Connect
MJA
MJA

Family planning, antenatal and post partum care in multiple sclerosis: a review and update

Anneke Van Der Walt, Ai‐Lan Nguyen and Vilija Jokubaitis
Med J Aust 2019; 211 (5): . || doi: 10.5694/mja2.50113
Published online: 1 April 2019

Summary

 

  • Multiple sclerosis is more prevalent in women of childbearing age than in any other group. As a result, the impact of multiple sclerosis and its treatment on fertility, planned and unplanned pregnancies, post partum care and breastfeeding presents unique challenges that need to be addressed in everyday clinical practice.
  • Given the increasing number of disease‐modifying agents now available in Australia for the treatment of multiple sclerosis, there is a growing need for clinicians to provide their patients with appropriate counselling on family planning.
  • Providing better evidence regarding the relative risks and benefits of continuing therapy before, during and after pregnancy is an important research priority. International pregnancy registries are essential in developing better evidence‐based practice guidelines, and neurologists should be encouraged to contribute to these when possible.
  • The management of women with multiple sclerosis, especially when they are taking disease‐modifying agents, requires careful assessment of fertility and disease characteristics as well as a multidisciplinary approach to ensure positive outcomes in both mothers and their children.

 


  • 1 Monash University, Melbourne, VIC
  • 2 University of Melbourne, Melbourne, VIC
  • 3 Alfred Health, Melbourne, VIC
  • 4 Royal Melbourne Hospital, Melbourne, VIC



Competing interests:

Anneke Van der Walt has received travel support, speaking honoraria and served on advisory boards for Biogen Australia, Novartis, Merck, Sanofi, Roche and Teva. Ai‐Lan Nguyen has received grant support and travel support from Biogen Australia. Vilija Jokubaitis has received travel support and speaking honoraria from Biogen Australia.

  • 1. Niedziela N, Adamczyk‐Sowa M, Pierzchała K. Epidemiology and clinical record of multiple sclerosis in selected countries: a systematic review. Int J Neurosci 2014; 124: 322–330.
  • 2. Hauser S, Oksenberg J. The neurobiology of multiple sclerosis: genes, inflammation, and neurodegeneration. Neuron 2006; 52: 61–76.
  • 3. Australian Bureau of Statistics. Multiple sclerosis (Cat. No. 4429.0). Canberra: Commonwealth of Australia, 2012. http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4429.0main+features100182009 (viewed Dec 2017).
  • 4. Amato MP, Portaccio E. Fertility, pregnancy and childbirth in patients with multiple sclerosis: impact of disease‐modifying drugs. CNS Drugs 2015; 29: 207–220.
  • 5. Broadley SA, Barnett MH, Boggild M, et al. A new era in the treatment of multiple sclerosis. Med J Aust 2015; 203: 139–141. https://www.mja.com.au/journal/2015/203/3/new-era-treatment-multiple-sclerosis
  • 6. Confavreux C, Hutchinson M, Hours MM, et al. Rate of pregnancy‐related relapse in multiple sclerosis. N Engl J Med 1998; 339: 285–291.
  • 7. Vukusic S, Marignier R. Multiple sclerosis and pregnancy in the “treatment era”. Nat Rev Neurol 2015; 11: 280–289.
  • 8. Lu E, Wang BW, Alwan S, et al. A review of safety‐related pregnancy data surrounding the oral disease‐modifying drugs for multiple sclerosis. CNS Drugs 2014; 28: 89–94.
  • 9. Friend S, Richman S, Bloomgren G, et al. Evaluation of pregnancy outcomes from the Tysabri® (natalizumab) Pregnancy Exposure Registry: a global, observational, follow‐up study. BMC Neurol 2016; 16: 150.
  • 10. Therapeutics and Goods Administration. TGA eBusiness Services. Australian Government Department of Health and Ageing. https://www.tga.gov.au/prescribing-medicines-pregnancy-database (viewed Dec 2017).
  • 11. National Clinical Guideline Centre (UK). Multiple sclerosis: management of multiple sclerosis in primary and secondary care (NICE clinical guidelines no. 186). London: National Institute for Health and Care Excellence (UK), 2014. https://www.ncbi.nlm.nih.gov/books/NBK248064 (viewed Dec 2017).
  • 12. Cavalla P, Rovei V, Masera S, et al. Fertility in patients with multiple sclerosis: current knowledge and future perspectives. Neurol Sci 2006; 27: 231–239.
  • 13. Roux T, Courtillot C, Debs R, et al. Fecundity in women with multiple sclerosis: an observational mono‐centric study. J Neurol 2015; 262: 957–960.
  • 14. Borisow N, Döring A, Pfueller CF, et al. Expert recommendations to personalization of medical approaches in treatment of multiple sclerosis: an overview of family planning and pregnancy. EPMA J 2012; 3: 9.
  • 15. Cordeau D, Courtois F. Sexual disorders in women with MS: assessment and management. Ann Phys Rehabil Med 2014; 57: 337–347.
  • 16. Schairer LC, Foley FW, Zemon V, et al. The impact of sexual dysfunction on health‐related quality of life in people with multiple sclerosis. Mult Scler 2014; 20: 610–616.
  • 17. Multiple Sclerosis International Foundation. Intimacy and sexuality. MS in focus 2005; 6. https://www.msif.org/wp-content/uploads/2014/09/MS-in-focus-6-Intimacy-and-sexuality-English.pdf (viewed Dec 2017).
  • 18. Hellwig K, Correale J. Artificial reproductive techniques in multiple sclerosis. Clin Immunol 2013; 149: 219–224.
  • 19. Laplaud DA, Leray E, Barrière P, et al. Increase in multiple sclerosis relapse rate following in vitro fertilization. Neurology 2006; 66: 1280–1281.
  • 20. Hellwig K, Schimrigk S, Beste C, et al. Increase in relapse rate during assisted reproduction technique in patients with multiple sclerosis. Eur Neurol 2009; 61: 65–68.
  • 21. Hellwig K, Beste C, Brune N, et al. Increased MS relapse rate during assisted reproduction technique. J Neurol 2008; 255: 592–593.
  • 22. Michel L, Foucher Y, Vukusic S, et al. Increased risk of multiple sclerosis relapse after in vitro fertilisation. J Neurol Neurosurg Psychiatr 2012; 83: 796–802.
  • 23. Correale J, Farez MF, Ysrraelit MC. Increase in multiple sclerosis activity after assisted reproduction technology. Ann Neurol 2012; 72: 682–694.
  • 24. Hughes SE, Spelman T, Gray OM, et al. Predictors and dynamics of postpartum relapses in women with multiple sclerosis. Mult Scler 2014; 20: 739–746.
  • 25. Coyle PK. Switching therapies in multiple sclerosis. CNS Drugs 2013; 27: 239–247.
  • 26. Australian categorisation system for prescribing medicines in pregnancy. Therapeutic Goods Administration, 2011. www.tga.gov.au/australian-categorisation-system-prescribing-medicines-pregnancy (viewed Dec 2017).
  • 27. Gur C, Diav‐Citrin O, Shechtman S, et al. Pregnancy outcome after first trimester exposure to corticosteroids: a prospective controlled study. Reprod Toxicol 2004; 18: 93–101.
  • 28. Coyle PK. Multiple sclerosis and pregnancy prescriptions. Expert Opin Drug Saf 2014; 13: 1565–1568.
  • 29. Achiron A, Chambers C, Fox EJ, et al. Pregnancy outcomes in patients with active RRMS who received alemtuzumab in the clinical development program [abstract]. Mult Scler J 2015; 21: 581–582.
  • 30. Haghikia A, Langer‐Gould A, Rellensmann G, et al. Natalizumab use during the third trimester of pregnancy. JAMA Neurol 2014; 71: 891–895.
  • 31. Vukusic S, Kappos L, Wray S, et al. An update on pregnancy outcomes following ocrelizumab treatment in patients with multiple sclerosis and other autoimmune diseases [abstract]. Mult Scler J 2017; 23: 85–426.
  • 32. Glazaka A, Nolting A, Cook S, et al. Pregnancy outcomes during the clinical development programme of cladribine in multiple sclerosis (MS): an integrated analysis of safety for all exposed patients [abstract]. Mult Scler J 2017; 23: 976–1023.
  • 33. Kieseier BC, Benamor M. Pregnancy outcomes following maternal and paternal exposure to teriflunomide during treatment for relapsing‐remitting multiple sclerosis. Neurol Ther 2014; 3: 133–138.
  • 34. Finkelsztejn A, Brooks J, Paschoal FM, Fragoso YD. What can we really tell women with multiple sclerosis regarding pregnancy? A systematic review and meta‐analysis of the literature. BJOG 2011; 118: 790–797.
  • 35. Harirchian MH, Fatehi F, Sarraf P, et al. Worldwide prevalence of familial multiple sclerosis: a systematic review and meta‐analysis. Mult Scler Relat Disord 2018; 20: 43–47.
  • 36. Compston A, Coles A. Multiple sclerosis. Lancet 2008; 372: 1502–1517.
  • 37. Fragoso YD, Boggild M, Macias‐Islas MA, et al. The effects of long‐term exposure to disease‐modifying drugs during pregnancy in multiple sclerosis. Clin Neurol Neurosurg 2013; 115: 154–159.
  • 38. Houtchens MK, Kolb CM. Multiple sclerosis and pregnancy: therapeutic considerations. J Neurol 2013; 260: 1202–1214.
  • 39. Polifka JE, Friedman JM. Medical genetics: 1. Clinical teratology in the age of genomics. CMAJ 2002; 167: 265–273.
  • 40. Alwan S, Yee IM, Dybalski M, Guimond C, Dwosh E, Greenwood TM, et al. Reproductive decision making after the diagnosis of multiple sclerosis (MS). Mult Scler 2013; 19: 351–358.
  • 41. Ferrero S, Pretta S, Ragni N. Multiple sclerosis: management issues during pregnancy. Eur J Obstet Gynecol Reprod Biol 2004; 115: 3–9.
  • 42. Iorio R, Frisullo G, Nociti V, et al. T‐bet, pSTAT1 and pSTAT3 expression in peripheral blood mononuclear cells during pregnancy correlates with post‐partum activation of multiple sclerosis. Clin Immunol 2009; 131: 70–83.
  • 43. Broadley SA, Barnett MH, Boggild M, et al. Therapeutic approaches to disease modifying therapy for multiple sclerosis in adults: an Australian and New Zealand perspective: part 3, treatment practicalities and recommendations. J Clin Neurosci 2014; 21: 1857–1865.
  • 44. Daclizumab withdrawn from the market worldwide [erratum for Daclizumab for MS]. Drug Ther Bull 2018; 56: 38–21.
  • 45. Broadley SA, Barnett MH, Boggild M, et al. Therapeutic approaches to disease modifying therapy for multiple sclerosis in adults: an Australian and New Zealand perspective: part 1, historical and established therapies. J Clin Neurosci 2014; 21: 1835–1846.
  • 46. Hellwig K, Haghikia A, Gold R. Pregnancy and natalizumab: results of an observational study in 35 accidental pregnancies during natalizumab treatment. Mult Scler 2011; 17: 958–963.
  • 47. Glazer CH, Tøttenborg SS, Giwercman A, et al. Male factor infertility and risk of multiple sclerosis: a register‐based cohort study. Mult Scler 2017; 46: 1–8.
  • 48. Strijbos E, Coenradie S, Touw DJ, Aerden L. High‐dose methylprednisolone for multiple sclerosis during lactation: concentrations in breast milk. Mult Scler 2015; 21: 797–798.
  • 49. Hellwig K, Haghikia A, Gold R. Parenthood and immunomodulation in patients with multiple sclerosis. J Neurol 2010; 257: 580–583.
  • 50. Vukusic S, Durand‐Dubief F, Benoit A, et al. Natalizumab for the prevention of post‐partum relapses in women with multiple sclerosis. Mult Scler 2015; 21: 953–955.
  • 51. Hellwig K, Rockhoff M, Herbstritt S, et al. Exclusive breastfeeding and the effect on postpartum multiple sclerosis relapses. JAMA Neurol 2015; 72: 1132–1138.
  • 52. Conradi S, Malzahn U, Paul F, et al. Breastfeeding is associated with lower risk for multiple sclerosis. Mult Scler 2013; 19: 553–558.
  • 53. Pakpoor J, Disanto G, Lacey MV, et al. Breastfeeding and multiple sclerosis relapses: a meta‐analysis. J Neurol 2012; 259: 2246–2248.
  • 54. Anderson PO. Monoclonal antibodies. Breastfeed Med 2016; 11: 100–101.
  • 55. McConnell RA, Mahadevan U. Pregnancy and the patient with inflammatory bowel disease: fertility, treatment, delivery, and complications. Gastroenterol Clin North Am 2016; 45: 285–301.
  • 56. Levy RA, de Jesús GR, de Jesús NR, Klumb EM. Critical review of the current recommendations for the treatment of systemic inflammatory rheumatic diseases during pregnancy and lactation. Autoimmun Rev 2016; 15: 955–963.
  • 57. Baker TE, Cooper SD, Kessler L, Hale TW. Transfer of natalizumab into breast milk in a mother with multiple sclerosis. J Hum Lact 2015; 31: 233–236.

Author

remove_circle_outline Delete Author
add_circle_outline Add Author

Comment
Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Online responses are no longer available. Please refer to our instructions for authors page for more information.