Mult Scler. 2018 Dec 3:1352458518816614. doi: 10.1177/1352458518816614. [Epub ahead of print]
Pregnancy and multiple sclerosis in the DMT era: A cohort study in Western Austria.
Multiple sclerosis (MS) predominantly affects women of child-bearing potential. Pregnancy in MS is still a controversial issue lacking standardized treatment recommendations.
To examine the reciprocal effects of pregnancy, MS, and disease-modifying treatment (DMT).
We analyzed 387 pregnancies in 239 women with relapsing remitting multiple sclerosis (RRMS) and ⩾1 pregnancy, establishment of diagnosis >1 year before conception, and ⩾2 years of follow-up after delivery. Relapse rates and Expanded Disability Status Scale (EDSS) scores were compared in the year before conception, during pregnancy, and 2 years postpartum. Binary logistic regression was used to investigate predictors of risk for relapses and disability progression during pregnancy and postpartum.
Risk of relapse and disability progression during pregnancy was predicted by pre-conception relapse activity, higher EDSS score at conception, use of highly effective disease-modifying treatment (H-DMT) pre-conception, and prolonged washout period. Postpartum relapse and disability progression was associated with relapse activity pre-conception and during pregnancy and use of H-DMT pre-conception. Early restart of DMT reduced the risk of postpartum relapse.
A personalized approach in planning pregnancy in women with MS while on H-DMT needs to be adopted. It seems reasonable maintaining natalizumab closer to conception and restarting the drug early postpartum to reduce the considerable risk of disease reactivation during early pregnancy and after delivery.
MS is a condition that predominantly affects women in their child bearing years. Around 20-30% of women with MS go on to have children. Although, pregnancy as a whole is protective, there is an increased risk of relapses during the first 3months post-delivery; particularly in those who don’t promptly re-start their DMTs.
If you’re on a DMT (disease modifying treatment), there isn’t clear evidence-based guidance on what to do with the treatment. There are recommendations from regulatory authorities that tell you to avoid pregnancy during the course of treatment and do a wash out of 2-3 months prior to conception. But, it’s only recently with the advent of highly active DMTS that we have realized that with this comes an increased risk of severe relapses upon on stopping them.
In Innsbruck, the authors retrospectively analyzed 387 pregnancies in 239 women. They found that the risk of relapse during the course of the pregnancy was determined by:
a) the pre-pregnancy relapse rate,
b) using a highly active DMT (natalizumab or fingolimod), and
c) a longer wash-out period.
The risk of worsening disability was also influenced by these factors. Those without a relapse in the year before pregnancy on highly active DMT and a wash-out period less than <4 weeks had a five-fold risk-reduction in relapse and disability progression. Equally, pregnancy appeared to have no impact on those on moderately effective DMT, such as interferons, copaxone and tecfidera, or no DMT at all.
Reassuringly there was not a disproportionate increase in spontaneous abortions nor foetal deaths in those on DMTs studied here, but MS did seem to result in lower birth weight.
In summary, the planning of pregnancy in MS for those on DMTs needs to be pre-planned. Given the findings from this study, continuing treatment up to conception or even until conception for the highly active DMTs and re-starting the treatment early seems sensible.