Abortion ban may mean denial of effective drugs for women with MS, migraine, epilepsy

The dissolution of Roe v. Wade is expected to lead to abortion bans or severe restrictions in as many as 28 states. These new restrictions may have life-changing and even life-threatening consequences in these states for women of childbearing age with conditions like migraine, multiple sclerosis (MS) and epilepsy.

In their perspective article, publishing in JAMA Neurology on July 13, 2022, neurologists from UC San Francisco focus on the hazards that abortion restrictions pose to women of reproductive age, who are disproportionately affected by these conditions, and the medications that treat them. These include drugs that have not been shown to be safe during pregnancy, and so-called teratogenic drugs that are linked to birth defects in the developing embryo and fetus.

"In a climate of increased limitations on reproductive rights, whereby pregnancies cannot be reliably timed or prevented, neurologists might possibly restrict use of the effective medications that are standard care for other patient groups because of potential concerns about causing fetal harm," writes corresponding author Sara LaHue, MD, of the UCSF Department of Neurology and the Weill Institute for Neurosciences. "This could increase risk of morbidity, mortality and irreversible disability accumulation for women with neurologic diseases."

Women with some neurological conditions, including epilepsy, face an increased likelihood of unplanned pregnancy, since certain treatments may reduce the efficacy of hormonal contraceptives. For those patients with status epilepticus, a type of seizure that may lead to brain damage or death, valproic acid, a teratogen, may be required to stop the seizures.

Other teratogenic drugs include methotrexate and mycophenolate mofetil, which treat autoimmune disorders like MS and myasthenia gravis. "Even if prescribed for a neurological condition, there are reports from patients across the country stating they are now unable to access methotrexate because it can also be used to induce abortion," said LaHue.

Some medications ruled out for all women of reproductive age

"Teratogenic drugs are only prescribed when it is possible for women to plan pregnancies and prevent fetal exposure. However, controlling the timing of teratogenic medication use may not be feasible in the short term," said LaHue, referring to status epilepticus, encephalitis and vasculitis.

Monoclonal antibody treatments are prescribed for patients with migraine, MS and myasthenia gravis, but may not be safe during pregnancy. Some neurologists may rule out these medications for all women of reproductive age, according to the authors.

"In many settings, women with MS are treated with less effective therapies, because these medications are perceived to be safer in pregnancy," said co-author Riley Bove, MD, MSc, of the UCSF Department of Neurology and the Weill Institute for Neurosciences. "Often, neurologists are not familiar with how to time or optimize certain medications, or of their updated safety profile. The reversal of Roe v. Wade may reinforce decisions to stick with the less effective therapies, which may result in irreversible disability for some women with MS."

Availability of reproductive health is "integral to equitable delivery of neurologic care," the authors conclude. Equity in care depends on the unrestricted liberty to make personal decisions affecting bodily autonomy, including "optimization of fertility windows, personal determination of pregnancy timing to limit disease progression or exacerbation, and pregnancy termination if necessary for the health of the mother, the fetus or both."