"Medical Journeys" is a set of clinical resources reviewed by doctors, meant for physicians and other healthcare professionals as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.
If you have multiple sclerosis (MS) and are hoping to get pregnant, the news is good: MS itself does not make a pregnancy high-risk. But it's important to work with your doctor to plan ahead for the best outcome.
Historically, physicians discouraged women with MS from getting pregnant but that changed in 1998 with the publication of a landmark study that showed that pregnancy generally does not make MS worse in the long term. In fact, many people with MS actually have less disease activity during pregnancy, but they do often relapse during the first few months postpartum.
"Conversations about intent for family planning should happen at every visit, and in the active decision-making phase should involve the patient's multidisciplinary team, including their neurologist, obstetric team, and primary physician," said Edith Graham, MD, of Northwestern University Feinberg School of Medicine in Chicago, and colleagues, in a .
Many neurologists recommend that newly diagnosed patients with MS receive a disease-modifying treatment (DMT) right away and that they should be stable on that drug for at least a year before attempting to conceive.
However, DMTs are not safe to take during pregnancy. What's more, some MS DMTs require a waiting period where women with MS avoid attempts at conception before safely trying to get pregnant.
Scientists are still studying how long the waiting period should be for each DMT. Current FDA guidance on waiting periods range from 1 week to 3 months for the class of drugs known as sphingosine-1-phosphate (S1P) receptor modulators, which include fingolimod (Gilenya) and ozanimod (Zeposia).
Monoclonal antibodies, which include drugs like ocrelizumab (Ocrevus) and ofatumumab (Kesimpta), have even longer waiting periods, ranging from 4 to 12 months.
Despite these longer waiting times, monoclonal antibodies may offer some advantages to women who want to get pregnant. As part of a strategy known as "early aggressive treatment," physicians often prescribe a higher-efficacy treatment (HET) right when a patient receives an MS diagnosis in hopes of preventing later disability and neurological damage.
"HETs seem to represent a particularly effective way of managing inflammatory activity before and after pregnancy," Graham and co-authors wrote. "Preconception use of DMTs like B-cell–depleting therapies [such as ocrelizumab and ofatumumab] may reduce the incidence of relapses in the pre-pregnancy period while offering some protection from peripartum/postpartum relapses."
The S1P receptor modulators are also considered to be HETs and have shorter waiting times prior to pregnancy. However, the that these drugs come with an increased risk of rebound disease activity after treatment is stopped.
Given these complexities, the physician who treats your MS is in the best position to recommend an appropriate DMT strategy and timing to help you achieve your goal of a healthy pregnancy.
Now That You're Pregnant
And when the time comes, just like anyone who is pregnant, you will take folic acid and prenatal vitamins, and your neurologist and obstetrician may decide to increase your vitamin D intake.
You should also follow the same vaccination schedule used for the general pregnant population. This includes a flu shot plus vaccines for COVID-19 and diphtheria, tetanus, and acellular pertussis (Tdap).
MRI during pregnancy is considered safe, but contrast agents cross the placenta and should be avoided.
People with MS are not limited to a specific type of anesthesia during labor and delivery. You and your obstetrician should choose pain relief based on your preferences and specific obstetric circumstances.
After the Birth
Most scientists believe that pregnancy is unlikely to have long-term negative effects on women with MS. In fact, the opposite may be true. A 2022 noted that "there is some evidence that pregnancy after MS onset could have a favorable long-term effect on the course of MS, as women who deliver one or more children after MS onset appear to have a slower disability progression than women with MS [who have not had a child]."
However, giving birth may trigger MS relapses. Many studies have shown that about one-third of patients with MS relapse in the first 3 months after delivery and about one half do so in the first 6 months after delivery. More recent studies, though, have suggested a lower actual postpartum relapse risk.
The main risk factors of postpartum relapse include:
- Maternal age less than 35
- Relapses before and during pregnancy
- Higher level of pre-pregnancy disability
- Not taking a DMT before pregnancy
- Stopping treatment with a DMT known to induce rebound disease activity
All new mothers benefit from doing pelvic floor exercises. Talk to your doctor about pelvic floor physical therapy if you need extra help.
You'll also want to be on the lookout for postpartum depression, since people with MS are more likely to have depression than the general population. Seek help from a mental healthcare provider promptly if you think you have anything more than a slight case of the baby blues.
Numerous studies have shown that breastfeeding your baby can significantly reduce the risk of postpartum MS relapses. The risk drops even further among women who breastfeed exclusively. One recent found that breastfeeding was associated with a 43% lower rate of postpartum relapse.
DMTs will end up in breast milk and are generally not safe for nursing babies, but you may have several options. Women with MS may be able to breastfeed while on monoclonal antibody treatments, including ocrelizumab, natalizumab, and ofatumumab, with low risk to the infant, Graham and co-authors said. They added that monoclonal antibodies are detected at trace levels in milk and further are likely to be partially destroyed in the infant's gastrointestinal tract.
New data continue to support the use of anti-CD20 monoclonal antibodies during breastfeeding, with infants exposed to ocrelizumab and rituximab throughout breastfeeding showing normal growth and development with no unexpected severe or frequent infections, the team noted.
Finally, just as coming off your DMT before pregnancy involves a series of complicated risk-benefit decisions, so does going back on a DMT once your baby arrives. Talk with your neurologist about when you should resume treatment and whether a different DMT would be a safer choice while you're breastfeeding.
Read previous installments in this series:
For Your Patients: What to Expect After a Multiple Sclerosis Diagnosis
For Your Patients: What Are the Different Types of MS?
For Your Patients: Coping With the Mental Health Challenges of Multiple Sclerosis
For Your Patients: The Benefits of Early Aggressive Treatment for MS
For Your Patients: Understanding Progressive MS and Relapsing MS
For Your Patients: Understanding Cognitive Changes in Multiple Sclerosis
For Your Patients: The Challenges Faced by Black People With MS