Practical Considerations for Managing Pregnancy in Patients With Multiple Sclerosis: Dispelling the Myths

Edith L Graham; Riley Bove; Kathleen Costello; Heidi Crayton; Dina A Jacobs; Suma Shah; Francesca Sorrell; Sharon S Stoll; Maria K Houtchens

doi:10.1212/CPJ.0000000000200253

Practical Considerations for Managing Pregnancy in Patients With Multiple Sclerosis: Dispelling the Myths

Neurol Clin Pract. 2024 Apr;14(2):e200253. doi: 10.1212/CPJ.0000000000200253. Epub 2024 Feb 13.

Authors

Edith L Graham¹, Riley Bove¹, Kathleen Costello¹, Heidi Crayton¹, Dina A Jacobs¹, Suma Shah¹, Francesca Sorrell¹, Sharon S Stoll¹, Maria K Houtchens¹

Affiliation

¹ Department of Neurology (ELG), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (RB), UCSF Weill Institute for Neurosciences, University of California, San Francisco; Can Do Multiple Sclerosis (KC), Avon, CO; Multiple Sclerosis Center of Greater Washington (HC), Vienna, VA; Department of Neurology (DAJ), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (SS), Duke University School of Medicine, Durham, NC; Envision Pharma Group (FS), Glasgow, UK; Stoll Medical Group (SSS), Philadelphia, PA; and Brigham Multiple Sclerosis Center (MKH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Abstract

Purpose of review: Lack of consistent data and guidance have led to variations between clinicians in the management of pregnancy in women with multiple sclerosis (MS). Pregnant and/or lactating women are often excluded from clinical trials conducted in MS, and thus, the labeling for most disease-modifying therapies (DMTs) excludes use during pregnancy. This has led to heterogeneity in interpretation and labeling regarding the safety of DMTs during pregnancy and lactation and the required preconception washout periods. This review identifies key themes where there is conflicting information surrounding family planning and pregnancy in MS, focusing on the most common discussion points between physicians and patients during preconception planning, pregnancy, postpartum, and lactation. The goal was to inform the patient-physician conversation and provide best practice recommendations based on expert clinical expertise and experience.

Recent findings: We outline the latest evidence-based data for DMT use during pregnancy and lactation, the effect of MS on fertility and fertility treatments, the risk of adverse pregnancy and delivery outcomes, the risk of postpartum relapse, and immunization and clinical imaging safety during pregnancy and breastfeeding.

Summary: Management of family planning and pregnancy in patients with MS requires the most current information. Health care providers should discuss family planning early and frequently with patients with MS, and partners where practicable. Because management of pregnant people with MS will often require a risk/benefit analysis of their needs, shared decision-making in family planning discussions is emphasized. Additional data are needed for specific and underrepresented populations with MS (e.g., single parents or those from the LGBTQ+ community) and those at risk of racial and socioeconomic disparities in care. Pregnancy registries and the design and conduct of clinical trials focused on pregnant and lactating patients should provide additional data to guide the ongoing management of patients with MS.

Publication types

Review