Year : 2016 | Volume
: 2 | Issue : 2 | Page : 106--108
Pregnancy with multiple sclerosis: The obstetricians' approach
Anjali Tempe, Nilanchali Singh, Jyotsana Bajaj
Department of Obstetrics and Gynaecology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
Department of Obstetrics and Gynaecology, Maulana Azad Medical College, New Delhi
Multiple sclerosis (MS), an inflammatory, demyelinating disease of central nervous system, is the most common cause of neurological disability in young females. MS occurs in India but is comparatively very less as compared to the West. Due to its rarity, obstetricians do not encounter pregnancies with MS in India often. We report a case of a 21-year-old, primigravida who presented to us at 9 weeks of pregnancy. She was a diagnosed case of MS for 4 years. Later in pregnancy, she had walking and gait difficulty. No change in drug dosage was required, and patient had a static course of disease during pregnancy. The patient had an emergency cesarean section. Pregnancy in women with MS is not considered high risk anymore; however, there are some challenges such as managing disability and modifying ongoing therapy. Multi-disciplinary approach is the mainstay of management. Due to severe disability of routine activities such as walking, nursing herself and the baby, pregnancy with MS poses big management challenge. Social issues should be taken care of prior to conception in Indian perspective.
|How to cite this article:|
Tempe A, Singh N, Bajaj J. Pregnancy with multiple sclerosis: The obstetricians' approach.MAMC J Med Sci 2016;2:106-108
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Tempe A, Singh N, Bajaj J. Pregnancy with multiple sclerosis: The obstetricians' approach. MAMC J Med Sci [serial online] 2016 [cited 2020 Sep 19 ];2:106-108
Available from: http://www.mamcjms.in/text.asp?2016/2/2/106/182728
Multiple sclerosis (MS), an inflammatory, demyelinating disease of central nervous system is the most common cause of neurological disability in young females. It frequently manifests in reproductive age group in women; hence, management in pregnancy becomes an important aspect. Despite this, little is known about the effect of pregnancy on disease progression and of the disease process on the outcome of pregnancy. Past data suggested controversial effect of pregnancy on MS. Studies performed in last few years suggest that MS is not a contraindication for pregnancy in women affected with the disease., Rather, pregnancy appears to be protective for disease progression, especially the third trimester. However, immunomodulatory drug usage during pregnancy needs monitoring and cessation if not safe for the fetus. MS occurs in India but is comparatively very less as compared to the West. Epidemiological studies in India are lacking; however, hospital data suggest an approximate prevalence rate of 0.17–1.33/100,000 of population in different parts of India. Due to its rarity, obstetricians do not encounter pregnancies with MS in India often. In this report, we will discuss the effect of pregnancy on MS and vice versa.
We report a case of a 21-year-old, primigravida who presented to us at 9 weeks of pregnancy. She was a diagnosed case of MS for 4 years. Her symptoms started with tonic-clonic convulsion, which was later followed by severe headache associated with vomiting. She had complaints of frontal headache, which was episodic, severe, nonthrobbing, lasting for 10–15 min, and occurring several times a day. Magnetic resonance imaging (MRI) revealed large predominantly white matter hyperintensities in the left frontal and right temporal regions with mass effect. There was evidence of hypointense areas with irregular open ring enhancement in the same area suggestive of multiple intracranial tuberculoma or abscess. She was started on anti-tubercular regime comprising four drugs (rifampicin, isoniazid, pyrazinamide, and ethambutol) along with prednisolone 40 mg/day and phenytoin 200 mg/day. She remained asymptomatic for the next 2 months. Later, she developed cognitive impairment in the form of forgetfulness for recent events along with difficulty in wearing clothes. There was, however, no history of hallucination, delusion, or change in behavior.
At the time of diagnosis, her mini-mental examination score was 23/30 (score of cognitive impairment). Positive findings included lack of orientation to time, difficulty in calculation and dressing, and constructional apraxia, suggestive of right-sided parietal lobe dysfunction. There was generalized hyperreflexia (left > right), increase in tone of both lower limbs, and extensor plantar response on the left side suggestive of pyramidal involvement. Patient could not walk easily and could walk with support only. In view of 10 months history with relapse and remission of neurological symptoms within the start of 1 month of anti-tubercular therapy (ATT), a review MRI was performed which suggested significant resolution of initial large necrotizing ring enhancing lesions and appearance of fresh lesion at different site suggestive of MS. Hence, ATT was stopped. She was started on antiepileptics and prednisolone 10–20 mg/day on and off. Repeat MRI was performed in after 2 years of therapy, which suggested presence of some residual disease but no fresh lesion.
When the patient presented to us, she was on oral carbamazepine 200 mg OD and prednisolone 10 mg OD. She was continued on same therapy, and routine antenatal follow-up was performed. She did not have any clinical remission or aggravation of disease during antenatal period. However, she had walking and gait difficulty due to pregnancy which increased after the 7th month. She also had complaints of fatigue. She followed up in an antenatal clinic till term. Neurologist opinion was taken from time to time. No change in drug dosage was required, and patient had a static course of disease during pregnancy. The patient went into spontaneous labor at 40 weeks. She had emergency cesarean section under general anesthesia due to fetal bradycardia. She delivered a male child of 2400 g. Deep vein thrombosis (DVT) prophylaxis was administered postoperatively for 10 days. She was observed in the hospital for 2 weeks postpartum, and there was no remission of disease. Stitches were removed on the 14th postoperative day with healthy wound. She was discharged on the same day. She continued oral carbamazepine 200 mg OD and prednisolone 10 mg OD. She followed with us for 6 months and had no remission or aggravation of disease.
MS is an autoimmune, demyelinating disease, which affects the central nervous system. It is the most widespread disabling neurological condition of young adults around the world. Most people are diagnosed between the age of 20 and 40 years though it can affect any age group, as in our patient, it was diagnosed at 17 years of age. About 5% of patients with MS are diagnosed before the age of 18 years. The ratio of women to men with MS is 2:1. Care of pregnant women with MS is challenging because of the multiple physiological changes associated with pregnancy and the need to consider the impact of any intervention on the fetus. Pregnancy is associated with clinical MS stability or improvement, while the rate of relapse increases significantly during the first 3 months postpartum before coming back to its level prior to pregnancy. Even if there is no deterioration of disease, pregnancy itself is a burden for the patient due to associated disability, increased risk of conditions such as DVT and inability to look after herself and her baby. The patient with MS mandates constant physical and psychological support.
Before 1998, most women with MS were counseled to avoid pregnancy because it was believed that the disease may worsen. However, a large study comprising 269 pregnancies from 12 European countries, reported that the rate of relapse declines during pregnancy, especially in the third trimester, and increases during the first 3 months postpartum before returning to the prepregnancy rate. Over the past few decades, many studies have been performed in hundreds of women with MS, and they have almost all reached the same conclusion that pregnancy reduces the number of MS relapses, especially in the second and third trimesters., Pregnancy is known to be associated with an increase in a number of circulating proteins and other factors that are natural immune-suppressants. Moreover, levels of natural corticosteroids are increased in pregnant women. These may lead to women with MS faring well during pregnancy. There is no evidence that MS is associated with infertility, spontaneous abortions, stillbirths, or congenital malformations. Several studies of large numbers of women have repeatedly demonstrated that pregnancy, labor, delivery, and the incidence of fetal complications are no different in women who have MS than in control groups without the disease. However, the logistics associated with taking care of the newborn baby and mother with impairment due to MS may pose a problem in the Indian context. Unlike Western countries, there are no trained MS nurses and strong family support may not be available. Therefore, planning pregnancy in these women in Indian context should be well thought of beforehand.
Young women with MS, who desire children can be reassured that their infants are not at increased risk of malformations, preterm delivery, low birth weight, or infant death. In lieu of progressive nature of the disease, women should be motivated to start or complete their families as soon as possible. Women with gait difficulties may find it getting worsened during late pregnancy as they become heavier and their center of gravity shifts as seen in our patient. Increased use of assistive devices to walk or use of a wheelchair may be advisable at these times. Bladder and bowel problems, which occur in all pregnant women may be aggravated in women with MS, who have preexisting urinary or bowel dysfunction. MS patients may also be more susceptible to fatigue as seen in our patient.
Most drugs such as prednisolone used as the first line of therapy to treat MS can be used by pregnant women (Category C). Intravenous steroids may be used with relative safety during pregnancy. Maternal use of azathioprine is not associated with an increased risk of congenital malformations, though impaired fetal immunity, intrauterine growth retardation, and prematurity are occasionally observed. Cyclosporin is not teratogenic, but may be associated with growth retardation and prematurity. Pregnancy should be avoided in women treated with methotrexate because of its known abortifacient effects and risk of causing typical malformations. Cyclophosphamide is teratogenic in animals, but population studies have not conclusively demonstrated its teratogenicity in humans. There is limited safety data of glatiramer acetate, mitoxantrone, interferon-beta-1a, and interferon-beta-1b; these should, therefore, be avoided during and before anticipated pregnancy. Disease-modifying medications are not approved for use; hence, avoided during pregnancy.,
Women with MS are unlikely to experience labor and delivery complications, and the mode of delivery should be decided based on obstetrical criteria. Spinal, epidural, and general anesthesia can all be used safely in MS patients. All forms of anesthesia are considered safe for women during labor and delivery.
The disease-modifying drugs are not recommended during breastfeeding. The use of prednisolone in a woman who is breastfeeding should be carefully monitored. Neurologist and obstetrician should review the women's medications before prescribing it during pregnancy and breastfeeding. About 20–40% of pregnant women with MS have a relapse within a few months of postpartum. Studies have indicated no increased risk of relapse of MS associated with breastfeeding. These relapses do not appear to contribute to increased long-term disability. There is 1–3% chance of having MS in offspring if there is a family history of MS in the parent.
Contraceptive counseling is important in these women. Some drugs used in the treatment of MS symptoms, such as phenytoin and carbamazepine, may reduce the effect of oral contraceptives. People with limited mobility may need extra monitoring as the risk of DVT may increase. A study reported that oral contraceptives did not affect the risk of developing MS but could delay the onset of MS.
Pregnancy in women with MS is not considered high-risk anymore; however, there are some challenges such as managing disability and modifying ongoing therapy. Fetal outcome remains unaffected. Close evaluation of drug safety during pregnancy is mandatory while managing these women. Multidisciplinary approach is the mainstay of management. Due to severe disability of routine activities such as walking, nursing herself and the baby, pregnancy with MS poses big management challenge. Social issues should be taken care of prior to conception in Indian perspective.
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