A 22-year-old woman comes to the physician with her husband for intermittent dizziness, weakness, and unsteady gait for the last several weeks. She has also had visual loss and pain in the right eye that worsens with eye movement for the past 2 days. A year ago, the patient had tingling and numbness of her right hand accompanied by unsteadiness, which improved spontaneously after 3-4 days. She has no other medical problems and does not take any medications. The patient has no significant social or family history. Her temperature is 37.2 C (99 F), blood pressure is 122/80 mm Hg, pulse is 82/min, and respirations are 16/min. On neurologic examination, her right eye has diminished visual acuity and an afferent pupillary defect. She also has a right arm intention tremor. Both lower extremities have spastic paresis, hyperreflexia, and positive Babinski sign. Four months later, the patient comes to the physician for a routine visit and asks for advice regarding pregnancy. She has been taking her medication regularly. Which of the following is the most appropriate response?

Question

A 22-year-old woman comes to the physician with her husband for intermittent dizziness, weakness, and unsteady gait for the last several weeks.  She has also had visual loss and pain in the right eye that worsens with eye movement for the past 2 days.  A year ago, the patient had tingling and numbness of her right hand accompanied by unsteadiness, which improved spontaneously after 3-4 days.  She has no other medical problems and does not take any medications.  The patient has no significant social or family history.  Her temperature is 37.2 C (99 F), blood pressure is 122/80 mm Hg, pulse is 82/min, and respirations are 16/min.  On neurologic examination, her right eye has diminished visual acuity and an afferent pupillary defect.  She also has a right arm intention tremor.  Both lower extremities have spastic paresis, hyperreflexia, and positive Babinski sign. Four months later, the patient comes to the physician for a routine visit and asks for advice regarding pregnancy.  She has been taking her medication regularly.  Which of the following is the most appropriate response?

Quizplus · Accepted Answer

Explanation: The management of pregnantpatients with multiple sclerosis (MS) may be similar to those who are not pregnant; however, there are several unique considerations. Pregnant women with MS have a modest increase in cesarean section and assisted delivery (eg, vacuum, forceps) rates compared to those without MS. As in nonpregnant patients, the preferred treatment for acute MS exacerbations in pregnant patients is short-term intravenous glucocorticoids as they are generally well tolerated and are not associated with teratogenicity (Choice A). (Choices B and D) The majority of disease-modifying agents used for relapsing-remitting MS also have category B (no evidence of risk in available studies) or C (risk cannot be ruled out) pregnancy risk. Teriflunomide and mitoxantrone are exceptions to this rule as they are both known teratogens that are contraindicated in pregnancy. Nonetheless, pregnant women with MS usually have lower disease activity during pregnancy and higher disease activity in the postpartum period. Some experts propose that disease-modifying therapy be discontinued during pregnancy if possible as a result of these observations. (Choice E) Infants born to women with MS also warrant special consideration as they have an increased risk of developing MS (eg, 3%-23% of MS cases are familial) and can be born with lower birth weights. Educational objective: Pregnant women with multiple sclerosis typically have lower disease activity during pregnancy and higher activity in the postpartum period. Acute exacerbations are treated similarly to nonpregnant patients, and most disease- modifying agents have relatively low pregnancy risk. References: Multiple sclerosis in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/24492810) Multiple sclerosis and pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/22011954)

A 22-Year-Old Woman Comes to the Physician with Her Husband