ACUTE EXACERBATION OF MULTIPLE SCLEROSIS IN PREGNANCY

Abstract

Multiple sclerosis (MS) is a chronic demyelinating neurologic disorder that mainly affects young individuals (aged 20 to 50 years). Approximately 85% of patients experience an initial course with relapses and remissions (relapsing-remitting multiple sclerosis). A lot of questions arise if patients with MS get pregnant or plan to conceive. It is important not to discourage these women but to comprehensively inform about possible risks and specific features of pregnancy in MS. These include a slightly elevated risk for heredity, the possibility of disease-related sexual dysfunctions and an increase of relapse rate during puerperium. On the other hand, specific complications during pregnancy or congenital abnormality are not to be feared for. Patients have to be aware of limited knowledge about the effect of various MS medication on pregnancy as well as that, until now, an unambiguous recommendation of breast feeding is not possible. Thus, a weighting between risk and benefit is frequently necessary, which should always be done after detailed counseling and together with an experienced physician. Prevention of postpartum relapses poses a challenge for the future to encourage even more patients to fulfill their desire to start a family Guidelines for the management of MS should be focused on three main areas: (a) The diagnosis of MS; (b) Treatment of relapses; and (c) Long-term preventive treatment including clinical follow up, dose adjustment, drug switch, control of therapeutic efficacy, and disease progression. Diagnosis should be established according to clinical and paraclinical criteria. Discussion on therapeutic recommendations is focused on the disease-modifying agents in acute phases and drugs for long-term treatment and symptomatic treatment. Differential diagnoses must be taken into account on making the diagnosis of MS. Therefore, diagnosis of MS should be established on clinical and radiological diagnostic criteria, cerebrospinal fluid analysis and evoked potentials. In order to evaluate treatment efficacy, once the diagnosis is confirmed and treatment has been established, first visit must be scheduled in 4-6 weeks and, in stable patients, follow up must be made every 3-6 months. If there are relapses, it is important to note duration of relapses, their frequency, severity, and subsequent recovery. Brain and spinal cord MRI during relapses is not mandatory (it does not alter the treatment course during acute episodes and is too costly for healthcare systems). Though data on the efficacy and/or safety of MS treatments during pregnancy and breastfeeding remain limited, completed or ongoing registry studies are providing essential real world data allowing healthcare professionals and patients to weigh the benefit of specific MS treatments against the potential risks to the fetus. Based on data from these registries, other published studies and analyses, and our own clinical experience, we have developed clinical considerations on the use of DMTs and corticosteroids during pregnancy and breastfeeding Ultimately, the treating physician and the patient involved must carefully consider the decision to either discontinue or continue using a particular agent during pregnancy or breastfeeding. Over the last thirty years enough evidence has been gathered to be able to reassure women with MS who desire a family that pregnancy and breastfeeding are not harmful. However, significant gaps in knowledge remain, particularly about modifiable risk factors of postpartum relapses that limit our ability to counsel women and develop strategies to decrease the risk of postpartum relapses. The most pressing issue that needs to be resolved is the trade-off between resuming MS treatments in lieu of breastfeeding. This issue should be approached both through epidemiological studies of postpartum relapses and studies aimed at establishing the safety of MS treatments during lactation and/or pregnancy. Even more significant gaps in knowledge exist in our understanding of the long and short-term biological effects of pregnancy and breastfeeding on MS disease course. Advances in metabolic diseases raise the intriguing possibility that pregnancy, particularly followed by prolonged breastfeeding, may have lasting immunomodulatory and/or neuroprotective benefits. Careful immunological studies of pregnant and postpartum women with MS also present a biologically rich opportunity to improve our understanding of MS relapse pathophysiology. Improving our understanding of the transient and potentially lasting immunomodulatory and/ or neuroprotective effects of pregnancy and breastfeeding is likely to shed light on MS pathophysiology in general and aids in optimizing treatment strategies