rate of recurrence in the postpartum period is the only real risk for these women. The relapse profile of MS patients before and after pregnancy, as found by Neuteboom R. F. in 2011, is shown in the table below. As shown in the table, the lowest relapse rate of MS was observed in the 3-6 months after pregnancy and the highest relapse rate was observed in the 1-3 months after delivery. Duan Ruisheng, Department of Neurology, Shandong Qianfo Mountain Hospital
The effects of drugs on the fetus and breastfeeding during pregnancy and after delivery in MS patients are shown in the table below
Based on the above studies, coping strategies for MS women who are pregnant and breastfeeding are as follows.
1. MS patients should generally discontinue all disease-relieving drugs (DMD) for 6 months prior to planned pregnancy. For example: first-line drugs interferon, gliamer acetate and fingolimod; second-line drugs: natalizumab, mitoxantrone; other immunosuppressive drugs: azathioprine, cyclosporine A, primaquine and cyclophosphamide.
2. For very severe and highly active MS patients, it has been recommended that either gliemide acetate or interferon be administered throughout preconception and pregnancy.
3. Intravenous immunoglobulin may be used in case of relapse during 1-3 months of pregnancy; methylprednisolone or intravenous immunoglobulin may be used in case of relapse during 4-9 months of pregnancy. (Multiple sclerosis and pregnancy 2007 states that hormones or intravenous immunoglobulins can be used before, during and after pregnancy, and that hormones can cause cleft palate or hypoadrenalism and need to be considered a risk Teratology. 2000;62(6):385-92)
4. stop breastfeeding and give immunosuppressive or interferon therapy during the first month after delivery (Maija Saraste, 2007). However, the new finding is that exclusive breastfeeding reduces MS relapse after delivery (Annette Langer-Gould, 2013)
5. MS patients who choose to breastfeed their children are advised not to undergo DMD medication, but some high-risk patients may forego breastfeeding in favor of DMD medication.
6. azathioprine (AZA): the fetal liver lacks the enzyme that converts AZA to its active form, so AZA itself cannot be converted to its active form in the fetus. the toxicity of AZA is attributed to its maternal metabolites 6-methylmercaptopurine (6-MMP) (hepatotoxicity), 6-thioinosine- triphosphate (6-TITP) (pancreatitis) and 6-TGN (bone marrow toxicity). AZA administration during pregnancy has not been found to cause fetal malformations, but elevated 6-TGN in the fetus can lead to thrombocytopenia and leukopenia. (Nanne K.H. de Boer 2006).
Recommendations for the use of multiple sclerosis disease relieving drugs in DMD during pregnancy and lactation (Ellen Lu, 2013)
Medications
Pregnancy
Lactation
Interferon-b
Pregnant women should be aware of the risk of miscarriage.
Mild patients.
Discontinuation recommended at least 1 month prior to pregnancy.
Discontinue immediately after knowledge of pregnancy.
Severe or high activity patients.
Continued application until pregnancy; or throughout pregnancy.
Not recommended
Gliemer acetate
Mild patients.
Discontinuation recommended at least 1 month prior to pregnancy.
Discontinue immediately after knowledge of pregnancy.
Severe or high activity patients.
Continued application until pregnancy; or throughout pregnancy.
Not recommended
Natalizumab
Discontinuation at least 3 months prior to pregnancy is recommended
Not recommended
Mitoxantrone
Not recommended (teratogenic)
Not recommended
Fingolimod
Women of childbearing potential should use contraception
Recommend that contraception should be used for 2 months after discontinuation of the drug
Not recommended
Teriflunomide
Women of childbearing potential should use contraception
Not recommended