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Pregnancy and Reproductive Issues
Multiple sclerosis (MS) is more prevalent in women of childbearing age than in any other group. Many women that receive a diagnosis of MS frequently have questions about the effects of the disease on having a child and the effects of having a child on the disease. Many studies during the past several decades have provided answers to some of these questions.

There is no evidence that MS impairs fertility or leads to an increased number of 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.

Effects of Pregnancy on MS

Prior to the 1960's, it was suggested to most women with MS that they avoid pregnancy because of the belief that it might make their MS worse. Since that time, many studies have been done involving hundreds of women with MS, and almost all reached the opposite conclusion: that pregnancy reduces the number of MS exacerbations, especially in the second and third trimesters.

For a woman with MS, pregnancy doesn't affect the long term course of the disease. MS has no adverse effects on the course of pregnancy, labor, or delivery but rather symptoms often stabilize or remit during pregnancy.

Many women with MS find their attacks are less frequent during pregnancy. This is thought to be caused by pregnancy hormones dampening the activity of the immune system. This temporary improvement is thought to relate to changes in a woman's immune system that allow her body to carry a baby. Every fetus has genetic material from the father as well as the mother, the mother's body should identify the growing fetus as foreign tissue and try to reject it in much the same way the body seeks to reject a transplanted organ. To prevent this from happening, a natural process takes place to suppress the mother's immune system in the uterus during pregnancy.

Two studies add important information about the mutual influences of pregnancy and MS. One study has shown that women who gave birth after the onset of MS, reached scores of 6 on the Expanded Disability Status Scale (EDSS). This score on the EDSS was significantly later in the disease course than those who didn't become pregnant.

A second study has shown that women with MS had a 30% higher risk for cesarean delivery and a 70% higher rate of intrauterine growth restriction (IUGR) than did healthy women. All other aspects of pregnancy with MS itself appeared to be in-line with an average healthy or non-MS pregnancy. Any added risk can have an affect upon the mother and/or child, however, no noted disease progression was shown.

The findings of these two studies, published in Journal Watch Neurology (JW Neurol Feb 09 2010), add support to earlier studies and should help alleviate fear that pregnancy might exacerbate disease progression. The effects of MS on pregnancy outcomes at present don't appear to adversely affect the child's health or directly influence the mother's health.

There is always a risk in any pregnancy and with the addition of MS the risk can increase. It's important that a woman's OB/GYN (obstetrician/gynecologist) and neurologist be involved prior to any pregnancy and for the duration.

Effects in the Postpartum Period

Exacerbation rates tend to rise in the first three to six months postpartum (after birth) and the risk of a relapse in the postpartum period is estimated to be 20 to 40%. These relapses don't appear to contribute to increased long-term disability. In the studies with long-term follow-up of women with MS who had children, no increased disability as a result of pregnancy was found.

Pregnancy is known to be associated with an increase in a number of circulating proteins and other factors that are natural immunosuppressants. Additionally, levels of natural corticosteroids are higher in pregnant than non-pregnant women. It's felt that these may be some of the reasons why women with MS tend to do well during pregnancy.

Medical Management during Pregnancy, Delivery, and Postpartum

None of the current disease-modifying therapies (DMTs) are approved for use during pregnancy. Women who are taking any of these medications should discuss their plan to become pregnant with their OB/GYN and neurologist prior to becoming pregnant.

Women with MS who are considering pregnancy need to be aware that certain drugs used to treat MS should be avoided during pregnancy and while breast feeding. These drugs can possibly cause birth defects and can be passed to the fetus via blood and to an infant via breast milk.

The DMTs specifically are not recommended during breastfeeding because it's not known if they are excreted in breast milk. A woman should also review any other medications she is taking with her OB/GYN and neurologist in order to identify those that are safe during pregnancy and breastfeeding. Studies have shown no increased risk of relapse of MS associated with breastfeeding.

Women with MS usually need no special gynecologic care during pregnancy. Labor and delivery are usually the same as in other women and no special management is needed. All forms of anesthesia seem to be well tolerated by women in labor. The forms of pain relief during delivery remain the same being narcotics, Lamaze techniques, an epidural, or general anesthesia. Women with a pronounced lack of sensation or paralysis may also be monitored closely during the ninth month in case they are unable to detect the onset of contractions or need to have labor induced after the cervix starts to open.

It's important to note that most women find their MS relapses or attacks are around two to three times more common than normal in the first six months after childbirth. There has been no evidence that pregnancy and childbirth affect the overall course of the disease one way or the other.

While MS isn't a reason to avoid pregnancy and poses no significant risks to the fetus, some physical limitations can make child care more difficult. Child care assistance from either friends and family or babysitters is strongly recommended.

Special Concerns for the Pregnant Patients with MS

Women with gait difficulties may find these get worse during late pregnancy as they become heavier and their center of gravity shifts. It's never easy for anyone to have a 50 pound moving weight taped to the front of their body, whether they have MS or not. Increased use of assistive devices to walk or use of a wheelchair may be advisable some during these times.

Bladder and bowel problems, which occur in most pregnant women, may be aggravated in women with MS who have pre-existing urinary or bowel dysfunction. Anyone who's been pregnant or spouse has been pregnant knows that there's increasing pressure on the lower abdomen as the baby grows larger, giving them sudden needs to relieve the pressure, and for those with MS, that need may be more urgent.

Women with MS may also experience greater fatigue. Anything from the added weight that is associated with pregnancy to a sense of increased body heat may have an affect on fatigue.

In general, pregnancy doesn't appear to affect the long-term clinical course of MS. Women who have MS and wish to have a family can usually do so successfully with the assistance of their OB/GYN and neurologist.

Use of Steroid Medications

Women who use steroids for acute MS exacerbations should be able to continue to use them during pregnancy but again it's important to discuss this with their OB/GYN and neurologist prior to becoming pregnant. The use of prednisone while breastfeeding should be carefully monitored. All of these options must be discussed with all physicians involved prior to pregnancy.
MS Remissions During Pregnancy
A recent study showing that significant changes occur in the brain and spinal cord tissue of pregnant mice and that may help to explain why remission occurs in many women with MS during pregnancy. The research has shown the functional differences in the myelin and indicating that the turnover of myelin-making cells is significantly higher in female mice.

The research looked to see if pregnancy would increase the proliferation of myelin-making cells. It was shown that significant increases early in pregnancy of myelin-making cells, myelin formation, and the capacity for myelin repair. Furthermore, prolactin the hormone that stimulates lactation regulated these effects. Prolactin treatments given to non-pregnant female mice with myelin damage promoted myelin repair. This study provides new information on gender differences in MS. Now if confirmed, the findings may present a new therapeutic strategy for MS utilizing prolactin.

Another study at Oregon Health & Science University and the Portland Veterans Affairs Medical Center has uncovered the mechanism by which estrogen, produced in high volumes during pregnancy, boosts the expression and number of regulatory cells that are key in fighting MS and other autoimmune diseases, such as arthritis and diabetes.

The study, published in The Journal of Immunology, shows the hormone augments a compartment containing T cells known as CD4+CD25+, and a regulatory protein called FoxP3. The cells are important for protecting mice against a model for human MS called experimental autoimmune encephalomyelitis (EAE). Autoimmune disease has been associated with a deficiency of FoxP3, whose expression is a reliable indicator of the regulatory T cells' function and development.

It's felt that understanding how estrogens boost of protective T cells to fight MS will lead to the development of "estrogen-like" drugs that could increase the cells without the female hormone's side effects. The study found that estrogen treatment simulates pregnancy in increasing T cell levels. It also demonstrated that estrogen boosts expression of the FoxP3 protein not only in a mouse model, but also in cell culture.

Scientists have long been interested in the role sex hormones play in the body's ability to fight autoimmune diseases like MS, particularly since these disorders occur more frequently in females than in males. But the link between pregnancy and MS has been hotly debated.

Estrogen levels during pregnancy can be 50 to 100 times higher than normal. Now this is due to the fact that jump to the body's natural defense against its own immune system, whose reaction to self-antigen proteins, or "self-Ags," in fetal tissue can lead to fetal rejection, as well as the chronic inflammation that is the root of autoimmune disease.

A small clinical trial at the University of California, Los Angeles, showed estriol, the estrogen hormone produced during pregnancy and available as an oral therapy, showed some benefit for MS patients. One problem with long-term estrogen therapy is the potential side effects so developing estrogen-like drugs can help women avoid these potentially detrimental effects.

A hormone produced during pregnancy spontaneously increases myelin, which enhances signaling within the nervous system, and helps repair damage in the brain and spinal cord, according to new animal research.