Pregnancy-Related Relapses and Breastfeeding in a Contemporary Multiple Sclerosis Cohort
Why is this study important?
A diagnosis of multiple sclerosis (MS) can have a significant impact on family planning. Women with MS often worry that pregnancy and breastfeeding may worsen their symptoms, or that the disease or treatment may pose a risk to their babies.
Mothers-to-be are typically told that MS symptoms decrease during pregnancy and increase in the first few months after delivery, making MS flares more likely during the postpartum period. Because most medications used to treat MS have been traditionally considered incompatible with breastfeeding, new mothers with MS often had to choose between foregoing breastfeeding to receive adequate treatment and stopping treatment until after weaning their infants. However, the use of disease-modifying therapies (DMTs) early after delivery has not been clearly shown to prevent postpartum MS relapses.
How did the authors study this issue?
MS diagnostic criteria have recently evolved, allowing health care providers to diagnose the disease earlier and to identify milder cases of MS. Following these developments, a study was designed to determine the risk for MS relapses after pregnancy, as well as the factors that influence this risk, among women enrolled in the Kaiser Permanente health plans in Northern and Southern California. The analysis included 375 women with MS who had live births between January 2008 and April 2016. More than half of those women had at least one MS flare within 2 years before pregnancy, and 67.2% had less than ideal disease control when they became pregnant.
NOTE: MS relapses were defined as new, recurring, or worsening symptoms of neurologic dysfunction lasting for 48 hours or longer documented during physical examinations.
Does pregnancy increase the risk of MS relapses?
Most women who participated in the Kaiser Permanente study had no MS relapses during the first year after giving birth, although less than half of them used DMTs. MS flares decreased during pregnancy, as expected, but, in most cases, did not increase in the first few months after delivery.
The results suggest that breastfeeding may have a positive impact on MS disease activity. The majority of women in the study (87.3%) breastfed their babies, and 35.8% breastfed exclusively for at least 2 months. Those who breastfed exclusively had fewer MS flares in the first 6 months after pregnancy compared with women who breastfed nonexclusively or not at all. This trend was also true for women with MS whose disease was severe or not well controlled before pregnancy.
Although the concern about postpartum MS flares is still a real challenge when considering pregnancy, these findings prove that most women diagnosed with MS today can have children and breastfeed without facing an increased risk of worsening symptoms after delivery.
Are there any strategies to prevent relapses?
One way to keep MS symptoms in check after pregnancy is to encourage exclusive breastfeeding, which was shown to reduce the risk of MS flares in women with active disease before pregnancy. However, finding the right treatment plan for each mother with MS and sticking to it before and after pregnancy also plays an essential role in postpartum health. For women who have active disease or have not completely recovered from previous MS relapses, it is especially important to find the optimal treatment regime before conception.
Providers in the Kaiser Permanente network have raised the standard by designing a pregnancy-specific treatment model for women with MS. Women with active disease and those with neurologic disability caused by MS are treated with highly effective, long-acting DMTs such as rituximab before pregnancy. Therapy is stopped during pregnancy and is typically resumed 6 to 12 months after delivery. Since rituximab and other monoclonal antibody DMTs are safe during breastfeeding, new mothers with MS are encouraged to breastfeed exclusively for 6 months, and longer if desired.
A game-changing message from the Kaiser Permanente study is that women with MS who are planning a pregnancy no longer have to choose between the health benefits of breastfeeding and DMTs that are not likely to reduce the risk of postpartum MS flares. If you have MS and are considering having children, discuss the benefits and risks of pregnancy and breastfeeding with your MS specialist.
Original Article
Pregnancy-related relapses and breastfeeding in a contemporary multiple sclerosis cohort
Neurology
Annette Langer-Gould, Jessica B. Smith, Kathleen B. Albers, Anny H. Xiang, Jun Wu, Erica H. Kerezsi, Keeli McClearnen, Edlin G. Gonzales, Amethyst D. Leimpeter, Stephen K. Van Den Eeden
Objective
To determine whether women with multiple sclerosis (MS) diagnosed according to current criteria are at an increased risk of postpartum relapses and to assess whether this risk is modified by breastfeeding or MS disease-modifying therapies (DMTs), we examined the electronic health records (EHRs) of 466 pregnancies among 375 women with MS and their infants.
Methods
We used prospectively collected information from the EHR at Kaiser Permanente Southern and Northern California between 2008 and 2016 of the mother and infant to identify treatment history, breastfeeding, and relapses. Multivariable models accounting for measures of disease severity were used.
Results
In the postpartum year, 26.4% relapsed, 87% breastfed, 36% breastfed exclusively for at least 2 months, and 58.8% did not use DMTs. At pregnancy onset, 67.2% had suboptimally controlled disease. Annualized relapse rates (ARRs) declined from 0.37 before pregnancy to 0.14–0.07 (p < 0.0001) during pregnancy, but in the postpartum period, we did not observe any rebound disease activity. The ARR was 0.27 in the first 3 months postpartum, returning to prepregnancy rates at 4–6 months (0.37). Exclusive breastfeeding reduced the risk of early postpartum relapses (adjusted hazard ratio = 0.37, p = 0.009), measures of disease severity increased the risk, and resuming modestly effective DMTs had no effect (time-dependent covariate, p = 0.62).
Conclusion
Most women diagnosed with MS today can have children without incurring an increased risk of relapses. Women with suboptimal disease control before pregnancy may benefit from highly effective DMTs that are compatible with pregnancy and lactation. Women with MS should be encouraged to breastfeed exclusively.