Women’s Health: Contemporary Management of MS in Pregnancy and Post-Partum

Tisovic, Kelly; Amezcua, Lilyana

doi:10.3390/biomedicines7020032

Cited by 14 publications

(10 citation statements)

References 78 publications

(182 reference statements)

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“…Furthermore, up to 30% of pregnancies are unplanned; thus, embryonal DMD exposure is relatively common in the first weeks of gestation [11]. Many DMDs and symptomatic treatments used in MS are not considered completely safe in women who are attempting to conceive, are pregnant or are breastfeeding [12][13][14]. Moreover, in MS, withdrawal of certain DMDs, mainly lymphocyte antitrafficking therapies, such as natalizumab and fingolimod (FTY), may result in severe disease reactivation or even rebound of disease activity.…”

Section: Introductionmentioning

confidence: 99%

Disease Reactivation after Fingolimod Discontinuation in Pregnant Multiple Sclerosis Patients

et al. 2021

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Recent studies estimated an incidence of 4–25% of disease rebound after withdrawal of fingolimod (FTY) for any reason, but specific data on disease reactivation after FTY withdrawal due to pregnancy are limited. The aim of the study was to evaluate the frequency and predictors of disease reactivation in patients who stopped FTY for pregnancy. A multicentre retrospective cohort study was conducted in four Italian MS centres in 2013–2019. Both planned and unplanned pregnancies were included. The annualized relapse rate (ARR) was calculated before FTY treatment, during FTY treatment, during pregnancy and during the year after delivery. In total, 27 patients (mean age 29 years) were included. The ARR 1 year before FTY treatment was 1.3. Patients were exposed to FTY for a median of 2.9 years. The ARR was 0.04 during the last year before conception (p < 0.001 compared with the ARR before FTY treatment). Eleven patients became pregnant after a mean of 88 days following FTY discontinuation, whereas 16 patients stopped FTY after pregnancy confirmation. Relapses were observed in 22% of patients during pregnancy and in 44% in the postpartum period. ARR increased both during pregnancy (0.49; p = 0.027) and in the first year after delivery (0.67; p < 0.001) compared to the last year before pregnancy. Compared with radiological assessment before pregnancy, more patients showed new or enlarging T2 lesions (63% vs 30%; p = 0.02) and gadolinium-enhancing lesions (44% vs 0; p = 0.0001) on brain Magnetic Resonance Imaging. Relapses during pregnancy were the only significant predictor for postpartum relapses (OR 1.9, 95% CI 1.11–3.1). One case of spontaneous abortion and no cases of abnormal foetal development were observed. Despite adequate and prolonged control of disease activity, women who discontinue FTY because of pregnancy are at risk for disease reactivation. In patients who relapsed during pregnancy, the initiation of high-efficacy disease modifying drugs (DMDs) soon after delivery is advisable to prevent postpartum relapses.

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Section: Introductionmentioning

confidence: 99%

Disease Reactivation after Fingolimod Discontinuation in Pregnant Multiple Sclerosis Patients

et al. 2021

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“…Recent guidelines and recommendations acknowledge such practices. 5,10–15 For recent DMTs, data are limited with the exception of teriflunomide which is known to be teratogenic on animals 13–15 and fingolimod from which birth defects may occur. 13–16 The objectives of this study were to estimate pregnancy incidence rates in women with MS, describe the use of DMTs before conception and during pregnancy, and describe pregnancy outcomes according to the use of DMTs.…”

Section: Introductionmentioning

confidence: 99%

Pregnancy in women with multiple sclerosis in France from 2010 to 2015: Incidence, outcomes, and exposure to disease-modifying therapies

et al. 2021

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Background: Multiple sclerosis (MS) is usually diagnosed between 20-40 years old, when women often plan to have children. Objective: Our objectives were to estimate pregnancy incidence rates in women with multiple sclerosis (MS), and to describe the use of disease-modifying therapies (DMTs) before conception and during pregnancy, and pregnancy outcomes. Methods: This retrospective cohort study included all 15- to 49-year-old women with MS in the French national health insurance database over 2010–2015. A pregnancy was exposed if a DMT reimbursement claim occurred during pregnancy or in the 14 preceding days. We used zero-inflated negative binomial (ZINB) regression models to estimate incidence rates and ordinal and multinomial regression models to estimate DMT exposure and pregnancy outcomes. Results: The pregnancy incidence rate was 4.5 per 100 person-years. The probability of having a DMT-exposed pregnancy increased from 0.22 in 2010 to 0.30 in 2015. The probability of live birth was 0.72 (95% CI = 0.70–0.74) for exposed pregnancies (varied considerably among DMTs), 0.77 (95% CI = 0.76–0.79) without treatment, and 0.81 (95% CI = 0.79–0.83) if treatment was stopped within the previous year. Conclusion: In this population-based study, we showed an increase of exposed pregnancies over time, beta-interferon and glatiramer acetate being the most used DMTs and associated with the highest probabilities of live birth. Interrupted exposed pregnancies may reflect undesired pregnancies or fear of an adverse outcome, while recent DMT stop probably reflects pregnancy planning.

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“…8–10 Whereas emerging data suggest that some DMTs, particularly glatiramer acetate and interferon-beta, may be safe in the earliest stages of pregnancy, most DMT and symptomatic treatments being used in MS are not considered completely safe in women who are attempting to conceive, are pregnant, or nursing. 11–15 Management of MS with DMT needs to be balanced with reproductive goals.…”

Section: Introductionmentioning

confidence: 99%

Pregnancy and multiple sclerosis: Risk of unplanned pregnancy and drug exposure in utero

Smith

Cohen

Ontaneda

et al. 2019

Multiple Sclerosis Journal - Experimental, Translational and Cl

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Background: Multiple sclerosis is a central nervous system demyelinating disease that affects women of reproductive potential. It is important to identify the frequency and risk factors of unplanned or disease-modifying therapy-exposed pregnancies to create interventions to reduce these. Methods: This retrospective, single-center, observational chart review study aims to identify risk factors for unplanned pregnancy to identify a target population for family counseling. Results: In total, 63 live births in 45 patients (20 unplanned and 43 planned) were analyzed. The percentage of unplanned pregnancy was 32%. The proportion of those receiving family planning counseling was lower in the patients with unplanned pregnancies (p < 0.001). The main risk factors for unplanned pregnancy were younger age (p ¼ 0.004), disease-modifying therapy exposure (p < 0.001), and being unmarried (p < 0.001). Overall, 16 pregnancies had disease-modifying therapy exposure and in a subsequent study the risk for disease-modifying therapy exposure was unplanned status (p < 0.001). Birth outcomes were not different between groups. There were more enhancing lesions in the postpartum magnetic resonance imaging of women with planned pregnancy (p < 0.04). Conclusion: Prevention of unplanned pregnancy could lead to less disease-modifying therapy exposed pregnancies. This study suggests a targeted intervention of family planning counseling in younger, unmarried multiple sclerosis patients could potentially lead to less unintended in utero diseasemodifying therapy exposure.

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Women’s Health: Contemporary Management of MS in Pregnancy and Post-Partum

Cited by 14 publications

References 78 publications

Disease Reactivation after Fingolimod Discontinuation in Pregnant Multiple Sclerosis Patients

Disease Reactivation after Fingolimod Discontinuation in Pregnant Multiple Sclerosis Patients

Pregnancy in women with multiple sclerosis in France from 2010 to 2015: Incidence, outcomes, and exposure to disease-modifying therapies

Pregnancy and multiple sclerosis: Risk of unplanned pregnancy and drug exposure in utero

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