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Pregnancy and Childbirth in Women with MS

Two studies add important information about the mutual influences of pregnancy and MS.

Multiple sclerosis (MS) preferentially affects women of childbearing age. Scant evidence and little agreement exist about the influence of pregnancy on disease activity and, conversely, the effects of MS on pregnancy outcomes. Two recent studies add important information on this subject.

In a cross-sectional study, D'hooghe and colleagues retrospectively examined childbirth's effects on disability progression in 330 women with MS (mean follow-up after diagnosis, 18 years) who underwent routine periodic neurological evaluations. Patients fell into four categories: no children, children born before MS onset, children born after MS onset, and children born before and after MS onset. The primary outcome was time from disease onset to an Expanded Disability Status Scale (EDSS) score of 6. Women who gave birth after MS onset reached EDSS scores of 6 significantly later in the disease course than those who did not (median time to progression, 22–23 vs. 13–15 years). However, younger age at disease onset accounted for some of this association (P=0.049 after adjustment).

Kelly and colleagues used information from the largest inpatient care database in the U.S. to evaluate obstetric outcomes in women with MS, epilepsy, or pregestational diabetes mellitus and in healthy controls. From 2003 through 2006, 10,000 obstetric hospitalizations of women with diagnoses of MS occurred, of which 7697 were deliveries. On average, women with MS were older than women in the other three groups. An analysis adjusted for maternal race and age showed that women with MS had a 30% higher risk for cesarean delivery and a 70% higher rate of intrauterine growth restriction (IUGR) than did healthy women (both statistically significant differences) but had similar rates of hypertensive disorders of pregnancy and premature rupture of membranes.

Comment: Although retrospective, these findings are reassuring. The first report supports previous observations that pregnancy might delay disability progression in MS (JW Neurol Aug 26 2004). Recent research has suggested a complex interplay between the pregnancy hormone estriol and decreased proinflammatory activity, as measured by the number of active MRI lesions, relapses, and improved ability to remyelinate axons (N Engl J Med 1998; 339:285, J Immunol 1997; 158:446, and Neurology 1999; 52:1230). Although the mechanisms of these effects are not well understood, the current findings, added to the weight of existing evidence, help alleviate fear that pregnancy might exacerbate disease progression. The findings of excess risk for cesarean delivery and IUGR in patients with MS are difficult to interpret without information about delivery outcomes. Prior studies report only a 3% to 4% reduction in birth weight, and no identifiable adverse health outcomes, in babies of women with MS. The consistent effects of MS on pregnancy outcomes do not appear to adversely affect the child's health or directly influence the mother's health. Moreover, no fetal abnormalities have been reported thus far in postmarketing surveillance of early-pregnancy exposure to natalizumab (Tysabri), which was not widely used during these studies. However, we generally advise discontinuation of all immunomodulating or immunosuppressive MS treatments prior to conception attempts. Each patient's illness and family dynamics are unique, but clinicians can now feel more reassured in counseling and supporting patients with MS who wish to bear children.

— Maria K. Houtchens, MD, MMSci

Dr. Houtchens is Staff Neurologist, Partners MS Center, Department of Neurology, Brigham and Women's Hospital, Boston.

Published in Journal Watch Neurology February 9, 2010

Citation(s):

D'hooghe MB et al. Long-term effects of childbirth in MS. J Neurol Neurosurg Psychiatry 2010 Jan; 81:38.

• Original article (Subscription may be required)
• Medline abstract (Free)

Kelly VM et al. Obstetric outcomes in women with multiple sclerosis and epilepsy. Neurology 2009 Dec 1; 73:1831.

• Original article (Subscription may be required)
• Medline abstract (Free)

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• Use of DMD glatiramer up to conception
  James A. Charles, MD, FAAN, New Jersey Medical School, Newark, NJ, 13 Feb 2010 12:10 AM EST
  The percent of women ages 15-44 who are infertile or cannot conceive is approximately 11%. Since many fertile couples do... [more]