Expert Panel Offers Pointers for Managing MS During Pregnancy

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MS does not carry an increased risk of high-risk pregnancy, but many clinicians are unclear about best practices for managing these patients.

Rohini Samudralwar, MD

Rohini Samudralwar, MD

(Credit: Penn Medicine)

Dina Jacobs, MD

Dina Jacobs, MD

(Credit: Penn Medicine)

Multiple sclerosis (MS) diagnosis has a female to male ratio of 3 to 1, and 90% of women with MS are diagnosed during the premenopausal stage. Yet too little is known about the optimal management of MS during pregnancy. In a panel discussion at the Consortium of Multiple Sclerosis Centers 2024 annual meeting, 4 speakers with recognized expertise in reproductive health and MS debated optimal strategies for managing the disease while protecting the safety of the mother and fetus.

What if the woman is diagnosed with MS during pregnancy?

Moderator Rohini Samudralwar, MD, of Penn Medicine, presented a case of a 30-year-old woman who developed new symptoms of right foot drop and spastic gait during her first trimester of pregnancy. “I have greater suspicion for an antibody-mediated disease like NMOSD when I see a patient presenting with these symptoms during pregnancy,” said UCSF neurologist Riley Bove, MD. “Assuming those antibodies are ruled out, another initial consideration is the need for social support and mental health care while coping with a new diagnosis.”

This is the point where shared decision-making gets real, added panelist Dina Jacobs, MD, of Penn Medicine. The overwhelming nature of an MS diagnosis, compounded by pregnancy, leaves the woman vulnerable to conflicted feelings about potentially harming the fetus while attempting to care for her own health. A maternal fetal medicine specialist should be part of multidisciplinary team, but also the patient’s partner or other support system.

What if a relapse occurs during pregnancy?

For a moderate to severe relapse, treatment with steroids is usually warranted, said Maria Houtchens, MD, of Brigham and Women’s Hospital. While some data suggest an elevated risk of cleft palate when steroids are used in the first trimester, Houtchens pointed out that this risk is very low. “The fetal palate has fully fused by 10 weeks, so presumably after this time you can safely administer steroids,” she said. Methylprednisolone is the agent of choice in these cases, the panelists agreed, while dexamethasone and other steroids are not recommended. Milder relapses may be managed with supportive care.

Riley Bove, MD

Riley Bove, MD

(Credit: UCSF)

Maria Houtchens, MD

Maria Houtchens, MD

(Credit: Brigham MS Center)

What are considerations for starting DMT in a pregnant woman?

Although this is a highly individualized decision, there are precedents for treatment with some disease-modifying therapies (DMTs) during pregnancy, Bove said. This includes B-cell depleting therapies for patients with highly active disease. Retrospective data from the use of rituximab in conditions other than MS suggest that the infants tend to do well and in some cases are found to have normal or normal B cell levels at delivery. Most data on MS DMT use during pregnancy are derived from registries, she noted, but new studies are currently under way to address this dearth of controlled data. The MINORE study, currently under analysis, looked at the transfer of ocrelizumab across the placenta in patients exposed to the drug around the time of the last menstrual period. As alternatives to standard DMT, the panelists discussed the potential for use of IV immunoglobulin or additional methylprednisolone doses when treatment is warranted.

What are the latest data on breastfeeding and DMT?

For guidance on MS drug use during breastfeeding, the panel highly recommended the National Institutes of Health (NIH) Drugs and Lactation Database, LactMed®. More studies are under way to evaluate the safety of DMT during breastfeeding. Data suggest that B-cell depleting therapies are associated with low transfer into breast milk. “These drugs are not orally bioavailable,” Houtchens noted. “So, the relative dose—what the baby receives through breastfeeding relative to the amount in the mother's bloodstream—is well under the theoretically OK level of 10% and is typically under 1%.” New data are emerging on the use of high-efficacy therapies during lactation, including the recently completed SOPRANINO study of ocrelizumab.

What aspects of peripartum and postpartum care tend to be overlooked?

The CMSC panelists all stressed that treating the woman’s mental health, including mood disorders like depression, should not be overlooked or delayed in the pregnant patient with MS. This is critical at all stages from family planning through the postpartum period. Studies suggest that children of people with MS tend to adjust and develop resiliency, but children whose parents who have untreated mental health disorders may have more problems. “At our center we follow women with MS very closely during the postpartum period, Jacobs said. “A new mother who has MS often needs extra reassurance, and it's a privilege to be able to provide that.”

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