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Neurology Today:
doi: 10.1097/01.NT.0000365666.31648.64
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Pregnancy Outcomes Encouraging for Women with MS, Epilepsy

FITZGERALD, SUSAN

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ARTICLE IN BRIEF

In an analysis of a huge database on hospital stays, investigators found that pregnant women with multiple sclerosis or epilepsy fared a bit worse than general obstetrical patients, but overall did not have as many pregnancy-related complications as women with diabetes.

Pregnant women who have multiple sclerosis or epilepsy are at heightened risk for antenatal hospitalization, intrauterine growth restriction (IUGR), and cesarean delivery, but for the most part the obstetrical picture is positive for these patients, according to a Dec. 1 paper in Neurology.

Researchers used a large national database to compare pregnancy outcomes for four groups of women: those with MS, epilepsy, pregestational diabetes, and in the general obstetrical population.

Women with MS or epilepsy fared a bit worse than general obstetrical patients, but overall did not have as many pregnancy-related complications as women with diabetes. MS and epilepsy are among the most common serious neurologic disorders found in women of child-bearing age, and many of those women wrestle with whether to have children.

“The overall results of our study are reassuring for women with MS and epilepsy,” concluded the research team, based at Stanford University School of Medicine. “While the rates of IUGR and cesarean delivery were higher in patients with those diseases, most other adverse outcomes were not more common than in the general obstetrical population.”

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ADVERSE OUTCOMES: DIABETES

In contrast, “There are many more adverse outcomes in women with pregestational DM [diabetes mellitus], the most common chronic disease affecting women during the childbearing years,” the researchers reported. That finding is particularly relevant since the prevalence of diabetes is rising in children and younger adults along with the growing obesity epidemic.

“The diabetics need to be followed closely during pregnancy. There are a lot of potentially bad outcomes for the babies and the mothers,” Eliza Chakravarty, MD, the study's senior author and an assistant professor of medicine in Stanford's Division of Immunology and Rheumatology, told Neurology Today.

On the other hand, Dr. Chakravarty said the study results should provide neurologists with some positive news to share with patients with MS or epilepsy who are contemplating pregnancy or are worried about an unplanned pregnancy.

“Women should not be discouraged from becoming pregnant and having children just because they have these diseases,” Dr. Chakravarty said.

The researchers tapped into data from the 2003–2006 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, an all-payer database that contains clinical and demographic information on hospital discharges from 1,054 hospitals around the country. Using obstetrical discharge abstracts, the researchers looked at maternal age and race; length of hospital stay, principal diagnosis, principal procedure and secondary diagnoses. They considered factors such as a hospitalizations separate from delivery, hypertension disorders including preeclampsia, premature rupture of membranes, IUGR and C-section deliveries. Since the database does not link maternal and neonatal records, it was not possible for the researchers to also evaluate the health of the babies.

The researchers said their sample represented 18.8 million deliveries nationwide over the time period studied, including more than 10,000 deliveries involving women with MS, almost 5,000 for women with epilepsy, and more than 187,000 deliveries involving women with diabetes.

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C-SECTIONS ARE More COMMoN

Women with MS or diabetes tended to be older, on average, (31.6 years and 30.2. years respectively) than women in the general obstetrical population (27.4 years), though women with epilepsy tended to be younger (26.8 years). All three of the disease groups were more likely than the general obstetrical patients to be hospitalized at some point during pregnancy — women with epilepsy were three times more likely than the controls) and they also had longer lengths of stay around delivery, perhaps because they were more likely to have C-sections. Just over 42 percent of MS patients and 44.5 percent of those with epilepsy had C-sections, compared to 62.1 percent of women with diabetes and 32.8 percent of controls.

The incidence of hypertension disorders, including preeclampsia, was highest among the diabetic women (30.3 percent) compared to 12.3 percent for women with epilepsy, 10.7 percent for those with MS, and 8.5 percent for controls.

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IUGR IN MS AND EPILEPSY

Premature rupture of membranes did not emerge as an issue for women with MS or epilepsy, though it was more likely to occur in diabetic women than in the general obstetrical patients. But the researchers noted that IURG — defined as weight less than tenth percentile for gestational age— was a concern when it came to both the women with MS and epilepsy. The women with MS had a 70 percent higher risk for IURG and those with epilepsy had a 90 percent higher risk than the general OB population. Even so, just 2.7 percent of the deliveries in the MS group and 3.8 percent of the deliveries among women with epilepsy had a classification of IUGR.

The study noted that the epilepsy-related findings may be skewed, since they were dependent on whether the obstetrician cited the disease in the discharge summary.

“It is likely that women without recent seizures, or those not taking AEDs [antiepileptic drugs], were not given the diagnosis of epilepsy at discharge, limiting the sample size and biasing it towards women with more active disease,” the researchers noted. “Given this selection bias, it is not surprising to see a high number of adverse outcomes in the epilepsy group.”

The researchers also noted other shortcomings of their study. The discharge summary data, for instance, did not include information on what medications the women were taking or the length and severity of their disease. Other risk factors, such as alcohol and tobacco use, were also not available.

Without the babies' hospital records, the study could not answer the most fundamental question many pregnant women want to know: Will my baby be born healthy?

The study authors acknowledged that their findings address only part of the picture because of the limited “ability to obtain information on adverse neonatal outcomes including congenital anomalies and neonatal deaths.” Babies born prematurely or at low birthweight, for whatever reason, are at heightened risk for a host of problems, including neonatal death.

In the case of epilepsy, pregnant women “face unique challenges not only from the risk of seizures, but also from the potential teratogenicity of many antiepileptic drugs (AEDs),” they wrote. Several national and international registries have been established to track pregnancy outcomes, in particular congenital malformations associated with certain AEDs.

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EXPERTS COMMENT

Despite the study's limitations, investigators who were not involved with the study said the findings were important for clinicians to be aware of as they counsel women who are pregnant or considering pregnancy.

Brian Weinshenker, MD, an MS expert and professor of neurology at the Mayo Clinic in Rochester, NY, told Neurology Today that while it's recognized that MS attacks may diminish during pregnancy, possibly due to pregnancy-related immunosuppression, the disease may flare up in the immediate postpartum period.

“I still think a childbearing decision has to be individualized based on the activity of MS, but at least most evidence, including the evidence from this study, shows no added delivery-associated risks or risks to the fetus,” Dr. Weinshenker said.

Dr. Weinshenker said he strives to get his MS patients off all medications before they become pregnant and also advises them on strategies to reduce stress and fatigue to lower the risk of postpartum worsening. For instance, “We encourage most patients to have epidurals because they are more rested and less drained by delivery,” he said.

Alison Pack, MD, associate professor of clinical neurology at Columbia University, likewise focuses on getting her patient's disease well under control prior to pregnancy.

“I like women to have good seizure control and I like the women to be on only one drug at the lowest dose possible,” Dr. Pack told Neurology Today. She said she is willing to tolerate certain types of seizures during the first trimester if the tradeoff is that the pregnant woman is on only one or even no medication.

Dr. Pack said neurologists need to stay in contact with their patients throughout pregnancy. She makes a point to closely monitor blood levels of medications that her pregnant patients are taking and doesn't hesitate to pick up the phone to call an obstetrician with a concern.

“Women will tell me, My OB said I need to have a C-section because I have epilepsy, but that is not necessarily the case with well-controlled seizures,” she said.

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REFERENCES

• Kelly VM, Nelson LM, Chakravarty EF. Obstetric outcomes in women with multiple sclerosis and epilepsy. Neurology 2009; Neurology 29:73:1831–1836

©2009 American Academy of Neurology

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