Family Planning and Pregnancy in Multiple Sclerosis

1. Family planning and pregnancy in MS Dr. Deepa Rajendran

2. Multiple sclerosis is the most common neurological disorder affecting young women. • Typically diagnosed when a woman is in her twenties or thirties – just when there are important decisions to be made about starting a job, finding a partner and having children.

3. Living with MS • Does NOT mean that you can no longer become pregnant, breastfeed or raise a child • However, your illness, and the medications used to treat it, will need to be considered as you make decisions about your future.

4. Decision-making • Having a child is a very personal decision for you and your partner, but it’s essential to discuss your plans with your doctors and MS clinic nurse before you become pregnant. • Decisions will need to be made about managing your MS and your medication regimen in the months before you become pregnant and after the delivery to ensure the health of you and your baby.

5. Effects of MS on fertility • MS does not affect a woman’s ability to become pregnant or to carry a healthy baby to term. • Women with MS don’t appear to have a higher riskof infertility, spontaneous abortion, complications during the delivery or birth defects compared to women in the general population.

6. Effects of pregnancy on MS • Your MS typically becomes less active. This is especially true during the third trimester. • In these last three months of your pregnancy, you’re less likely to have an MS relapse. • MS relapses are usually less common during pregnancy.This is believed to be due to the hormonal changes that occur.

7. Will my baby get MS? • Genetic factors do influence your risk of developing MS, but no “MS gene” has been identified. • Rather, genetic and environmental factors appear to affect a person’s susceptibility to MS and how the illness develops over the course of your lifetime.

8. This means that MS is not inherited, in the way that some genetic diseases (such as cystic fibrosis) are heritable. Babies are not born with MS, so there’s no test during pregnancy (such as amniocentesis) that’s able to determine whether your child will develop MS later in life. • There is a low risk that MS will develop in babies bornto mothers with MS. Environmental factors will also affect a child’s risk of MS.

9. What to consider before you try

10. How well controlled is your MS? • When was your last relapse? • When was your last MRI? • Stability of blood tests • What MS drug (immunomodulatory therapy) are you on?

11. Injectables • Interferon beta-1a (Avonex, Rebif) • Peginterferon beta-1a (Plegridy) • Interferon beta-1b (Betaferon) All Category C, no washout needed. Not recommended in pregnancy

12. Copaxone • Glatiramer acetate • Large molecule, does not cross the placenta • Category B, best pregnancy rating amongst injectables • Probably safe to use in pregnancy and during breast-feeding but not generally used

13. Oral agents • Gilenya • Aubagio • Tecfidera

14. Fingolimod (Gilenya) • Category D • Not routinely recommended for use in pregnancy or breastfeeding • 2-month washout period before attempting pregnancy

15. Teriflunomide (Aubagio) • Category X • Not recommended for use in women of childbearing age without strict adherence to contraception • Rapid elimination protocol exists

16. Tecfidera • Dimethyl fumarate • Safest oral drug • Category B1 (in Australia) • Can be used up until positive pregnancy test, no washout necessary

17. Infusional therapies • Natalizumab (Tysabri) • Alemtuzumab (Lemtrada)

18. Natalizumab (Tysabri) • Category C • Washout not necessary • Can continue infusions until positive pregnancy test (esp in highly active patients) • Risk of rebound activity after stopping Tysabri • Rarely – can continue in pregnancy

19. Alemtuzumab (Lemtrada) • Category C • 4 month washout recommended • Not recommended to be used in pregnancy or during breastfeeding

20. Newer agents • Limited data, use not recommended • Ocrelizumab (Ocrevus) – Category C , 4-6 month washout • Cladribine (Mavenclad) – Category D, use not recommended, washout unknown

21. MS meds and fatherhood • Not much is known about safety of using MS immunotherapy in men at the time of conception • Interferons, Copaxone– thought to be safe • Tecfidera– safe too • Aubagio– guidelines recommend washout prior to attempting conception • Very limited data about newer agents

22. Management of a relapse in pregnancy

23. How to manage • Contact your GP/MS nurse/Neurologist • Urgent review – in most cases • Rule out other causes – pregnancy related/infection • Steroids - Can be used in pregnancy after discussion about risks and benefits

24. Having MRI in pregnancy

25. Exposure to MRI during the first trimester of pregnancy was not associated with any increased risk of harm to the baby in several trials • Scans should be requested if it will change our management • Use of contrast is discouraged unless deemed absolutely essential but is thought to be safe too

26. Does MS impact on “how you deliver” NO

27. Not unless a specific physical disability due to the MS affects mode of delivery • Women with MS no more likely to experience delivery complications than women without MS • Mode of delivery should be dictated strictly by obstetric criteria • Epidural, spinals and GA – all safe

28. What happens to MS after childbirth • The risk of having a relapse increases in the first three months after childbirth. This is a concern if your MS was very active in the year before you became pregnant. • About 3-6 months after childbirth, the symptoms and severity of your MS typically return to how they were before your pregnancy.

29. Breast-feeding • There’s some evidence to suggest that the post-partum flare-up in your MS symptoms can be delayed if you exclusively breastfeed (i.e. no bottle feeding). • But after the baby is weaned, there’s a risk that your MS will become active once again.

30. Restarting therapy • The short-term flare-ups of MS activity that can occur after pregnancy don’t appear to have an impact on the long-term course of your disease. • Pregnancy is not believed to affect your chances of developing disability later on. However, it’s important to consider that a short-term worsening of your MS – a relapse, MS fatigue or other symptoms – can be an added challenge in those early months of feeding and caring for your new baby. • So it’s often best to re-start your MS medication as soon as possible after childbirth.

31. Tips to plan your pregnancy • Be as healthy as you can be. Exercise regularly, quit smoking, avoid junk foods and get enough sleep. Talk to your obstetrician-gynecologist about the vitamins and supplements (e.g. folic acid) you’ll need. • Drink water regularly to ensure you are well hydrated – especially after exercise. Overheating can worsen your MS symptoms. • Investigate the maternity benefits to which you’re entitled (e.g. income, time off work, reintegration after maternity leave). • Discuss your plans with your family doctor. • Discuss the timing of your pregnancy with your neurologist– before you get pregnant! You’ll need to make some decisions about how best to treat your MS.

32. Tips after the baby is born • Maintain your wellness – eat well and stay hydrated. • Try to avoid getting overtired. Childbirth can worsen your MS fatigue. • Ask for help – from your partner, family and friends. You’ll need to take a break if you’re troubled by any MS symptoms. • Talk to your GP or obstetrician if you’re feeling depressed or anxious. • Talk to your neurologist about how long you plan to breastfeed, and when you should start taking your MS medication.