C-sections: how common are they in women with MS?

C

Barts-MS rose-tinted-odometer: ★★ (Indian summer orange #FF7722)

I have always said that women with early MS who start and extend families should have no reason to worry about additional problems with their pregnancy and childbirth because. It may be different for women with more advanced MS who are disabled. Maybe I should revise this general advice based on the study below.

In this study, 15 women with MS had 16 children. The cesarean section rate was 14 out of 16 deliveries or a staggering 87.5% of pregnancies. The main reason for C-sections was given as chronic fatigue and neurological deficits. The latter is interesting in that the mean disease duration of this cohort was less than 10 years with an average EDSS of 2.0. I suspect this cohort is biased and recruited women with MS via a high-risk clinic or an obstetric unit.

These results are incongruent with my experience as an MSologist. What about you? If there are any women with MS reading this post who have had children after being diagnosed with MS did you have a natural vaginal delivery, assisted delivery or a C-section? 

Biringer et al. Fatigue as the limiting factor for vaginal birth in patients with multiple sclerosis. Neuro Endocrinol Lett. 2021 Aug 28;42(4):222-228. 

Objectives: Multiple sclerosis (MS) is a chronic autoimmune and neurodegenerative disease. This study evaluated pregnancy-related issues in patients with MS in one perinatological centre.

Material and methods: A single-centre, retrospective study of the perinatal period in patients with MS admitted at the Dpt. of Gynaecology and Obstetrics, Jessenius Faculty of Medicine, Comenius University and the University Hospital in Martin, Slovak Republic, European Union from January 1, 2015 to December 1, 2020 was performed. Selected parameters from personal, obstetric, and neurological histories were analysed.

Results: A cohort of 15 patients (32.5±5.3 years) with a relapsing-remitting form of MS gave birth to 16 children. The mean length of MS at the time of delivery was 9±3.6 years. The severity of the Expanded Disability Status Scale score was 2.0±1.5. Caesarean section (CS) was indicated in 14 deliveries (87.5%). It was elective CS in 10 patients. The most common indication for elective CS was a combination of significant chronic fatigue syndrome and neurological deficit (paresis).

Conclusions: The basis for the management of pregnancy, childbirth, and the postpartum period in women with MS is a planned pregnancy based on close cooperation among patients, gynaecologists, and neurologists. Vaginal delivery is not primarily contraindicated. Indications for CS should be considered individually. One way to minimise the indications for CS is a more accurate diagnosis and personalised treatment of fatigue in pregnant women with MS. Presumably, both obstetricians and neurologists prefer vaginal delivery as the first choice in patients with fatigue syndrome.

Conflicts of Interest

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General Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of the Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust and are not meant to be interpreted as personal clinical advice. 

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

16 comments

  • I had a natural delivery with only gas and air in 2016 at the age of 34. EDSS between 0.5 and 2.0 depending on the day. Fatigue also my no.1 symptom but didn’t come into play during labour.

  • I had my first and only son at the ripe age of 40, 13 years after my first optic neuritis and 8 years after the official diagnosis. I had had several relapses, 6 years of Avonex and was very apprehensive about giving birth naturally and indeed mainly of the fatigue. Luckily, I had a fantastic obstetrician in Brussels, who reassured me that a C section was not necessarily indicated and openly discussed the pros and cons. I chose not to have one and eventually gave birth without even as much as a painkiller. Yoga and bringing along my physiotherapist sure helped. I credit this great obstetrician (who was very thorough and saw me almost weekly towards the end) with giving me the confidence to give birth like this and to this day it remains a beautiful memory.

  • Though I wasn’t diagnosed back then I recognise symptoms going back to before first pregnancy. Both my pregnancies were c-section. First one was pre-eclampsia and distressed baby but it was later found that my pelvic dimensions are an issue for natural child birth so following pregnancy was a planned c-section. My childbirth experiences are unrelated to ms unless there is a connection with pre-eclampsia.

  • As someone who wants to have a baby in the next year or two, I sort of want a c-section. Mainly because my bladder function is appalling, and I’m keen to avoid further damage that might occur during a natural birth. I work in surgery, so possibly biased towards a more medicalised option. Is this a justified concern or not?

  • I had an elective c-section in 2015, age 34, > 10 years of MS with EDSS <2.0. I had an uncomplicated pregnancy but I opted for c-section. Doctor wanted me to consider vaginal birth, and I thought about it for a long time. But so many friends were in labour for days only to have a c-section anyway and I did not feel physically fit enough for that (this feeling was related to my MS). But I'm fine with the c-section because it was MY decision.

  • I had an elective c-section in 2015, age 34, > 10 years of MS with EDSS <2.0. I had an uncomplicated pregnancy but I opted for c-section. Doctor wanted me to consider vaginal birth, and I thought about it for a long time. But so many friends were in labour for days only to have a c-section anyway and I did not feel physically fit enough for that (this feeling was related to my MS). But I'm fine with the c-section because it was MY decision.

  • my wife has ms for 12 years – highly active and thats why on OCR since 3 years after giving birth the natural way – EDSS 0-1 (1 would account for some optical nerve impairment).
    thinking about another one but combination of COVID-CD20-Pregnancy give some discomfort (vaccinated with t-cell response but no b-cell antibodies – anything you can reccomend? booster shot before pregnancy but as blunted antibody response after 7m post OCR it wont help that much after 5m right?)

  • Diagnosis in 2011 and had 2 very uncomplicated and dare I say relaxed labours. I was on the high risk group for both , first because I had MMR vaccine in the week I actually fell pregnant and second time due to EXCESSIVE MS related fatigue .

    However , i never asked about c-section and it was not brought up i conversation with midwives and obstetrician.

  • I had been had mild relapse remitting m.s. in 2000 and had a c-section with my son. Thr labor was intense and the drug to speed the labor back fired. It made things worse. Was my reaction to the drug because of my oversensitivity to all drugs??? Is this due to m.s.? I don’t know.

    My second child was also c-section. Post second birth I have never been as strong. But I am happy to have the kids. I think I passed on an autoimmune problem.to them and I regret this.

  • Like many of your other commenters I had my first child at 34 approx 10 years after what was an undiagnosed relapse, no issues relating to MS, second at 36. Both natural labours, not C-section. But surely the figures in the study are puzzling/skewed/less meaningful because 10 elected to have a C-Section?

  • I was advised as a healthy woman (aged 32) with RRMS I would be treated no differently from my peers. I agreed with this and stopped using Beta interferon while trying to conceive. I had a vaginal delivery but did suffer a relapse subsequently. I breast fed for 9 weeks before deciding to bottle feed and restart my drugs. This was in 2007 and when I gave birth to my second child (again vaginal delivery) in 2010 the midwives and consultant were far more accepting and supportive of my decision to only breast feed for 8 weeks before restarting my medication. I feel that it should always be up to the individual to make decisions but I’m grateful that I was never pushed to have a C section despite being ‘late’. I was also lucky that second time round I didn’t feel ashamed at stopping breast feeding in order to focus on my well-being and capabilities as a mother.

  • I’m a midwife (with MS who had a CS), women with MS will be on a high risk obstetric pathway. They will be booked for ElCS if they wish or come to us with a birth plan from obstetrics – advising a shortened second stage ( of 30 minutes) to mitigate against fatigue. They will be advised epidural anaesthesia. The latter 2 are more likely to result in CS.

  • I have had two children since my diagnosis at 29, one vaginal and one by c-section. I was in labour for 20 hours with my first by which time i was completely exhausted resulting in a forceps delivery and a major tear. I had been seeing a consultant about bowel urgency who recommended having an elective section for my section as he didn’t want me to risk any further damage. The recovery from the section was 1,000 times easier than the difficult vaginal birth!

  • I had two children in urban big US north east teaching hospitals. For first child, I was tagged likely MS and had a natural birth , but was only woman on entire floor, MS or not, having a vaginal natural birth. I was concerned about having an epidural with possible MS, so memorized a book called the Bradley Method, had a birth plan, and a spouse in room. It went ok, baby healthy, I had slow recovery. For 2nd child, I was tagged aggressive ms but was unable to have a vaginal birth for a non ms reason, but was in middle of severe flare. OB would have permitted vaginal birth. I was concerned about anesthesia in spinal space during flare and brought multiple medical journal articles to anesthesiologist about this issue and requested an epidural instead of spinal for my planned c section. This is not for the weak of heart. The risk is that Some spots won’t take, and that is what happened to me. But I knew risk and decided to not go under gas and tough it out for my body’s sake. Baby was healthy and I had no worsening of MS flare at time. Hey what about Breastfeeding? I found it was odd territory as pwms. Dr simply advised dmd was not proven safe and so no go. Someone suggested to me that I nurse for a week to give baby colostrum and then start dmd, which I did. And very aggressive la lache league visited and called me multiple times a day telling me I should nurse while on dmd because it wasn’t proven unsafe. This made for a very difficult decision.

By Prof G

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