MS and pregnancy – part 1

Pregnancy is an exciting time, but it can also be an uncertain one, due to the physical and emotional changes it brings. If you have Multiple Sclerosis (MS), you’re likely to have a few added concerns about the next nine months. You may be wondering how having MS may impact pregnancy… but it’s also important to understand how pregnancy may impact MS.

To get the facts, we spoke to Dr Magnhild Sandberg-Wollheim, associate professor of neurology at Lund University Hospital in Sweden, and an expert on pregnancy in MS. Here we’ll look at the ways in which MS may impact pregnancy. In the second part of this series, we will explore the potential impact of pregnancy on MS. 

Please note this piece is not intended to recommend any particular treatment options, or to replace important conversations with your healthcare professional.

Does MS make it harder to get pregnant?

MS is typically diagnosed in people ages 20 to 40 – key childbearing years for women – so fertility can be a concern. “Generally speaking, MS does not seem to affect a woman’s ability to get pregnant^{1, 2}, however, some small studies report reduced fertility or decreased levels of certain hormones that are used as an indicator of fertility in women with MS ^{3, 4}” explains Dr Sandberg. “That said, problems conceiving can happen to anyone – around 10% of couples in Western countries suffer from reduced fertility or infertility⁵. If you are thinking about starting a family, it is important to talk things through with your neurologist and gynecologist first.”

Do I need to stop my MS treatment while pregnant?

“You may need to modify the way in which you manage your MS, as some drug treatments can be harmful to an unborn baby⁶,” says Dr Sandberg. Indeed, some doctors suggest stopping taking certain disease-modifying therapies (DMTs) before trying to get pregnant (when to stop certain treatments depends on the type of therapy). “In the meantime, effective contraception is a must,” counsels Dr Sandberg. “If you do become pregnant without trying, it is important to tell your neurologist so you can begin discussing the options immediately. We know that around 40% of pregnancies are unplanned⁷, so you are not alone – and we do not judge!”

Will MS affect my pregnancy?

It should not, no. “There is no evidence to suggest that MS increases risk of ectopic pregnancy, miscarriage, premature birth, stillbirth or birth abnormalities⁸,” Dr Sandberg reassures us. And although there is a genetic component to MS, it is not considered an inherited disease, as there is no single gene that causes it. A review of U.S. data comparing pregnancies and deliveries in women with MS, epilepsy or diabetes mellitus with those in the general healthy population found a slightly higher risk of low birth-weight babies and Caesarean delivery. However, MS was not associated with a higher risk of other pregnancy complications⁹. Similar results were found in a study conducted in Norway¹⁰.

According to Dr Sandberg, women with MS do not need to be monitored more closely during pregnancy than women who don’t have MS. “The only real exception is if you became pregnant while taking DMTs (disease-modifying therapies), in which case additional ultrasounds may be performed to keep a close eye on your baby’s development,” she adds.

Will MS affect my labor?

The short answer is, maybe. For some women with MS, reduced pelvic sensation means less pain during contractions – while this sounds like a good thing, it could mean that you may not recognize when labor begins. “The muscles and nerves needed for pushing out the baby can also be affected by MS, which may make Caesarean section or vacuum-assisted deliveries more likely¹¹,” explains Dr Sandberg. “If your doctor has any reservations about your ability to give birth, however, he or she will recommend an elective Caesarean well in advance, to avoid complications.”

Like all expectant mothers, you will likely be advised to write a birth plan. This should include where you want to give birth, whom you want present, as well as your pain relief preferences. “Generally, most types of pain relief are fine if you have MS¹²,” explains Dr Sandberg. “In fact, an epidural can be particularly helpful if you suffer from fatigue, as it will allow you to conserve your energy during the early stages of labor.” If you have a physical disability or suffer from muscle spasms, your midwife will be able to talk you through positions and birthing options that will make the birth more comfortable. Giving birth is not for the faint of heart, but the more prepared you are, the better the experience will be.

With a little care and planning, there is no reason why MS should prevent you from having a normal pregnancy and labor and a healthy baby.

We would like to thank Dr Sandberg-Wollheim very much for her time and expert advice.

References:

1. Pregnancy, sex and hormonal factors in multiple sclerosis. Miller DH, Fazekas F, Montalban X, et al. 2014 Apr;20(5):527-36. doi: 10.1177/1352458513519840. Available at: http://www.ncbi.nlm.nih.gov/pubmed/?term=24446387
2. Artificial reproductive techniques in multiple sclerosis. Hellwig K, Correale J. Clin Immunol. 2013 Nov;149(2):219-24. doi: 10.1016/j.clim.2013.02.001. Available at: http://www.ncbi.nlm.nih.gov/pubmed/?term=23507401
3. Serum anti-Müllerian hormone levels in reproductive-age women with relapsing-remitting multiple sclerosis. Thöne J, Kollar S, Nousome D, Ellrichmann G, Kleiter I, Gold R, Hellwig K. Mult Scler. 2015 Jan;21(1):41-7. doi: 10.1177/1352458514540843. Available at: http://www.ncbi.nlm.nih.gov/pubmed/?term=25145691
4. Female infertility and multiple sclerosis: is this an issue? McCombe PA, Stenager E.  Mult Scler. 2015 Jan;21(1):5-7. doi: 10.1177/1352458514549406. Available at: http://www.ncbi.nlm.nih.gov/pubmed/?term=25583835
5. Definition and prevalence of subfertility and infertility. Gnoth C, Godehardt E, Frank-Herrmann P, Friol K, et al. 2005 May;20(5):1144-7. Available at: http://www.ncbi.nlm.nih.gov/pubmed/?term=15802321
6. Multiple sclerosis: current and emerging disease-modifying therapies and treatment strategies. Wingerchuk DM, Carter JL. Mayo Clin Proc. 2014 Feb;89(2):225-40. Available at: http://www.mayoclinicproceedings.org/article/S0025-6196%2813%2900986-5/pdf
7. The potential of long-acting reversible contraception to decrease unintended pregnancy. Speidel JJ, Harper CC, Shields WC. Contraception. 2008 Sep;78(3):197-200. doi: 10.1016/j.contraception.2008.06.001. http://www.ncbi.nlm.nih.gov/pubmed/?term=18692608 https://www.arhp.org/uploadDocs/journaleditorialsep2008.pdf
8. Website ‘Multiple Sclerosis Society’ – Pregnancy and birth. Available at: http://www.mssociety.org.uk/what-is-ms/womens-health/pregnancy-and-birth
9. Obstetric outcomes in women with multiple sclerosis and epilepsy. Kelly VM, Nelson LM, Chakravarty EF. Neurology. 2009 Dec 1;73(22):1831-6. doi: 10.1212/WNL.0b013e3181c3f27d. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19923552
10. Pregnancy, delivery, and birth outcome in women with multiple sclerosis. Dahl J, Myhr KM, Daltveit AK, Hoff JM, Gilhus NE. Neurology. 2005 Dec 27;65(12):1961-3. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16380620
11. Website ‘Johns Hopkins Medicine’ – Multiple Sclerosis and Pregnancy. Available at: http://www.hopkinsmedicine.org/healthlibrary/conditions/physical_medicine_and_rehabilitation/multiple_sclerosis_and_pregnancy_85,P01160/
12. Epidural analgesia and cesarean delivery in multiple sclerosis post-partum relapses: the Italian cohort study. Pastò L et al. BMC Neurol. 2012 Dec 31;12:165. doi: 10.1186/1471-2377-12-165. Available at: http://www.ncbi.nlm.nih.gov/pubmed/?term=23276328