Multiple Sclerosis, Pregnancy and Postpartum: What’s the Story?
The relationship between multiple sclerosis, pregnancy and breastfeeding is of great interest for several reasons, not least of which is the fact that MS affects more women than men and it typically strikes during prime childbearing years. So whether you have MS and are contemplating starting a family, are already pregnant, or are curious about the impact of the disease and treatment on pregnancy, breastfeeding, and postpartum, here are some of the latest research findings.
MS treatment and pregnancy
One thing that concerns women who have MS is the effect of using medications before, during, and after pregnancy. Generally the recommendation for women with MS who want to become pregnant is to stop all treatment until they give birth because of worries about the potential long-term effects of the drugs on the children.
That concern was addressed in a recent retrospective study in which the authors reviewed data on the children of women with MS. Some of the women had avoided all disease-modifying drugs (DMDs) for at least three months before getting pregnant and during their pregnancy while another group had been exposed to DMDs (mainly the injectables glatiramer and interferon beta) for a minimum of two weeks.
The average age of the women’s children was 6.6 years. Review of the children’s health and any patterns of drug-related long-term side effects showed no differences between those whose mothers had taken DMDs and those who had not.
What about the effects of oral DMDs? In a study from the University of British Columbia, the investigators looked at what’s known (and not known) about the effect of oral DMDs on pregnancy and the fetus.
Unfortunately, for now not much is understood about the possible impacts, except that animal studies suggest oral DMDs have the potential for an increased risk of impaired fetal growth, early pregnancy loss, and birth defects. A report in a recent issues of Expert Review of Clinical Immunology noted that “there is strong evidence that relapses are fewer during pregnancy but more frequent during postpartum,” and that even though interferon beta and glatiramer do not appear to expose offspring to any significant adverse effects, these drugs should not be taken before conception and during pregnancy.
The authors did point out, however, that if stopping treatment of these two drugs before conception exposed women to a significant risk of disease activity, they should continue treatment until pregnancy is confirmed. Thus far little is known about the potential impact of natalizumab (Tysabri) and fingolimod (Gilenya).
MS treatment and relapses postpartum
Since evidence indicates relapses decline during pregnancy but are more frequent postpartum, researchers looked at the role of DMDs on relapses and disability progression during the postpartum period. For the purposes of this study, “postpartum” was one year after delivery.
Here’s what the reviewers found after evaluating 350 women followed up for one year:
- 148 (42.3%) experienced at least one relapse during the 12 months after delivery
- Women who had a greater number of relapses both before and during pregnancy and an Expanded Disability Status Scale score of at least 2.0 at conception were at greater risk of experiencing postpartum relapses
- Resuming DMD use shortly after giving birth reduced the risk of experiencing postpartum relapses by a small margin
- Progression of disability was associated with a greater number of relapses both before and after delivery
The authors concluded that resuming the use of DMDs shortly after delivery may reduce a woman’s risk of experiencing postpartum relapses. This suggestion may be especially helpful for women with more active MS.
MS and breastfeeding
Finally, there are questions concerning the impact of breastfeeding on MS. Mostly the questions such as “Does breastfeeding have any long-term impact on the course or progression of MS?” or “Could exclusive breastfeeding reduce the risk of postpartum relapses?” are currently unanswered.
However, obtaining answers to these and other questions regarding MS and breastfeeding “will improve our ability to care for women with MS and may provide a greater understanding of the pathophysiology of the disease,” according to the authors of a recent report in Clinical Immunology. For now, it is recommended that women with MS who want to breastfeed avoid use of DMDs.
A research team has investigated one facet of the breastfeeding and MS dilemma, and that was the association between breastfeeding and the risk of developing MS in the future. The study population consisted of 245 MS patients and 296 healthy controls who provided information about duration of breastfeeding and demographic factors.
After analysis of the data, the reviewers concluded that breastfeeding provides a protective effect against MS among those who were breastfed for at least four months. This finding was similar to previous studies in which breastfeeding has been shown to protect against development of other autoimmune diseases.
The bottom line
Women who have MS and who want get pregnant need to discuss all the factors with their healthcare professional. For now, it appears the “better safe than sorry” approach to use of DMDs before and during pregnancy is the gold standard, but not in all cases.
Men with MS also have a role in the pregnancy question, as use of Aubagio (teriflunomide) may pose a risk to the fetus. In fact, teriflunomide can stay in your system for up to two years, so both women and men who take this drug need to have a blood test to check levels of the drug in their system before getting pregnant.
Conradi S et al. Breastfeeding is associated with lower risk for multiple sclerosis. Multiple Sclerosis 2013 Apr; 19(5): 553-58
Fragoso YD et al. Long-term effects of exposure to disease-modifying drugs in the offspring of mothers with multiple sclerosis: a retrospective chart review. CNS Drugs 2013 Nov; 27(11): 955-61
Ghezzi A et al. Current recommendations for multiple sclerosis treatment in pregnancy and puerperium. Expert Review of Clinical Immunology 2013 Jul; 9(7): 683-91
Langer-Gould A, Beaber BE. Effects of pregnancy and breastfeeding on the multiple sclerosis disease course. Clinical Immunology 2013 Nov; 149(2): 244-50
Lu E et al. A review of safety-related pregnancy data surrounding the oral disease-modifying drugs for multiple sclerosis. CNS Drugs 2013 Dec 17.
Portaccio E et al. Postpartum relapses increase the risk of disability progression in multiple sclerosis: the role of disease modifying drugs. Journal of Neurology, Neurosurgery and Psychiatry 2014 Jan 8. Epub ahead of print