Dr Rhonda Voskuhl is the Director of the UCLA MS Program, holds the Jack H. Skirball Chair in multiple sclerosis, and is a Professor in the UCLA Department of Neurology. She has received national and international awards for her research and has continuous funding for over 20 years. Professor Voskuhl uses a “Bedside to Bench to Bedside” approach, basing research on clinical observations, understanding them in the lab, then designing novel clinical trials. She sees MS patients in the neurology clinic and mentors at the postdoctoral, graduate, and undergraduate levels.

Multiple sclerosis (MS) is more prevalent in women than men and is most commonly diagnosed in early adulthood; therefore, it affects many women of childbearing age. It is increasingly recognised that early treatment can prevent long-term disability in MS. However, concerns about the safety of early disease-modifying drugs in pregnancy, has resulted in many women either deferring the initiation of therapy until after they completing their families, or being less likely to have children.¹

In an expert interview, Dr Voskuhl reviews the latest evidence on pregnancy and MS and provides guidance for women who are living with MS and planning families.

What factors should be considered by women with MS planning a pregnancy?

First, MS itself does not negatively impact a woman’s ability to have successful pregnancies and deliveries.² Indeed, pregnancy offers some disease protection.³

That said, management of MS treatments during pregnancy and breast feeding is needed. This can be done by talking with your neurologist as part of planning your pregnancy.

 

What is known about the risk of relapse during pregnancy and while breastfeeding?

The risk of relapse during pregnancy is low. In the latter half of pregnancy, particularly the third trimester, the risk of relapse is reduced by over 70%.³

However, in the 3 to 6 months postpartum there is an increase in likelihood to relapse in some patients.⁴ The major factor that indicates likelihood for a postpartum relapse is the pre-pregnancy relapse rate. People with less aggressive relapsing disease are less likely to relapse postpartum. Breastfeeding which is exclusive (not partial) has shown some protection from relapse in some studies, but not other studies.⁵ One should not rely on breastfeeding to provide protection from postpartum relapse. Since MS treatments are not taken during pregnancy, each person must weigh their risk for relapse postpartum with their desire to breastfeed for a given duration. Each woman should make their decision with their doctor about when to resume their MS treatments after delivery

 

Which disease modifying therapies (DMTs) are most compatible with breastfeeding and pregnancy?

There are now over 20 MS treatments and there is a wide range of compatibility, from contraindicated to some safety data available from people being pregnant while on treatment. It is imperative that the specific treatment that you are on be reviewed with you by your neurologist as together you plan your MS treatment management around pregnancy and breast feeding.

What are the key take-home messages of your presentation?

Pregnancy has benefits – decreased relapses during the third trimester. Also, some data suggests that multiple pregnancies, as compared to none, are good for long term disability in women with MS.  MS treatment management can be done with your neurologist during this exciting phase of your life.

References

1. Bonavita S, Lavorgna L, Worton H, Russell S, Jack D. Family Planning Decision Making in People With Multiple Sclerosis. Front Neurol. 2021 Apr 28;12:620772. doi: 10.3389/fneur.2021.620772
2. Pozzilli C, Pugliatti M, Paradig MSG. An overview of pregnancy-related issues in patients with multiple sclerosis. Eur J Neurol. 2015 22(Suppl.2):34–9. 10.1111/ene.12797
3. Confavreux C, Hutchinson M, Hours MM, Cortinovis-Tourniaire P, Moreau T. Rate of pregnancy-related relapse in multiple sclerosis. Pregnancy in Multiple Sclerosis Group. N Engl J Med. 1998 Jul 30;339(5):285-91.
4. Hellwig K, Verdun di Cantogno E, Sabidó M. A systematic review of relapse rates during pregnancy and postpartum in patients with relapsing multiple sclerosis. Therapeutic Advances in Neurological Disorders. 2021;14.
5. Krysko KM, Rutatangwa A, Graves J, Lazar A, Waubant E. Association Between Breastfeeding and Postpartum Multiple Sclerosis Relapses: A Systematic Review and Meta-analysis. JAMA Neurol. 2020;77(3):327–338.

Article information:

Disclosures: Rhonda Voskuhl receives grant/research support from The National Institutes of Health; and is on the advisory board for NeuroCure German Clusters of Excellence, and ANI Pharma; an recevies honoraria/honorarium from NeuroCure, and US Dept of Defense MS Research Program; and is the inventor on UCLA patents for estriol and ER beta ligand treatments.

Data availability: Data sharing is not applicable to this article as no datasets were generated or analysed during the current study/during the writing of this article.

Access: This article is freely accessible at touchNEUROLOGY.com © Touch Medical Media 2022

Corresponding author: Rhonda Voskuhl, UCLA Department of Neurology, UCLA Multiple Sclerosis Program, Los Angeles, CA, USA

Support: Writing of this article was supported by Touch Medical Media.