Strategies and Considerations for Managing MS in Pregnant Women

Announcer:
You’re listening to On the Frontlines of Multiple Sclerosis on ReachMD. And now, here’s your host, Dr. Charles Turck.

Dr. Turck:
Welcome to On the Frontlines of Multiple Sclerosis on ReachMD. I’m Dr. Charles Turck, and joining me to share management strategies for pregnant women who have multiple sclerosis, or MS, is Dr. Anna Shah. She’s the Associate Clinic Director for the Department of Neurology at the University of Colorado.

Dr. Shah, thanks so much for being here today.

Dr. Shah:
Thank you, Dr. Turck. Thank you for having me.

Dr. Turck:
So, starting with preconception care, Dr. Shah, what are some key family planning considerations for patients with MS? 

Dr. Shah:
That’s a great question, and I think this is one of the areas where it’s helpful to provide a little bit more anticipatory guidance rather than play catch-up once someone is pregnant. Key family planning considerations include getting a sense of when a woman with MS might be considering expanding her family and whether that means natural conception or some other means. Those are important things for us as neurologists to know for multiple reasons. One is to ask, do we need to alter your longstanding immunosuppression or disease-modifying therapy to minimize risk to the potentially developing fetus, as well as to the mom, if there is a risk of rebound with stopping that medication? Other considerations that are important to think about are, given that we also use a lot of symptomatic medications within the field of MS, whether it’s medicines for neuropathic pain, spasticity, or fatigue, there are definitely some that are not compatible with pregnancy. So we have to come up with a good plan of either transitioning to medications that are safe during pregnancy or coming up with mitigation strategies to manage those symptoms in lieu of medications.

Dr. Turck:
And are there specific vitamins or supplements to support both maternal and fetal health that you recommend for pregnant women with MS? 

Dr. Shah:
I think the recommendations for women with MS are not really too different than what our recommendations are for women without MS. So we certainly recommend a multivitamin or a prenatal vitamin for all pregnant women. There is some data that perhaps making sure that vitamin D levels are maintained at normal ranges helps reduce the infant’s chance of development of MS, but those studies are quite old and have not been well substantiated. 

So I often say thinking about the addition of vitamin D if you’re someone that has a hard time keeping that level up or if your prenatal does not contain vitamin D.

Dr. Turck:
For those just turning in, you’re listening to On the Frontlines of Multiple Sclerosis on ReachMD. I’m Dr. Charles Turck, and I’m speaking with Dr. Anna Shah about what we need to consider when managing pregnant patients with MS.

So, Dr. Shah, if we continue along the patient journey and focus on the postpartum period, how do you approach treatment and counselling of patients who wish to breastfeed? 

Dr. Shah:
I think that is a great question, and one of the most exciting developments in our field is gaining more and more data about how women with MS can breastfeed safely. And so the biggest thing to counsel patients on is saying, “Well, if you would like to breastfeed having MS or have the desire to start disease-modifying therapy soon after delivery, it’s entirely feasible.” And so what I counsel patients about is our natural breast milk pathophysiology. So when a woman first delivers, we often see a type of breast milk called colostrum, which then transitions to transitional breast milk and then ultimately becomes mature breast milk, which is often around seven to 10 days postpartum or post-delivery. That is important to know for these patients because all of the data that we have about pharmacodynamics and kinetics in breast milk, as well as breast milk concentrations of some of these medications, is all in the setting of mature breast milk. So we want to make sure that we are not treating patients before they have the presence of mature breast milk. Other points that are important to think about when we think about treatment or counselling is also that exclusive breastfeeding helps reduce the odds ratio of postpartum relapses by about a third. But if a woman is an exact producer or an under-producer and not able to breastfeed—which is an ailment that strikes both women that have MS and women who don’t—that’s okay, and I think that picture looks a little bit different for each patient. 

Dr. Turck:
And what else is the latest research saying about the risk of postpartum MS relapse? 

Dr. Shah:
Great question. So a lot of the data that we originally started working off of was the data that came with the PRIMS trial, which was published in the early 2000s. And from that trial we knew that the risk of relapses in those first three to six months postpartum was about a 70 percent increase from what their relapse rates were like before they conceived or got pregnant. And so one of the biggest concerns when you’re seeing data that shows that significant increase is, “Well, when do we get people back on treatment?” And one of the cooler things in the last several years—including a project that I’m currently working on—is to look at these rates in the setting of more modern medicine where we have disease-modifying therapies and patients are not only treated more aggressively beforehand to mitigate those relapses prepartum, but are also treated postpartum. And so I think with that being said, one of the things that we’re seeing is that the risk of relapse postpartum becomes a lot more manageable. I don’t want to say it’s negligible because I don’t think we’re quite there yet, but I think it’s quite a bit more manageable, particularly if we’re thinking about how we use some of these medications in the setting of mature breast milk to allow moms to do what they want to do, which includes breastfeeding, but also allow them to be safe from an MS standpoint. 

Dr. Turck:
Before we close, Dr. Shah, let’s look ahead for just a moment. What emerging research or treatment advances for pregnant patients with MS are you most excited about?

Dr. Shah:
There’s quite a few. Thinking about how we keep our pregnant patients with MS safest, there is a lot of data emerging about how short of an interval is safe to use these disease-modifying therapies when women are trying to conceive. We know that if we’re looking at FDA regulations, a lot of them will illustrate time periods that are perhaps longer than makes sense from a pharmacology standpoint and so we should look at real world data from which we’re able to say how we can minimize time that patients are off of treatment but maximize their chances to get pregnant. I think other emerging research that’s being done is looking at that postpartum period and how we can use particular medications safely if women would like to breastfeed, while maintaining safety for the mom from an MS standpoint and also the infant from a drug exposure standpoint.

The last thing that is very relevant is that we know in the U.S. we’re seeing the average age of patients conceiving or having pregnancies increasing over the years. And so one of the areas that has really been emerging in terms of looking at safety is the use of assistive reproductive technologies: things like IUI or IVF to help patients get pregnant if they have decreased fertility. The topic of fertility in MS I think is still a little unknown. There are some studies that indicate that there may be some effect on fertility for MS patients and so knowing that we can use some of these assisted reproductive techniques to allow them to have families if that’s something they’re interested in and do it safely is quite exciting.

Dr. Turck:
Well, as those comments bring us to the end of today’s program, I want to thank my guest, Dr. Anna Shah, for joining me to share her insights on how we can best manage pregnant patients who have multiple sclerosis.

Dr. Shah, it was great speaking with you today. 

Dr. Shah:
Thank you, Dr. Turck. I appreciate the invitation.

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