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Sunday, May 31, 2015
Expert Tips for Managing Pregnancy in MS
INDIANAPOLIS, Indiana — When a patient with multiple sclerosis (MS) wants to get pregnant, chances are she'll turn to her neurologist for advice.
Doctors shouldn't discourage these women from fulfilling what for many is a life-long dream of having a family, according to Maria Houtchens, MD, assistant professor, Department of Neurology, Harvard Medical School, director, Women's Health Program, and staff neurologist, Partners MS Center, Boston, Massachusetts.
A specialist in managing MS during pregnancy, Dr Houtchens shared some information and tips with delegates during a clinical course here at the Consortium of Multiple Sclerosis Centers (CMSC) 2015 Annual Meeting.
Pregnancy is an important and often complex issue for patients with MS. Of the 500,000 patients with MS in the United States, two thirds are women, most of whom are diagnosed before menopause. Half of all pregnancies in the United States are unplanned.
There are no evidence-based practice guidelines for managing patients with MS during pregnancy, said Dr Houtchens. Care during this period varies "dramatically" depending on the knowledge and comfort level of caregivers, she said.
Women wanting to have a baby are concerned about passing on MS to their offspring and about the effect on the fetus of drugs they have taken to control their disease. But perhaps their biggest worry, she says, is how they will raise a child should their disease worsen.
"They worry about how to manage their symptoms and care for the child at the same time," she said.
The worries are so great for some women that they decide to terminate the pregnancy. Dr Houtchens cited one survey showing that 20% of women with MS elected to have their pregnancy terminated compared with 12% of heathy controls.
She stressed the importance of alleviating the fears and anxieties that many female patients with MS have about pregnancy, and this is where the neurologist might come in.
A preconception counseling session should include a discussion about family planning, including timing, genetic risks, and an assessment of MS disease activity.
Before trying to conceive, women should cease MS treatments — 1 to 4 weeks before, depending on the medication. To optimize chances of getting pregnant while minimizing time off therapy, patients may want to determine their "fertility window," that is, the 6-day period ending with the ovulation day.
Women can estimate this window on the basis of basal body temperature, duration of the menstrual cycle, cervical mucus, or commercial ovulation kits.
Doctors might consider alternative therapy at this time to stabilize active patients.
If a patient doesn't get pregnant within 3 to 6 months, physicians might refer her to an infertility clinic. Patients without MS are typically not referred to such clinics until after a year of trying to get pregnant.
Dr Houtchens noted that while no convincing data indicate that MS decreases fertility, women with this disease may have more endometriosis and disease-related sexual dysfunction, which could affect their chances of getting pregnant.
However, not all pregnancies in women with MS are clear sailing. While most patients with MS are stable throughout pregnancy and during the postpartum period, some will have attacks and develop serious symptoms.
Intravenous corticosteroids are used widely to treat acute attacks, noted Dr Houtchens. Prednisone, prednisolone, and methylprednisolone can be administered with low levels of fetal exposure, she said.
Dr Houtchens outlined the teratogenicity of various MS drugs. Many appear safe, but fingolimod (Gilenya, Novartis), for example, is teratogenic in animal studies; breast-feeding is contraindicated while using it. There's a worldwide pregnancy registry for this drug.
Secondary symptoms of MS, such as fatigue and mobility issues, may worsen during pregnancy, said Dr Houtchens.
Babies born to mothers with MS might be slightly smaller, but their Apgar scores are similar to those of babies born to women without MS. They have no increased risk for birth defects or perinatal mortality.
The method of delivery doesn't affect the postpartum course of the disease, nor does having an epidural during labor.
Lactating moms with previous active disease may safely take monthly steroids or intravenous immunoglobulin. But they should discontinue breast-feeding for 24 hours after taking this treatment, said Dr Houtchens.
Nonlactating patients can safely resume MS therapy within a week of birth. After abstaining from intercourse for up to 6 weeks, these women can return to their preferred method of birth control.
The birth control choice for patients with MS involves "common sense," noted Dr Houtchens. Those with problems with hand control may not be able to manipulate a sponge, while those at increased risk for blood clots may not be good candidates for oral contraceptives. Condoms or an intrauterine device are generally a "good choice" for these women, said Dr Houtchens.
While active disease is controlled during pregnancy for many women, 30% will have relapse following the birth.
Postpartum depression is an issue for all women, including those with MS. Depression after giving birth can affect a woman's ability to care for herself or her child during a time that may already be complicated by more relapses and added stress, noted Dr Houtchens.
She recommends that patients with MS undergo MRI within 6 months of the birth to assess disease activity.
Session chair, Tanuja Chitnis, MD, associate professor, neurology, Harvard Medical School, and associate neurologist, Brigham and Women's Hospital, Boston, asked about using vitamin D supplements during pregnancy.
While low vitamin D levels are associated with adverse pregnancy outcomes and poorer clinical and radiologic MS course, "we don't know the optimal levels of vitamin D in pregnancy," said Dr Houtchens.
Dr Houtchens has received research grants from Genzyme Sanofi, Biogen Idec, and Novartis and has had consultant engagements with Teva, Genzyme Sanofi, Questcor, Biogen Idec, and Novartis. Dr Chitnis is a consultant for Merck-Serono, Novartis, and Biogen; is on the clinical trials advisory board at Novartis and Sanofi-Genzyme; received industry research funding from Merck-Serono and Novartis; and has nonindustry affiliations with the National Institutes of Health, National MS Society, Guthy-Jackson Foundation, and the Peabody Foundation.
Consortium of Multiple Sclerosis Centers (CMSC) 2015 Annual Meeting. Gender Issues in MS Care. May 28, 2015.
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