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Advances in disease-modifying and symptomatic treatments over recent years have revolutionised neurological care. We are now able to offer our patients a range of therapies, with modern treatment paradigms demonstrating the benefit of early treatment for many long-term neurological conditions.
A shift towards earlier treatment means that patients and clinicians must increasingly consider family planning in their treatment decisions. Neurologists are well aware of the avoidable harms to the developing fetus associated with taking medication in pregnancy. Fetal valproate syndrome and the markedly increased risk of adverse long term neurodevelopmental outcomes following in utero valproate exposure have necessitated pregnancy prevention programmes and led to class action lawsuits. However, there is also a risk of avoidable harms resulting from delays in starting or from withdrawing medication because of pregnancy. For those with epilepsy, suboptimal management may contribute to uncontrolled seizures, a leading cause of maternal morbidity and mortality in the UK.1 For those with multiple sclerosis (MS) reactivation and severe relapses may follow the withdrawal of certain disease modifying therapies, such as natalizumab and fingolimod, for pregnancy.2
Across all specialities, it is estimated that more than 80% of pregnant patients receive at least one medication during pregnancy; 17% take medication for chronic conditions. Despite this, the vast majority of medications have no evidence-based safety data specific to pregnancy.3 Pregnant women and those considering pregnancy are systematically excluded from most clinical trials, meaning …
Contributors This editorial was commissioned. RD wrote the initial draft with subsequent input from all authors.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests RD and PB are on the steering committee for the UK MS Pregnancy Register, which seeks to improve our understanding of the safety of DMT in pregnancy. RD has received honoraria for sitting on advisory boards from Roche and Novartis. She sits on the steering committee for the MINORE and SOPRANINO studies, which are examining the safety of ocrelizumab in pregnancy and breastfeeding. She receives grant support from the UK MS Society, BMA foundation, NIHR, MRC, NMSS, Horne Family Charitable Trust, Biogen, Celgene, and Merck. She has received honoraria for advisory boards and/or educational activities from Biogen, Teva, Sanofi, Merck, Janssen, Novartis, and Roche. CO consults for Mirum Pharmaceuticals. KM reports honoraria for advisory boards/educational activities from Biogen, Roche, Merck, Teva, Novartis, Sanofi. JM has received advisory boards fees from Novartis, Sanofi, Roche and Merck PB has received honoraria for advisory boards and/or educational activities from Merck, Biogen, Roche, MS Academy, Janssen, Sanofi-Genzyme, Teva and MedDay Pharmacuticals.
Provenance and peer review Commissioned. Externally peer reviewed by Angela O’Neal, Boston, USA.