MANAGING MULTIPLE SCLEROSIS IN PREGNANCY

Managing Multiple Sclerosis (MS) in Pregnancy

How common is this situation- pregnancy in women with MS?

MS is most often diagnosed between the ages of 20 to 40 years. This is the age when most women plan their pregnancies. Therefore, it is very common to find women with MS, who are pregnant or those who are planning pregnancy.

Which is a better option- starting MS treatment and then planning pregnancy or delaying MS treatments until after completing family?

MS is characterized by multiple relapses (when new symptoms occur). With each relapse, the disability increases. These relapses are often more frequent in the initial years after diagnosis of MS. Disease modifying drugs (DMD) can reduce relapses and disability. Therefore, it is always better to start DMD and then plan pregnancy. One should not postpone starting DMD after pregnancy/delivery.

How does pregnancy affect MS?

Pregnancy does not affect MS in the first trimester.

The MS relapses are lesser in 2^nd and 3^rd trimesters, which is good news.

However, the relapses become more frequent in the post partum period (after delivery) and this higher risk persists until 6 months after delivery.

How does MS affect pregnancy?

By and large, there are no adverse effects of MS on pregnancy. Women with MS have no extra risk of miscarriage or birth defects in their babies; as compared to women without MS. The mode of delivery too need not be altered just because the patient has MS.      

MS has no direct effect on fertility. Women with MS may have sexual dysfunction resulting in lesser libido. Male partners who have MS may suffer from erectile dysfunction.  

What MS medications are safe in pregnancy?

No DMD has yet been tested in pregnancy and hence none can be declared safe. However, recent evidence suggests that some DMDs are less risky than others. Less risky DMDs in pregnant women with MS include beta interferons (Avonex, Rebif, Betaseron) and Glatiramer acetate.

For prospective fathers, beta interferon and Glatiramer acetate as DMD showed no risk to baby’s health. Teriflunomide is detected in semen and it should be discontinued before trying to conceive.

Steroids can be safely used to treat MS relapses during pregnancy.

Will babies born to women with MS have a higher risk of getting MS themselves?

Most cases of MS are sporadic and most women with MS do not have a history of MS in their family members. However, having a relative with MS does slightly increase the risk of being diagnosed with MS.

In UK, the lifetime risk of being diagnosed with MS in general population in 1 in 330. The risk increases to 1 in 48, if one of the first degree relatives has MS. If one of the second-degree relatives has MS, the risk of being diagnosed with MS is 1 in 100.

an women with MS breastfeed?

Breastfeeding is safe and can be continued as usual.

What impact does pregnancy have on the course of MS?

There is limited data on this topic. However, in one study, pregnancy and childbirth were associated with lesser chances of developing severe disability. Women who gave birth at any time (either before or after the onset of MS) were 34% less likely to develop severe disability (as defined by need to use walking aid).

(For more reading, Multiple sclerosis Trust, UK)

Dr Sudhir Kumar MD DM
Consultant Neurologist
Apollo Hospitals, Hyderabad
04023607777
drsudhirkumar@yahoo.com

MYASTHENIA GRAVIS

MYASTHENIA GRAVIS

Introduction

Myasthenia gravis is an uncommon auto-immune disease, characterised by muscle weakness.

Common symptoms of Myasthenia Gravis

Myasthenia gravis presents with symptoms due to weakness of various muscles. 

Common presentations of this include:

1. Drooping of one or both eyelids (usually, there is a difference in the degree of eyelid drooping). Drooping of eyelid is also called as ptosis. 

2. Double vision, on looking up, down, left, right or sideways.

3. Slurring of speech or nasal twang in voice,

4. Difficulty in chewing food,

5. Difficulty in swallowing food, or nasal regurgitation of liquids, 

6. Weakness of arms or legs,

7. Breathing difficulty,

8. Difficulty in holding neck straight (tends to droop forwards)

Please note

The sensations are normal in the affected parts of body.

Urinary and bowel control is preserved. 

Please also note

1. Symptoms may vary at different times of day, most often they are worse in evenings,

2. There is fatiguability, symptoms get worse on repeating the same movements,

3. There may be periods (days to weeks) of remission, when all symptoms seem to disappear, only to return back later. 

The following factors may trigger or worsen exacerbations:

• Bright sunlight
• Surgery
• Immunization
• Emotional stress
• Menstruation
• Intercurrent illness (eg, viral infection)
• Medication (eg, aminoglycosides, ciprofloxacin, chloroquine, lithium, phenytoin, beta-blockers, statins)

How do we confirm the diagnosis of myasthenia gravis?

1. Clinical symptoms, as described above make us suspect a diagnosis of MG, 

2. Tensilon test- where tensilon (edrophonium) injection is given, after which there is temporary improvement of symptoms such as ptosis,

3. Repetitive nerve stimulation- This test in done in the electrophysiology laboratory, where the muscle fatigue is shown (by seeing reduced amplitude with repeated stimulation of muscles),

4. Anti-Acetylcholine receptor antibody levels are elevated in about 80% of people. These antibodies are supposed to be released from thymus gland (located behind the upper chest wall in the centre). These antibodies prevent the action of acetylcholine on the muscles, making them weak. 

5. CT scan of chest is done to look for enlargement or tumor in thymus gland. 

6. Other less common antibodies seen in some patients with MG are anti-straited muscle antibody, anti-MuSK antibody, and anti-striational antibody.

What is the medical management of Myasthenia Gravis?

The medical management is classified into two categories:

1. Symptomatic treatment- to improve the symptoms. Pyridostigmine is commonly used.

We usually start a dose of 60 mg two times daily, and the maximum dose can be unto 720 mg per day.

Common side effects include increased salivation, abdominal pain and cramps, diarrhoea, muscle twitchings, etc.

2. Definitive treatment- is used to suppress the antibodies.

Steroids are commonly used. 

Other agents used are azathioprine, mycophenolate, cyclosporine, methotrexate, and cyclophosphamide.

3. In patients with myasthenic crisis (severe disease requiring feeding tube due to swallowing problem), or requiring mechanical ventilation (due to respiratory distress), PLASMAPHERESIS (blood is purified, and antibodies are removed, something similar to dialysis) or IV IMMUNOGLOBULINS (injections are given by drip over five days) are required.

4. THYMECTOMY- the best and permanent treatment for MG is thymectomy operation. In this, the thymus gland located behind the sternum bone (chest wall) is removed by operation. This removes the source of antibodies and the disease gets cured in most people.

What is the outcome of myasthenia gravis after treatment?

Earlier, the disease had a high morbidity and mortality, as treatments were not available. However, now, with good treatments available, more than 95% people do well and are fully cured.

I hope this articles helps people with myasthenia gravis as well as their caregivers. I would be pleased to answer any further queries. 

Please send email at drsudhirkumar@yahoo.com 

If anyone prefers ONLINE CONSULTATION, please visit http://bit.ly/Dr-Sudhir-kumar

DR SUDHIR KUMAR MD (INTERNAL MEDICINE) DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HEALTH CITY

Phone (for appointment): 0091-40-23607777 (extension 6634/3011)

Email: drsudhirkumar@yahoo.com 

Online consultation: http://members.tripod.com/sudhirkumar_5/neurologist/id6.html

FACIAL PALSY (BELL'S PALSY)

FACIAL PALSY (BELL'S PALSY)

What is Bell's palsy?

Bell's palsy refers to unilateral (one side) paralysis of muscles of face.

What are the symptoms of facial palsy?

Facial palsy causes weakness of facial muscles. So, patients may face the following problems:

1. Difficulty in closing the eye, so, the eye on affected side may look bigger.

2. Difficulty in frowning, leading to absence of wrinkles over forehead on the affected side.

3. Difficulty in blowing out cheeks (air leaks out on the affected side).

4. Watering of eye on the affected side,

5. Difficulty in chewing food, food may get stuck within the mouth on the affected side

6. Facial asymmetry, face may seem to get pulled to the normal side.

Other symptoms may include:

1. Loss of taste on the affected side,

2. Faint sounds may also seem louder (hyperacusis)

3. Headache, facial pain and neck pain may occur on the affected side. The pain may start a few days prior to the onset of facial paralysis. 

How does facial palsy start?

Symptoms of facial palsy starts suddenly over hours, so, it is very alarming for the patient. At the onset, patient may have pain behind the ear, in the neck, or the head on the side of paralysis. Symptoms are minor in the beginning, so, they often get noticed first by others or may be noticed on looking into a mirror.

What should be done, if one suspects facial palsy?

There is no need to panic, as it is a benign condition, and often improves over time. One should first consult their family physician or GP and subsequently a neurologist. Care should be taken to avoid any dirt entering the eye (as the eye can not be properly closed) to prevent corneal (a part of eye) infection.

What are the causes of facial palsy?

Bell's palsy is idiopathic (no definite cause has been identified). However, research has shown that it is often caused by viral infections such as herpes simplex. Facial palsy is more common in people with diabetes mellitus and in pregnant women. Patients with facial palsy often give a history of exposure to cold prior to the onset of symptoms (such as direct exposure of AC wind, going out at night or early morning, or long road journey with open windows), but their role in causing facial palsy has not been proven.

Other causes of facial palsy may include brain stroke (decreased blood supply to brain), tumors, other infections, trauma, infections of ear, etc.

What investigations would the doctor ask in facial palsy?

• Generally, no investigations are necessary as the diagnosis of facial palsy is obvious on clinical examination.
• However, brain scan (CT or MRI) may be done if one suspects brain stroke or tumors.
• Blood sugar should be checked to exclude diabetes mellitus.
• Nerve conduction studies (NCV/EMG) may be done to estimate the extent and severity of facial nerve involvement and in some cases to predict the outcome of facial palsy.
• In patients with recurrent facial palsy, certain blood tests may be done to look for the presence of disorders like collagen vascular diseases or vasculitis.

How is facial palsy treated?

Medical management of facial palsy may include the following:

1. Anti-viral drugs: Aciclovir tablets (2000 mg per day in divided doses) are given for 7-10 days.

2. Corticosteroids: Prednisolone 50-60 mg per day for 5-10 days are helpful in speeding the recovery. 

3. Vitamins: Mecobalamin (vitamin B12), alpha lipoic acid, etc are given to speed up recovery and regeneration of the facial nerve.

4. Physiotherapy: includes facial exercises, massage, and electrical stimulation of the facial nerve.

What is the prognosis of facial palsy?

• As earlier mentioned, facial palsy is not a serious condition and most patients recover well. Almost 60-70% patients recover in 3-4 weeks and the remainder in another few months.
• Less than 5% patients either do not recover or recover only partially.
• Facial palsy does not lead to death.
• Facial palsy usually does not recur, and recurrence is seen in only about 2-5% of cases.
• Patients with residual palsy may have facial asymmetry and they may consult cosmetologist/cosmetic surgeon for correction of asymmetry.

Miscellaneous questions about facial palsy

1. Is it contagious?

No, facial palsy does not spread from one patient to another, so, isolation is not required.

2. How common is Bell's palsy?

It is quite common and I see about 5-10 new cases per month.

3. Is Bell's palsy hereditary?

No

DR SUDHIR KUMAR MD (MEDICINE) DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, HYDERABAD, INDIA

Email: drsudhirkumar@yahoo.com

Phone: 040-23607777/60601066
Facebook: www.facebook.com/bestneurologist