Evidence-based consensus on pregnancy in NMOSD

The French MS Society (SFSEP) has developed a national, evidence-based consensus on pregnancy in NMOSD. Their recommendations were very similar to those for women with MS, with some notable exceptions, namely an increased risk of miscarriage, foetal growth retardation and pre-eclampsia in anti-aquaporin-4 antibody-positive (AQP4-IgG+) patients , that warrant a closer obstetric monitoring and follow-up.

The main SFSEP recommendations were presented by Prof. Sandra Vukusic (University Hospital Lyon, France) and were published soon after [1,2]. NMOSD represents a distinct pathophysiological entity with very little literature on pregnancy. Still, there was a strong agreement on all 66 proposed recommendations. Prof. Vukusic focused on the most important recommendations, including the following:

• Pregnancy is not contraindicated in women with NMOSD. However, pregnancy planning should be favoured during a period of inactivity of the disease for at least 12 months.
• It is recommended to carry out a reinforced obstetric follow-up, with an expert neurological team, in women with NMOSD. “The reason for this is the high prevalence of autoimmune disorders in women with NMOSD that can have implications for obstetric outcomes,” Prof. Vukusic explained,
• It is recommended to inform patients of the increased risk of miscarriage and pre-eclampsia in case of AQP4-antibody-seropositive status, and to plan for obstetric follow-up by an experienced team.
• Breastfeeding is not contraindicated, but it is recommended to discuss this topic and when to resume immunoactive treatment, considering the patient's preferences and disease activity, and reminding the patient of the importance of rapid resumption of the treatment (because of the severity of relapses in NMOSD).
• Relapse management during pregnancy and breastfeeding is the same as when not pregnant.
• There is no evidence for specific, postpartum therapy to prevent relapses, but if immunoactive therapy was stopped, then an early restart after childbirth is recommended, because of the high risk and severity of those relapses.
• It is recommended to not use anti-CD20 therapy (off-label rituximab) during pregnancy. A 2-month delay is recommended between the last infusion and terminating contraception.
• Azathioprine can be continued during pregnancy if need be.
• Mycophenolate mofetil is contraindicated during pregnancy. There should be 6 weeks between the last dose and stopping contraception.
• The use of eculizumab during pregnancy is not recommended. There should be 3 months between the last infusion and stopping contraception.
• Available evidence on eculizumab during pregnancy is lacking; data from other indications are reassuring, according to Prof. Vukusic.

1. Vukusic S, Marignier R, Ciron J, et al. Pregnancy in women with neuromyelitis optica spectrum disorders: recommendations from the French multiple sclerosis society. Abstract O052, ECTRIMS 2022, 26–28 October, Amsterdam, the Netherlands.
2. Vukusic S, et al. Mult Scler. 2022;13524585221130934.

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Posted on 20 December 202216 February 2024