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Pregnancy and MS: Everything you need to know

What affect does an MS diagnosis have on fertility, pregnancy and starting a family? What effect does pregnancy have on MS symptoms?

What have studies into MS and pregnancy found?

A number of reviews, including a meta-analysis of 23 papers reporting on 13,144 women with MS, have found that:

  • MS has little or no effect on pregnancy
  • People with MS can expect normal fertility and normal pregnancy outcomes
  • MS produces no increase in adverse outcomes for mother or baby

This confirms findings from a study in British Columbia that reviewed the records of 432 births to women with MS. Compared to control groups, there were no differences in gestational age, birth weight, or rates of assisted vaginal delivery or caesarean section. However, an estimated 50% to 90% of people with MS experience symptoms of sexual dysfunction, which affect conception rates.

MS relapses during pregnancy

Pregnancy is associated with a reduced relapse rate, particularly during the third trimester. The Pregnancy and Multiple Sclerosis (PRIMS) trial, which looked at 269 pregnancies, found that pregnancy resulted in:

  • A 70% reduction in relapse rate in the third trimester
  • A corresponding increase in the relapse rate in the three months after childbirth

Despite the relative increase in relapses in the postnatal period, 72% of women experienced no relapses during this period. Predictors for postpartum relapses included:

  • Increased relapse rate in the year before pregnancy or during pregnancy
  • Higher EDSS score at the onset of pregnancy

In the longer term, there is evidence that pregnancy may be beneficial for women with MS:

  • A 10-year follow-up study found a lower relapse rate in women with pregnancies after MS onset compared to those without pregnancies after MS onset
  • A prospective 5-year study compared the rate of progression in disability between childless women, women who had onset of MS after childbirth, and women who had onset before or during pregnancy. Disability rates increased most rapidly in women with no children

Pregnancy after onset of MS is associated with a longer duration until wheelchair dependence develops, as compared to never-pregnant women or those who had children only before onset of the disease, and less risk of conversion to secondary progressive MS. 

Oral contraceptive use and childbirth are associated with a later age of MS onset. An Australian study found that the risk of women developing MS drops by half with each child born and is unaffected by time since last birth, suggesting that the protective effect is due to pregnancy and is lifelong.

What expecting mothers who have MS should eat in pregnancy

The importance of a mother’s diet has been extensively studied, and findings support the OMS recommendation for a diet rich in omega-3s and vitamin D and folic acid supplementation.

A recent review confirmed that: “Maternal DHA [one of the fatty acids in fish oil] intake during pregnancy and/or lactation can prolong high-risk pregnancies, increase birth weight, head circumference and birth length, and can enhance visual acuity, hand and eye coordination, attention, problem solving and information processing.”

Increasing omega-3s in the diet is also likely to reduce illnesses caused by an overactive and inflammatory immune system. Studies have shown that fish oil consumed during pregnancy reduces asthma, allergy and dermatitis in the offspring. 

Conversely, diets low in fish and vegetables have been linked to low birth weights. However, because mercury and other toxic substances collect in fish, pregnant women should limit fish consumption in the following ways:

  1. Don’t eat shark, marlin and swordfish, because they contain high mercury levels
  2. Limit weekly tuna intake to no more than two steaks or four medium cans
  3. Eat no more than two portions of oily fish a week, including fresh tuna, salmon, mackerel, sardines, and trout. It is best, as per the OMS approach, to eat plant-based omega-3s; i.e., flaxseed oil

Effects of a mother’s high-fat diet on offspring

Maternal high-fat diets appear to have harmful effects in lowering the age of puberty, increasing the risk of breast cancer in offspring and their children, and increasing anxiety in offspring. This applies only to saturated and trans-fats, not omega-3s. 

Studies show that food choices made in pregnancy can directly affect the offspring’s own food choices. Mothers who eat healthy foods are likely to have children who also prefer healthy foods. These findings offer a persuasive explanation for the rising incidence of breast cancer, the falling age of puberty, and high anxiety levels in industrialized countries.

They also support the argument for a plant-based diet of whole foods, supplemented with omega-3s.

Mind-body connection and pregnancy

Stress and stress management are closely linked to the development of MS and relapses.

In a recent randomized controlled trial (RCT), those taking part in a stress-reduction program reduced the onset of new lesions. This effect was seen during the period of the program but not when the participants stopped. This followed previous work, again an RCT, which confirmed that mindfulness-based stillness meditation (MBSM) improves quality of life in MS, including reducing depression, fatigue and anxiety. 

Stress negatively affects a mother and her developing baby. This has previously been looked at in epidemiological and prospective studies. More recent studies have looked at stress-reduction interventions with positive results.

Maternal stress during pregnancy is associated with a number of negative outcomes for the baby including:

  • Types 1 and 2 diabetes
  • Increased risk of asthma
  • ADHD and autistic traits in childhood
  • Cerebral palsy
  • Miscarriage, preterm labor, malformations and asymmetric growth retardation

Depressive symptoms in pregnant women are associated with elevated pro-inflammatory cytokines, including IL-6 and TNF-alpha, which are increased in active relapsing-remitting MS. In addition, raised levels of stress hormones are associated with pre-eclampsia and hypertension.

Stress reduction interventions in pregnancy

Studies on stress reduction programs in pregnancy have found improvements in many of the issues above, including:

  • Reduced anxiety and depression
  • Improved sleep
  • Reduced discomfort
  • Improvements in blood pressure
  • Fewer preterm pregnancies
  • Reduced hospital admissions
  • Improved birth weights
  • Improvements in maternal asthma
  • Shorter labor times 

In 2010, an RCT showed that a brief intervention of progressive muscle relaxation or guided imagery reduced anxiety and stress. Indian studies have shown that yoga and meditation improve birth weight and reduce preterm labor, blood pressure, diabetes and pre-eclampsia, while reducing growth abnormalities compared to standard treatment. These studies confirm that balance and reduced stress improve health.

Pregnancy and MS medications

The current advice is often to discontinue DMTs prior to conception, although studies have found only very minor adverse effects of beta-interferons (Avonex, Rebif and Betaferon or Betaseron) and no effect of glatiramer (Copaxone) and no association with fetal anomalies.

People with more aggressive MS may be prescribed natalizumab (Tysabri) or fingolimod (Gilenya). It is currently advised that these medications be ceased (three and two months, respectively) prior to conception. Ocrelizumab is currently advised to stop 12 month prior to pregnancy.

Short courses of steroids have generally been regarded as safe in pregnancy. Treatment with intravenous immunoglobulins (IVIg) looks promising in the period around childbirth. (See the Immunoglobulins section.) These are naturally produced by the immune system and have been used to treat a variety of neurological diseases, including MS. As well as being effective at reducing relapse rates, they appear to have no significant side effects or detrimental effects on pregnancy. At present, this treatment is not widely available.

For further information and specific DMD guidance in pregnancy, please refer to the 2019 ABN Guidance on pregnancy in multiple sclerosis. https://pn.bmj.com/content/practneurol/19/2/106.full.pdf

Breastfeeding and MS

Studies suggest a reduction in relapse rates among women who breastfeed for at least 2 months after childbirth.

A recent meta-analysis found that women who breastfed were half as likely to experience a postpartum relapse, compared to women who did not. There are other well-established reasons why breastfeeding is preferable if possible: considered the optimal nutrition for babies, it helps protect them from many illnesses, including type 1 diabetes, asthma, dermatitis and Crohn’s disease.

It also appears to provide protection against MS. A German study showed that breastfeeding for at least 4 months halves a baby’s risk of developing MS later in life.

MS and IVF

Although MS has not been shown to affect fertility, approximately 15% of all couples have trouble conceiving. Given that the hormonal changes of pregnancy affect MS, it is to be expected that the hormonal changes induced by IVF would affect the disease.

Three studies have addressed this issue. It seems that one type of medication used, GnRH (gonadotropin releasing hormone) agonists (LONG protocol), may increase relapse rates. This increase is present for at least 3 months following treatment. Failure of IVF was also shown to be associated with an increased relapse rate. 

Given that some of the DMTs (IFN and particularly GA) appear safe in the perinatal period, some authorities now advocate continuing these when having IVF.

In MS, it is generally thought best to use the ANTAGONIST or SHORT protocol, if possible, as this has no effect on relapse rates.  It is worth discussing this with your gynaecologist at an early stage in the IVF process.

Interestingly, low-dose naltrexone (LDN) has been shown to be an effective treatment for infertility in people with polycystic ovarian syndrome. Given its possible benefits in MS, this warrants further research.

Conclusion

The evidence cited above suggests that following the OMS Program can provide a number of benefits. During pregnancy, the mother will experience reduced MS disease activity and progression over and above the benefits derived from pregnancy alone. She will also have a reduced risk of:

  • Pre-eclampsia
  • Gestational diabetes
  • Preterm delivery
  • Discomfort
  • Prolonged labor

Children will have improved neurological development and a reduced risk of:

  • MS
  • Type 1 diabetes
  • Rheumatoid arthritis
  • Ulcerative colitis
  • SLE (lupus)
  • Asthma
  • Respiratory tract infections
  • Allergic dermatitis
  • Breast cancer
  • Anxiety-like behaviors

Research suggests that these benefits will be passed on for at least two generations.

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