1) Welcome to our accredited tweetorial on Specific #MultipleSclerosis Care Needs for Women of Child-Bearing Age. Expert faculty Alissa Willis @myelinMD. Earn 0.5h CME/CE credit by following this thread. #MStwitter #neurotwitter @MedTweetorials @JennyFengMD @alisecarlsonmd pic.twitter.com/6CR1hL5krg
— MultipleSclerosis_CME (@ms_cme) September 20, 2021
3) Many women with #MultipleSclerosis are diagnosed at a time in life that family planning may be a concern. It is important to consider this in education of patients and in therapy selection.
— MultipleSclerosis_CME (@ms_cme) September 20, 2021
5) In women with MS…
a. Epidural analgesia should be avoided
b. Rate of adverse pregnancy outcomes is increased
c. Relapse rate declines during pregnancy
d. Breast-feeding should be always avoided— MultipleSclerosis_CME (@ms_cme) September 20, 2021
7) MS does not increase risk for complications from epidural analgesia or adverse pregnancy outcomes. More to come on the latest thoughts on breastfeeding… (doi: 10.1097/AOG.0000000000000541)
— MultipleSclerosis_CME (@ms_cme) September 20, 2021
9) Improved disease control before pregnancy can reduce the risk of post-partum relapse. Selection of DMT requires consideration of disease course, contraception use, and plan for pregnancy.
— MultipleSclerosis_CME (@ms_cme) September 20, 2021
11) Do you recommend…
a. Start ocrelizumab now
b. Start glatiramer acetate and continue through pregnancy
c. Start teriflunomide and stop when she is ready
d. Monitor off therapy— MultipleSclerosis_CME (@ms_cme) September 20, 2021
13) Teriflunomide would not be the best option for a woman or a man who is not practicing effective contraception due to risk for teratogenicity with fetal exposure.
— MultipleSclerosis_CME (@ms_cme) September 20, 2021
15) What about breast-feeding & resuming DMT in women with MS? We’ll talk about that tomorrow. Come back and join us! I am @myelinmd & program chair @SKriegerMD & I invite you to FOLLOW us. @MSHSNeurology @MSUnites @MS_Focus @MustStopMS @mscare @mssociety @MSassociation
— MultipleSclerosis_CME (@ms_cme) September 20, 2021
17) A number of short- and long-term infant and maternal benefits of breast-feeding are well established. Concerns for fetal exposure to DMT and increased risk for post-partum relapse led many neurologists to discourage breast-feeding in the past.
— MultipleSclerosis_CME (@ms_cme) September 21, 2021
19) What about resuming DMT during breastfeeding? This one is tricky. There is little human data to guide recommendations. How can we help a woman with previously very active MS or concern for relapse risk decide?
— MultipleSclerosis_CME (@ms_cme) September 21, 2021
21) And the oral agents? These small molecules are more likely to be excreted in breast milk and would be more likely to result in transluminal transfer. Infants should be completely weaned before resuming oral agents.
— MultipleSclerosis_CME (@ms_cme) September 21, 2021
23) #MRI up to 3T can be safely done during preg but gadolinium should not be used unless absolutely necessary. The risk of infant exposure to the small amounts of Gd in breast milk is low so Gd can be given without interrupting breast-feeding. (DOI: 10.1097/AOG.0000000000000541)
— MultipleSclerosis_CME (@ms_cme) September 21, 2021
25) Of the following, which symptomatic medication is safest for continuation during pregnancy and lactation in a patient with #multiplesclerosis?
— MultipleSclerosis_CME (@ms_cme) September 21, 2021
26) Mark your response and return tomorrow for the correct answer and more education—symptomatic medication in women of childbearing age! @MSviewsandnews @yogamovesms @StaceyLClardy @AaronBosterMD @DrJNicholas @DanOntaneda @Brandon_Beaber @DocforMS @NerdyNeuroMD @GavinGiovannoni
— MultipleSclerosis_CME (@ms_cme) September 21, 2021
28) Now let's look at symptomatic medications in #MultipleSclerosis women of child-bearing age. Common symptoms such as fatigue, spasticity, neuropathic pain, mood disorders can sometimes be managed without medication as @DrJNicholas taught us at https://t.co/qgXiTM7Cpa.
— MultipleSclerosis_CME (@ms_cme) September 22, 2021
30) This is not an exhaustive list but includes meds poss assoc'd with fetal malformations or withdrawal symptoms for infants exposed in pregnancy. Safer options for neuropathic pain are physical therapy, topical agents (capsaicin, lidocaine), amitriptyline, SNRIs (venlafaxine).
— MultipleSclerosis_CME (@ms_cme) September 22, 2021
32) Remember that some women experience depression in the first 6 months post-partum. Prior depression is a risk factor for this and we know that the lifetime prevalence of depression in #MultipleSclerosis is around 50%. (DOI: 10.1177/1352458511417835)
— MultipleSclerosis_CME (@ms_cme) September 22, 2021
34) Now we’ve covered basics about DMT pitfalls while planning for pregnancy and breastfeeding. We’ve talked about symptomatic management and watching out for depression. What if a relapse happens? What do we do? @MarisaMcGinley @GMacaronMD @sumadshah
— MultipleSclerosis_CME (@ms_cme) September 22, 2021
36) Yes, that's true. Older studies suggest a risk for cleft palate and cleft lip w/corticosteroid exposure in the 1st trimester so early use should be limited to relapses affecting function. Small amts of methylprednisolone are found in breast milk but ⬇️ rapidly post infusion.
— MultipleSclerosis_CME (@ms_cme) September 22, 2021
38) Summary: Treatment of relapses during pregnancy or lactation is similar to standard practice with a few special considerations. Care review and counseling about medication use in women with #MultipleSclerosis should include symptomatic medication as well as DMT.
— MultipleSclerosis_CME (@ms_cme) September 22, 2021
39) That's it, you made it! Free CE/#CME! Now go to https://t.co/FFQ7tANNvU and claim your 0.5h credit! I am @myelinMD and program chair @SKriegerMD hope u will follow @MS_CME for more tweetorials! #neurotwitter @IntNatlWiMS @MSUnites @MS_Focus @MustStopMS @mscare @mssociety
— MultipleSclerosis_CME (@ms_cme) September 22, 2021
