How is myasthenia gravis (MG) managed during pregnancy?

Updated: Aug 27, 2018
  • Author: Abbas Jowkar, MD; Chief Editor: Nicholas Lorenzo, MD, MHA, CPE  more...
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Answer

In an review of literature involving 322 pregnancies in 225 myasthenic mothers, 31% had no change in their myasthenic symptoms, 28% improved, and 41% deteriorated during pregnancy.{Plauche WC. Myasthenia gravis in mother and their new-borns. Clin Obstet Gynecol 1991;34:82-99}. Of the pregnant myasthenic mothers, 30% had exacerbation of the disease in the post-partum period. In general, pyridostigmine and, if needed, prednisone are used, whereas other immunomodulating agents are avoided if possible beause of teratogenic concerns.

Current information indicates that azathioprine and cyclosporine are relatively safe in expectant mothers who are not satisfactorily controlled with or cannot tolerate corticosteroids. Current evidence indicates that mycophenolate mofetil and methotrexate increase the risk of teratogenicity and are contraindicated during pregnancy. (These agents previously carried Food and Drug Administration [FDA] Category C (cyclosporine), D (azathioprine and mycophenolate mofetil), and X (methotrexate) ratings.) The FDA has recently discontinued this rating system, and replaced it with a summary of the risks of using a drug during pregnancy and breastfeeding, along with supporting data and relevant information to help health care providers make prescribing and counseling decisions. Although this statement achieved consensus, there was a strong minority opinion against the use of azathioprine in pregnancy. Azathioprine is the nonsteroidal immunosuppressant of choice for MG in pregnancy in Europe but is considered high risk in the United States. This difference is based on a small number of animal studies and case reports.


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