http://neurology.medscape.com/Medscape/Neurology/AskExperts/MS/2001/06/NEUR-ae85.html

Question

Is it safe to give IV steroids for first attack of multiple sclerosis (hemisensory symptoms) to a 28-year-old woman in her 19th week of pregnancy with evidence of demyelination on cervical MRI?

Response
from Rohit Bakshi, MD, 05/08/01

The safety of high-dose intravenous methylprednisolone (IVMP) for pregnant patients with demyelinating disorders is not established. I would use it only when the benefits clearly outweigh the risks. I always involve the patient's obstetrician in the decision-making process and document that the patient has been advised of the risks of receiving IVMP during pregnancy.

What are the benefits of IVMP in attacks of MS? This question is highly controversial.[1-7] Evidence from clinical trials of exacerbations in patients with established MS and acute optic neuritis in patients with a first attack of demyelination indicate that IVMP accelerates the speed and degree of recovery of neurologic function. There is, however, no evidence of long-term benefit towards neurologic disability associated with the attack. The decision to use IVMP in relapses of demyelination should be based on quality of life, risk to the patient, and overall preattack neurologic functioning.

One possible use of IVMP in pregnancy is for a patient who is experiencing an acute severe attack of demyelination in whom rapid recovery from the attack would provide overall benefit to the pregnancy. A study involving 50 clinical centers in the United States and Canada evaluated long-term benefits of IVMP after a first attack of MS.[8] To be eligible for the study, patients had to present with a first acute clinical demyelinating event (optic neuritis, myelitis, or a posterior fossa syndrome) with at least 2 lesions on brain MRI, 1 of which had to be characteristic of MS (ovoid or periventricular). All patients received a course of IVMP within 2 weeks of the event, along with interferon-beta-1a (n=193) or placebo (n=190) by weekly intramuscular injection. During 3 years of follow-up, the probability of developing MS and new MRI lesions was significantly lower in the treatment group. Fifty percent of placebo patients and 35% of treated patients developed a second demyelinating attack by 3 years.

This study indicates that even with IVMP therapy, many patients will convert to clinically definite MS. After she has given birth and ceased breastfeeding, your patient might benefit from long-term interferon-beta-1a therapy, assuming that the brain MRI shows the appropriate amount and type of lesions.

References

1. Weinstock-Guttman B, Miller DM, Bethoux F, et al. A meta-analysis of methylprednisolone in recovery from multiple sclerosis exacerbations. Mult Scler. 2000;6:267-273.
2. Brusaferri F, Candelise L. Steroids for multiple sclerosis and optic neuritis: a meta-analysis of randomized controlled clinical trials. J Neurology. 2000;247:435-442.
3. Kaufman DI, Trobe JD, Eggenberger ER, Whitaker JN. Practice parameter: The role of corticosteroids in the management of acute monosymptomatic optic neuritis - Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;54:2039-2044.
4. Sharrack B, Hughes RAC, Morris RW, et al. The effect of oral and intravenous methylprednisolone treatment on subsequent relapse rate in multiple sclerosis. J Neurol Sci. 2000;173:73-77.
5. Andersson PB, Goodkin DE. Glucocorticosteroid therapy for multiple sclerosis - a critical review. J Neurol Sci. 1998;160:16-25.
6. Beck RW, Cleary PA, Anderson MM, et al. A randomized, controlled trial of corticosteroids in the treatment of acute optic neuritis. The Optic Neuritis Study Group. N Engl J Med. 1992;326:581-588.
7. Beck RW, Cleary PA, Trobe JD, et al. The effect of corticosteroids for acute optic neuritis on the subsequent development of multiple sclerosis. The Optic Neuritis Study Group. N Engl J Med. 1993;324:1764-1769.
8. Jacobs LD, Beck RW, Simon JH, et al. Intramuscular interferon beta-1a therapy initiated during a first demyelinating event in multiple sclerosis. N Engl J Med. 2000;343:898-904.