Pocket ObGyn – Multiple Sclerois in Pregnancy
See Abbreviations
Definition/Epidemiology
- Immune-mediated demyelinating neurologic condition, characterized by inflamm lesions affecting the brain & spinal cord & resulting in neurologic disability
- Dz classification:
Relapsing-remitting (RR): Manifestations develop in the context of clearly defined acute relapses followed by partial or complete recovery
Secondary progressive: Following an initial RR course, manifestations worsen gradually w/ or w/o superimposed acute relapses
Primary progressive: Manifestations gradually progress from onset w/o relapses
Progressive relapsing: Manifestations gradually progress from onset w/ subseq superimposed relapses
- Occurs in 3:2 ratio of females to males; peak incid of 30 y of age
- Effect of Preg on MS activity (PRIMS N Engl J Med 1998;339:285; Brain 2004;127:1353)
- 70% reduction in relapse risk in the 3rd trimester of Preg in RRMS pts
- 72% relapse in 1st 3 mo PP – a/w relapse in prepregnancy year, relapse during Preg, no association w/ breastfeeding or epidural placement (Brain 2004;127:1353)
- Long-term prog – increasing disability not related to Preg – fullterm Preg can lengthen time to secondarily progressive course (N Engl J Med 1998;339:285)
Diagnosis During Pregnancy and Postpartum
- Most common presenting sx are paresthesia in 1 or more ext, or 1 side of the face, weakness or clumsiness of leg or hand, or visual disturbances (eg, partial blindness, dimness of vision, or scotoma). Optic neuritis has been reported as the 1st symptom of MS in lactating women (Obstet Gynecol 2001;98:902).
- T2-weighted imaging remains the std tool for dx confirmation after 1st trimester
rx During Preg
- Acute flare: 3–5-d course of high-dose corticosteroids administered IV
- Some corticosteroids cross the placenta. No association w/ prematurity, IUFD, or SABs
- DMT are offered to MS pt experiencing at least 1 relapse per year
- Interferon B–reduces relapse rates by ~30%; animal, human studies limited, but show no adverse fetal effects–not a/w increased risk of SAB (Exp Cell Res 2011;317:1301; J Neurol 2010;257:2020; Neurol 2010;75:1794)
- Natalizumab (monoclonal Ab against VCAM alpha-4-integrin) may be used for more aggressive dz; safety has not been established in Preg – pts should stop drug 3 mo prior to conception
- Fingolimod (modifies receptors involved in vascular genesis); no evid regarding safety in Preg – pts should stop drug 2 mo prior to conception
- IVIG – not licensed as std MS therapy, but beneficial effects reported w/ use during Preg
Treatment Postpartum
- 3–5-d course of high-dose corticosteroids (Solu Medrol 1000 mg QD) – protection from relapse for 4 w PP (J Neurol 2004;251:1133)
- DMT can be restarted but protective effects may be delayed for weeks