Managing Multiple Sclerosis During Pregnancy: A Guide to Treatment and Safety

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• Pre-Pregnancy Planning for MS
• MS Medications and Pregnancy Safety
• Impact of Pregnancy on MS Symptoms
• The Multidisciplinary Care Team Approach
• Postpartum and Breastfeeding MS Management
• Case Studies: Severe MS in Pregnancy
• Overall Prognosis for MS and Pregnancy

Pre-Pregnancy Planning for MS

The first step for any woman with multiple sclerosis considering pregnancy is a detailed discussion with both a neurologist and an obstetrician. Dr. Marc Dommergues, MD, emphasizes that pre-pregnancy counseling is essential to assess individual risks and create a tailored management plan. The complexity of this planning depends heavily on the type and severity of a patient's MS, ranging from straightforward cases to those requiring intensive, coordinated care.

MS Medications and Pregnancy Safety

A central challenge in managing MS during pregnancy is the use of disease-modifying therapies. Dr. Marc Dommergues, MD, notes that for many medications, there is limited data on their precise impact on a developing fetus. This often leads to difficult, individualized decisions about whether to continue or discontinue treatment. Dr. Marc Dommergues, MD, explains that discontinuing medication can sometimes lead to a severe worsening of multiple sclerosis, which itself poses a risk to both the mother and the pregnancy.

Impact of Pregnancy on MS Symptoms

Contrary to what some may fear, pregnancy itself generally has a protective effect on multiple sclerosis. Dr. Marc Dommergues, MD, states that on average, pregnancy tends to improve MS symptoms due to natural immunosuppressive mechanisms. He clarifies through his discussion with Dr. Anton Titov, MD, that the real risk often comes not from the pregnancy but from the necessary alterations to the MS drug regimen. However, this positive average effect does not guarantee improvement for every single patient.

The Multidisciplinary Care Team Approach

Successful management of pregnancy in multiple sclerosis patients requires very close collaboration between several medical specialties. Dr. Marc Dommergues, MD, highlights the need for a team that includes neurologists, obstetricians, anesthesiologists, and pediatricians. This is especially critical for women with severe MS and significant disability, where pregnancy can exacerbate existing challenges like motor function and breathing, necessitating delivery in a specialized center.

Postpartum and Breastfeeding MS Management

For the vast majority of patients, disease-modifying medications can be safely continued throughout pregnancy and during breastfeeding. Dr. Marc Dommergues, MD, offers a hopeful message, confirming that with a controlled disease, women have excellent chances for a healthy pregnancy and baby. The postpartum period requires careful observation, as the protective effect of pregnancy wanes and the risk of relapse may increase.

Case Studies: Severe MS in Pregnancy

Dr. Marc Dommergues, MD, illustrates the high-stakes nature of severe MS in pregnancy with two powerful cases from his practice. In one instance, a woman with significant motor disability deteriorated so severely by the seventh month that she required premature delivery. In another case, discontinuing medication led to blindness and an inability to walk, necessitating emergency treatment with steroids. These cases underscore that while pregnancy is often safe, complex cases demand extreme vigilance.

Overall Prognosis for MS and Pregnancy

The long-term outlook for women with multiple sclerosis who become pregnant is positive. Dr. Dommergues concludes his conversation with Dr. Anton Titov, MD, by noting that when looking at the entire life of women with MS, there is no difference in disease progression between those who become pregnant and those who do not. This provides crucial reassurance that family planning is a viable and safe option for many women living with this condition.

Full Transcript

Dr. Anton Titov, MD: Multiple sclerosis and pregnancy. Young women are more often affected by multiple sclerosis than men. The issue of pregnancy and successfully managing pregnancy, and how to help a mother and child comes up in multiple sclerosis. What are your views on how to best manage pregnancy in multiple sclerosis patients?

Dr. Marc Dommergues, MD: As usual, the first step is that the project of becoming pregnant must be discussed, on the one hand, with the neurologist, and on the other hand, with an obstetrician. Things may be more or less complicated, depending on what type of multiple sclerosis we're talking about.

Let's go through examples of multiple sclerosis situations. If you consider a woman who had a few multiple sclerosis attacks but she's now doing well, she's not taking any multiple sclerosis medications, things are perfect. It is likely that pregnancy is not going to have any impact on her disease and that her disease is not going to have any impact on her pregnancy.

However, it may be reassuring for the woman to deliver her child in a center in which there are neurologists and obstetricians familiar with multiple sclerosis. This is, in general, something that we could consider for psychological reasons rather than for true medical reasons.

At the other end of the spectrum, you may have a woman with very severe multiple sclerosis. She is taking complicated MS medications. We don't know exactly the impact of multiple sclerosis medications on the fetus. But she has a disability, for example, motor disability, and we know that if she discontinues the medications, things are going to become worse and worse.

This is a hard case. This is the type of case that needs to be discussed beforehand. This situation requires very close collaboration between the neurologists and the obstetrical, anesthesia, and pediatric care teams.

One of the issues will be this: can we continue the multiple sclerosis medications, or should we discontinue them? Quite often, we don't have much data on that. So it's kind of a guess that we do with the woman. It's also difficult to anticipate for sure what's going to happen if the medications are discontinued.

What's going to happen may be terrible. I remember a case of a woman with multiple sclerosis who had a severe significant motor disability. By the seventh month of pregnancy, she could hardly eat, and she had difficulties breathing. We reintroduced potentially harmful multiple sclerosis drugs.

But eventually, we had to deliver her prematurely because she was not doing well at all.

Here is another example of a woman with a severe form of multiple sclerosis. She was taking medications that we were not quite sure of their impact on the fetus. So she discontinued the MS drugs. Then she was very severely affected. She couldn't walk anymore. She became blind at the beginning of the pregnancy.

So she had to get very intensive treatment with steroids and other multiple sclerosis drugs that were possible to be used in pregnancy. Eventually, she recovered, and she did well. But some other patients will have a severe worsening of multiple sclerosis not because of pregnancy, but because they are stopping the medications during pregnancy.

Dr. Anton Titov, MD: So generally, it's not the pregnancy that can affect multiple sclerosis, but the alterations in the drug regimen to treat multiple sclerosis during pregnancy.

Dr. Marc Dommergues, MD: Exactly! On average, pregnancy tends to improve multiple sclerosis. And if we look at the entire life of women with multiple sclerosis, there is no difference between those who become pregnant and those who don't become pregnant.

Dr. Anton Titov, MD: There are two questions. One question is, what's going to happen if we stop using multiple sclerosis medications during pregnancy. The other question is when we say that multiple sclerosis is improved by pregnancy, this is on average.

Dr. Marc Dommergues, MD: And it is not true for every single person, of course.

Dr. Anton Titov, MD: So again, for multiple sclerosis, a very close interaction between all members of the medical team is required. You discussed two extreme examples: a woman with multiple sclerosis who does well during pregnancy, and a woman who is in a difficult stage of the disease and on multiple medications.

If we imagine a pregnant woman with multiple sclerosis who is on disease-modifying medications, but her MS is perfectly well controlled, there are no recent flare-ups. Once a baby is delivered, does the same MS medication regimen continue? Or is there a trial of discontinuing the drugs and seeing if the flare-up appears? If we take a middle ground in MS and pregnancy, how does it usually look like? What are the questions to think about?

Dr. Marc Dommergues, MD: I would say that the middle ground and the majority of patients take disease-modifying medications that can be continued throughout pregnancy. MS drugs can be continued during breastfeeding, and usually, things go perfectly well. This is the vast majority.

Dr. Anton Titov, MD: That's a very hopeful message. You can have a baby if you have multiple sclerosis. If your MS is controlled, you have good chances for a healthy pregnancy and baby.

Dr. Marc Dommergues, MD: Certainly!