Eliza F. Chakravarty, MD, Assistant Professor of Medicine in the Division of Immunology and Rheumatology at Stanford University School of Medicine, discusses her paper, "Obstetric outcomes in women with multiple sclerosis and epilepsy," which was recently published in Neurology® (2009; 73:1831-1836.). She spoke with Bianca Weinstock-Guttman, MD.
AAN.com: Can you summarize the methodology and major findings of your study?
Chakravarty: We assessed a large, nationwide database of discharge summaries (the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project) with the primary goal of evaluating pregnancy outcomes in women with MS, epilepsy, and diabetes versus healthy pregnant women. What we found was quite reassuring for women with MS and epilepsy: women with MS did not appear to have higher risks of preeclampsia or increased length of hospital stay with childbirth, when we controlled for maternal age and race. Compared with pregnant healthy women, women with MS did have a higher risk of hospitalization for reasons other than childbirth (30 percent), intrauterine growth restriction (70 percent), and cesarean delivery (30 percent). Women with epilepsy had higher risks: a three-fold higher risk of hospitalization before delivery, almost double the risk of intrauterine growth restriction, and 50 percent increase in the risk of C-section.
AAN.com: How do your findings compare with previous available data?
Chakravarty: Until recently, there were few studies that looked specifically at pregnancy outcomes in women with MS. The focus had been more about how a pregnancy affects MS rather than what we considered: How MS affects pregnancy. Our results seem consistent with what has been reported in more recent studies. Epilepsy is a bit harder, since we had fewer deliveries in women with epilepsy than we had expected. Other studies have been mixed regarding pregnancy outcomes, but most generally we find an increased risk of growth restriction or small for-gestational-age babies. Because we could not link maternal records to infant records in this database, we could not evaluate the rates of congenital malformations among infants born to moms with epilepsy. Our database is unique because it provides outcomes across diverse populations and not just pregnancies occurring in women who are followed at tertiary care, university-based hospitals. However, the tradeoff with large, administrative databases is that we lose granularity and many details that may be important, such as medication use, disease severity, and prenatal care among others
AAN.com: What are the possible biological explanations for the higher number of cesarean delivery and the intrauterine growth restriction (IUGR) in MS patients?
Chakravarty: The C-section rate is difficult to understand because indications for C-section are so varied and range from previous C-section, emergency C-section for maternal or fetal health, patient or provider preference, or lower threshold to go to c-section in women with chronic diseases. We were not able to look at the reasons for C-section in this database. However, across all chronic diseases we have studied, C-section rates are higher.
Similarly, this database does not have good data to understand why IUGR is more frequent in MS patients. It's important to remember that, although a 70 percent increase sounds like a high number, the actual rates were less than three percent (2.7 percent in women with MS compared to 1.9 percent in healthy women). We speculate that, in some situations, active disease during pregnancy may contribute to growth restriction, and in other situations, medications may play a role. Again, without the data on disease activity or medications, we cannot say for sure.
AAN.com: Could you identify whether the perinatal adverse outcomes in African-Americans were related to socio-economic factors or to elements of disease severity?
Authors: Many studies show that race and ethnicity influence pregnancy outcomes irrespective of other health-related variables. We confirmed these findings, but could not assess the specific contribution of disease-related variables, prenatal care, socioeconomic factors, access to health care, medication use, smoking, or other factors to outcome.
AAN.com: What are the implications of your findings for the clinical neurologists?
Chakravarty: We hope that this study will reassure women with MS or epilepsy and their neurologists. We found that pregnancy outcomes were similar in healthy women and women with MS or epilepsy, and that women with these illnesses should not be discouraged from getting pregnant solely because of their diagnosis. Of course, every woman needs to discuss her particular situation with her doctors. All should take into account other factors such as the requirement of medications that can affect the pregnancy and the presence of other chronic conditions, including diabetes, kidney disease, or hypertension when making decisions about pregnancy.
AAN.com: Which specific recommendations should be given to MS and epilepsy patients respectively in regard to the perinatal period?
Chakravarty: It is important that women discuss pregnancy issues with their neurologist and gynecologist before conceiving, in order to minimize risks for adverse outcomes as much as possible. Important issues include minimizing the activity of the underlying disease while using only medications that are considered safe for pregnancy. Women with epilepsy need to be particularly careful about folic acid supplementation. Patients also should be followed carefully by both neurologists and obstetricians during pregnancy.
Within the past 24 months, Dr. Weinstock-Guttman received compensation for speaking and consulting from Biogen Idec, EMD Serono, TEVA Neurosciences, and Pfizer.