On the question of pregnancy.

MS, we often say, "strikes young adults just when they're starting to build careers." That statement also covers the important phrase "and bear children." And with about twice as many women as men having multiple sclerosis, those words assume a special prominence, particularly with the increasing amount of information being discovered about genes and heritability. Little wonder that whether or not to have children is often a persistent and anxiety-provoking issue. In this issue, INSIDE MS tackles questions of pregnancy from the immediate practicalities of the obstetrician's office to the more far-ranging genetic implications of the research laboratory. We think the answers will be reassuring for the present and heartening for the future. Dr. Cassandra Henderson is assistant professor, obstetrics and gynecology, Albert Einstein College of Medicine and associate director of obstetrics and perinatology at its Jack D. Weiler Hospital. She has an active private practice which includes women with MS. We asked Dr. Henderson to take part in a hypothetical question-and-answer session with a first-time visitor who is considering having a baby. Below are the questions asked and Dr. Henderson's answers.

We are including supplementary information by Kathy A. Birk, MD, clinical instructor of obstetrics and gynecology, University of Rochester School of Medicine and Dentistry, and Richard A. Rudick, MD, director, Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic Foundation. Both Dr. Birk and Dr. Rudick have published numbers of papers and have presented their work and research since 1985. Dr. Birk cares for pregnant patients with MS. The information which appears in the italicized sections is excerpted from a co-authored article, "Caring for the ob (obstetrical) patient who has multiple sclerosis," and was published in CONTEMPORARY OB/GYN, July 1989.

QUESTION

1.

Q. "I have MS and want to have a child. What do you advise?"

A. We know that pregnancy and childbirth do not adversely affect the long-term course of MS. Therefore, what concerns me most is not your disorder, but your social situation. If you are asymptomatic or have only mild symptoms, I would say "go ahead," and would not concern myself too much about your immediate support system. But I would make very sure you understand the course your MS might follow during and immediately after the pregnancy. You also have to understand that while MS is an unpredictable disease the severity and duration of your previous exacerbations are the best clues to predicting future illness.

However, if you were a woman with a permanent or severe disability, I would carefully and fully discuss the social situation-it is key on two counts. One: the course of the pregnancy and the postpartum situation can be somewhat more complex as a result of the disability. The probability of an exacerbation after delivery becomes increased, although, on the whole, it is not any more permanent for such a person than for a woman with mild MS. Two: After the child is born, adequate support is more likely to be required than in the case of an asymptomatic woman.

My final advice is a question to you: "Why do you and your partner want a child?" In the last analysis, the joy of raising a child often overcomes many of the problems associated with MS and child bearing. Birk & Rudick: The decision to become a parent should rest primarily on the desire to have a family. Current degree of physical impairment and support from the father, friends, and relatives are important considerations .. The unpredictable and potentially disabling nature of the disease makes careful counseling and judicious treatment critical..Ideally, preconception counseling should be sought.

QUESTION

2.

Q. Will pregnancy cause exacerbations?

A. It has been established that during a pregnancy there is rarely an exacerbation. As a matter of fact, pregnancy actually seems to act as a protection against disease activity. On the other hand, it was found that exacerbations do increase in the postpartum period in almost 50% of the cases. If you have been prone to exacerbations in the course of your MS, it is more likely that you will have one in the postpartum period. However, the exacerbations are rarely permanent.

Birk & Rudick: During pregnancy, the disease tends to stabilize .. There is no evidence that pregnancy alters the lifetime relapse rate or extends ultimate disability.

A relapse may occur in half of all patients and remains a concern for at least six months postpartum, during which risk is increased by at least threefold. In practical terms, adequate rest, treatment of anemia, minimizing stress, and avoiding infection and temperature elevation may all contribute to reducing the risk of postpartum relapse. In the US., many women on maternity leave must return to work six to eight weeks after delivery. Since this coincides with the period of high risk for relapse, it should be considered carefully before a pregnancy is attempted, especially if the patient's employer has not been told that she had the disease.

QUESTION

3.

Q. Are there any special problems that can arise during pregnancy due to MS?

A. As I said, studies have shown that women with MS usually feel better during pregnancy. There may be certain symptoms, however, that may need some special care. For instance, constipation may be one of the symptoms you've been experiencing as part of your MS. If I prescribe iron supplements, which I sometimes do, your problems may be worsened because iron tends to increase constipation. In such a case, I would prescribe a stool softener and dietary changes to alleviate the situation. Fatigue may increase, especially during the first trimester. You may want to make certain you can rest a little more frequently if necessary. Urinary tract infections, which are common among women with MS, also may be more common in pregnancy. Therefore, you may be more prone to such an infection. As a result, I generally take urine cultures once a month. If an infection is present, I treat it with antibiotics and it usually clears pretty readily. Toward the end of pregnancy, gait problems may worsen somewhat because of the weight gain. For safety reasons you may want a few more sturdy chairs or bars around especially in the bathroom. However, none of these possible problems is usually severe enough to affect a decision to become pregnant.

QUESTION

4.

Q. Will my MS affect the course of the labor or the anesthesia?

A. On the whole, labor is handled as it would be in any pregnancy. A small minority of patients have sensory deficits severe enough so they may not perceive uterine contractions. As a result they may be in labor for a long time without knowing it and may deliver inadvertently. I would be aware of this condition and monitor them very closely as the ninth month approached. Once the cervix dilates, I would induce labor. In terms of anesthesia, I recommend narcotics, lamaze or other relaxation techniques.

Birk & Rudick: Labor management should be routine .. Epidural anesthesia is felt to be safe to use in MS patients and is preferable to spinal anesthesia for Caesarean section. General anesthesia is considered safe as well.

QUESTION

5.

Q. Does natural childbirth tend to promote exacerbations?

A. No, it does not and I encourage it. Childbirth classes actually reduce stress.

QUESTION

6.

Q. Would medications I might be taking for MS have to be stopped during my pregnancy?

A. As a rule of thumb, I advise not taking anything you don't have to take, but if there is a medication that is important enough for you to take because of your MS, continue to take it only after full discussion with your obstetrician and neurologist. Medications never should be treated lightly and always need to be discussed carefully on an individual basis-even before becoming pregnant. For instance, it is generally considered safer not to become pregnant while you're taking an immunosuppressant. At all times-before, during and after pregnancy-keep in close touch with your neurologist and obstetrician. Birk & Rudick: Since exacerbation is unlikely during pregnancy, and chronic use is not typical, corticosteroids are not commonly encountered. Should steroid use be necessary, prednisone rather than ACTH is recommended and is considered safe .. Postpartum exacerbations may require steroid administration in a nursing mother The use of amounts as moderate as 40 mg. of prednisone a day is considered safe for the nursing infant.

QUESTION

7.

Q. Will I be able to breast-feed?

A. My answer is generally yes. Sometimes, however, it can be found to be too fatiguing. Also medications taken during this period may contra-indicate breast-feeding. For instance diazepan (Valium) has been associate@ with lethargy and weight loss in infants. As I've said, it is important to keep in close touch with your neurologist and obstetrician (or pediatrician) during this period.

Birk & Rudick: In the past, neurologists have discouraged nursing, which they thought posed additional demands during a period of increased risk for disease activity. A recent retrospective report found no statistical differences in the risk or timing of postpartum exacerbations between women who nursed and those who did not.

QUESTION

8.

Q. Will I be able to take care of my baby?

A. In general the answer is yes. You may need to be creative in establishing household routines and daily schedules. You and your spouse will have to have a sense of humor and even a sense of adventure. And there could be times when you will wonder how you can manage, but with any kind of support system most people do cope.

QUESTION

9.

Q. Are there any special points that I need to consider?

A. Yes. First it is vital that you use an obstetrician who is comfortable with MS. It is equally vital to work with a neurologist who is comfortable with pregnancy. And then it is essential that attention be paid to the relationship between the neurologist and the obstetrician. They should be compatible with each other. It will be part of your responsibility to keep your neurologist and obstetrician in touch with each other.

Second, I would like to reiterate that I feel comfortable with the idea of women with MS having children, but I wish to emphasize again that you must understand MS and understand that a support system might be more necessary in your long-range outlook than in another household. It's the parents' reasons for wanting children that make the final determination.

I might just add as a final personal note, I haven't yet met a mother with MS who is sorry she decided "to go for it."

In general it is found that the risk is somewhere between 1% and 5%, which means there is a 95-99% chance of not getting it. The range depends on whether the mother or the father has MS and whether the child is a boy or a girl. The greater risk is if the mother has MS and she has a baby girl.

For a full research report on genetics and its connection with MS, turn to page 14.