Pregnancy and Family Planning in Multiple Sclerosis

Annette M. Langer-Gould, MD, PhD p. 773-792 June 2019, Vol.25, No.3 doi: 10.1212/CON.0000000000000745
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PURPOSE OF REVIEW: This article provides practical guidance on successful management of women with multiple sclerosis (MS) through pregnancy and the postpartum period.

RECENT FINDINGS: Recent studies indicate that most women diagnosed with MS today can have children, breast-feed, and resume beta interferons or glatiramer acetate per their preferences without incurring an increased risk of relapses during the postpartum period. More than 40% of women with mild MS do not require any treatment before conception or in the postpartum period. Women with highly active MS can now become well-controlled before, throughout, and after pregnancy via highly effective treatments. Unfortunately, pregnancy does not protect against relapses following the cessation of fingolimod or natalizumab, and some women experience severe rebound relapses during pregnancy. Accidental first-trimester exposure to teriflunomide or fingolimod increases the risk of fetal harm.

SUMMARY: Most women with MS can have normal pregnancies and breast-feed without incurring harm. Clinicians should avoid prescribing medications with known teratogenic potential (teriflunomide, fingolimod), known risk of severe rebound relapses (fingolimod, natalizumab), or unclear but plausible risks (dimethyl fumarate, alemtuzumab) to women of childbearing age who desire pregnancy or are not on reliable birth control. If a treatment needs to be resumed during breast-feeding, clinicians should opt for glatiramer acetate, interferon beta, natalizumab, or rituximab/ocrelizumab, as biologically plausible risks to the infant are exceedingly low.

Address correspondence to Dr Annette M. Langer-Gould, Kaiser Permanente Southern California Permanente Medical Group, 100 S Los Robles Ave, Pasadena, CA 91101,

RELATIONSHIP DISCLOSURE: Dr Langer-Gould receives research/grant support from the National Multiple Sclerosis Society and the Patient-Centered Outcomes Research Institute.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Dr Langer-Gould discusses the use of corticosteroids and plasma exchange to treat multiple sclerosis relapse during pregnancy, gabapentin to treat neuropathic pain, natalizumab to treat multiple sclerosis during pregnancy, and rituximab to treat multiple sclerosis.

© 2019 American Academy of Neurology.