Exploring Patients’ Knowledge and Misconceptions about Multiple Sclerosis and Pregnancy

US Neurology, 2016;12(1):34–8 DOI: http://doi.org/10.17925/USN.2016.12.01.34

Abstract:

Multiple sclerosis (MS) has a high incidence in women of childbearing age. Accurate understanding of family planning matters is crucial for best outcomes. Methods: Thirty-seven women with MS aged 18 to 50 completed an anonymous questionnaire at an MS Center in New York City. There were 22 questions pertaining to four main categories: effect of pregnancy on MS, effect of MS on pregnancy, MS medication safety during pregnancy and breastfeeding, and effect of MS on offspring. Results: Mean age of patients was 36 years (standard deviation [SD] ±5.6); 86% had relapsing-remitting (RRMS). Mean time since diagnosis was 6.7 years (SD±5.2); 30.6% had been pregnant since diagnosis. Average correct score was 32.8% (SD±20.3), and while higher in patients who had been pregnant since diagnosis, 40.5% (SD±24.7) versus 31.3% (SD±17.9), there was no statistically significant difference; p=0.21. Largest knowledge deficit pertained to effect of MS on reproduction: average score 27.7% (SD±10.1). Only 21.0% knew that relapses can be treated with steroids during pregnancy; 50.0% of those with prior pregnancy knew this fact. Thirtyfour percent of patients on disease-modifying therapies (DMTs) reported not consistently using birth control. Conclusions: Our data identified misconceptions on important reproductive topics. It is important that providers educate effectively their patients on matters of reproduction.
Keywords: Multiple sclerosis, pregnancy, reproduction, contraception, education, knowledge, medication safety, questionnaire
Disclosure: Sarah Flanagan Wesley, is on the editorial team for the Neurology® Resident and Fellow Section. Michelle Fabian, has nothing to declare in relation to this article. Stephen Krieger, has received compensation for consulting and advisory board work with Acorda Therapeutics, Bayer HealthCare, Biogen Idec, EMD Serono, Genentech, Genzyme, Questcor, and Teva, and has given nonpromotional lectures with Biogen Idec and Genzyme. No funding was received in the publication of this article.
Received: December 17, 2015 Accepted January 26, 2016
Correspondence: Sarah Flanagan Wesley, MD, MPH, Mount Sinai Beth Israel, Department of Neurology, 10 Union Square East, Suite 5D, New York, NY 10003, US. E: sarwesley@chpnet.org
Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit.

Multiple sclerosis (MS) is a lifelong neurologic disease affecting the central nervous system and resulting in demyelination and axonal loss over time. Symptoms are widely variable and often involve motor and sensory impairment, vision loss, gait disturbance, cognitive dysfunction, and fatigue. Furthermore, MS is a disease common to women of childbearing age, with 70% of patients being women and with 90% of patients presenting between the ages of 15 and 50.1 Family planning must be taken into account at time of diagnosis and when discussing which disease modifying agent to employ. Accurate knowledge and understanding of family planning issues is important for best outcomes.

The relationship between pregnancy and relapse outcomes is complex and might not be fully understood by many patients. Many studies have shown that pregnancy can have a protective effect against MS relapses, although the mechanisms underlying this phenomenon are still being studied. The Pregnancy in Multiple Sclerosis (PRIMS) study evaluated 227 women with MS from 1 year prior to pregnancy until 2 years after delivery and found that the risk for relapse decreased by about 70% during the third trimester but increased by twofold in the 3 months postpartum compared with the risk for relapse during the prepregnancy year.2,3 Furthermore, the long-term favorable effects of pregnancy on patients with relapsing-remitting MS have been established by several studies, demonstrating a lower risk for reaching an Expanded Disability Status Scale of 6.0 and thus a decreased possibility of needing an ambulatory device.4

Education about peripartum concerns is also paramount. In a study of 461 women with MS, there was a higher rate of caesarian section; however, these findings represented a concurrently higher rate of planned, rather than emergency, caesarian sections,5 a finding that might reflect an overly cautious approach. Previous practice advocated for caesarian sections to avoid pelvic floor trauma and thus exacerbation of preexisting urinary frequency and bladder control issues; however, it was shown in a study of 273 women in 2006 that urinary incontinence postpartum was more related to duration and severity of MS and not method of delivery.6

Similarly, accurate knowledge about environmental and genetic influences on MS is crucial for informed family planning considerations. Overall, MS is not considered a principally hereditary illness, and the risk for MS in the general population is approximately 0.1% compared with the risk in children of an affected parent, which is approximately 3%. For dizygotic twins, the risk for the second twin developing MS is about 4%, and for monozygotic twins the risk is about 30% over their lifetime.7,8 In terms of environmental risks, there was previous concern over use of oral contraceptives, which has been dispelled by studies showing both no effect and even possible association with a milder MS course. It is also important that women with MS and their offspring are not dissuaded from using oral contraceptives over concerns of developing MS.9,10

Furthermore, familiarity with pregnancy risks with MS disease-modifying therapies (DMTs) can lead to safe family planning practices. Current safety data is only based on animal studies and/or human observational cohorts and registries. Of the 13 approved medications, glatiramer acetate has shown no evidence to date of any danger to fetuses, but there is possible evidence for toxic effects with the other medications in animal and/or human studies, including known harm with teriflunomide in animal studies for which there is an absolute contraindication during pregnancy.11 Patients on certain DMTs must be aware that they might need to undergo a washout period prior to becoming pregnant. Moreover, it is equally important for women to know that it is safe to receive intravenous methylprednisolone (IVMP) for treatment of MS exacerbations during the second and third trimesters, and with caution during the first trimester. For breastfeeding women it is recommended to “pump and dump” for four hours after IVMP treatment.1,5,12

Use of DMTs then necessitates education about consistent contraception and safety while breastfeeding. For example, while there is no evidence that glatiramer acetate is absorbed into a newborn’s gastrointestinal tract to any significant degree, safety has not been established. There was one study of interferons and breast milk that showed that it is present in extremely small amounts,13 and natalizumab is detectable in breast milk but might not be absorbed by an infant. All three oral MS medications (fingolimod, dimethyl fumarate, teriflunomide) are known to be detectable in animal breast milk.11 In terms of relapse risk, the decision to breastfeed versus restarting MS therapy after delivery is complex, as patients must weigh increased risk for postpartum relapse off of therapy with the putative protective benefits of breastfeeding. However, exclusive breastfeeding typically requires a patient to remain off of DMTs, and thus the risks and benefits of these highly personal decisions must be made on an individual basis.14

References:
1. Coyle PK, Review article: Multiple sclerosis in pregnancy, Continuum, 2014;20:42–59.
2. Vukusic S, Hutchinson M, Hours M, et al., Pregnancy and multiple sclerosis (the PRIMS study): clinical predictors of postpartum relapse, Brain, 2004;127:1353–60.
3. Coyle PK, Pregnancy and multiple sclerosis, Neurol Clic, 2012;30:877–88.
4. D’Hooghe MB, Haentjens P, Nagels G, et al., Menarche, oral contraceptives, pregnancy and progression of disability in relapsing onset and progressive onset multiple sclerosis, J Neurology, 2012;259;85561.
5. Dahl J, Myhr KM, Daltveit AK, et al., Pregnancy, delivery, and birth outcome in women with multiple sclerosis, Neurology, 2005;65;1961–3.
6. Durufle A, Nicolas B, Petrilli S, et al., Effects of pregnancy and childbirth on the incidence of urinary disorders in multiple sclerosis, Clin Exp Obstet Gynecol, 2006;33:215–8.
7. Ebers G, Sadovnick A, Risch N, A genetic basis for familial aggregation in multiple sclerosis, Nature, 1995;377():150–1.
8. Westerlind H, et al. Modest familial risks for multiple sclerosis: a registry-based study of the population of Sweden, Brain, 2014;137:770–8.
9. Gava G, Bartolomei I, Costantino A, et al., Long-term influence of combined oral contraceptive use on the clinical course of relapsing-remitting multiple sclerosis, Fertil Steril, 2014;102:116–22.
10. Sena A, Couderc R, Vasconcelos JC, et al., Oral contraceptive use and clinical outcomes in patients with multiple sclerosis, J Neurol Sci, 2012;15;317(1–2):47–51.
11. Cree BA, Update on reproductive safety of current and emerging disease-modifying therapies for multiple sclerosis, Mult Scler, 2013;19:835.
12. Hoes JN, Jacobs JWG, Boers M, et al., EULAR evidencebased recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases, Ann Rheum Dis, 2007;66:1560–7.
13. Hale TW, Siddiqui AA, Baker TE, Transfer of interferon beta-1a into human breastmilk. Breastfeed Med. 2012;7:123–5.
14. Portaccio E, Ghezzi A, Hakiki B, et al., Breastfeeding is not related to postpartum relapses in multiple sclerosis, Neurology, 2011;12;77:145–50.
15. Lu E, Zhao Y, Zhu F, et al., Birth hospitalization in mothers with multiple sclerosis and their newborns, Neurology, 2013;80:447–52.
16. Content and Format of Labeling for Human Prescription Drug and Biological Products; Requirements for Pregnancy and Lactation Labeling. HHS, Food and Drug Administration, Docket No. FDA-2006-N-0515; Dec 4, 2014.
Keywords: Multiple sclerosis, pregnancy, reproduction, contraception, education, knowledge, medication safety, questionnaire