DIAGNOSIS: DEVIC DISEASE
Also known as neuromyelitis optica, Devic disease, a demyelinating condition, is considered a variant of multiple sclerosis (MS); it involves the optic nerves and the spinal cord, sparing the brain. The acute treatment includes high dose steroids or plasmapheresis. The long-term management of Devic disease is the same as that of MS—disease-modifying therapies (DMTs) can be used chronically to prevent progression and relapses.
Pregnancy and the postpartum period are common times of disease exacerbation, and the first signs of disease can occur during pregnancy or the first year after delivery1. It is unclear whether this patient’s vision complaints over the past few years are related to the optic neuritis.
At the time of her diagnosis, this patient was breastfeeding her baby and regularly pumping milk. It was decided that she would be treated with a course of high dose steroids for her exacerbation, and she discontinued breastfeeding. Her paresthesias improved within a few days, but her vision did not improve right away. About a week after treatment, the vision in her left eye began to improve, but not completely.
After the course of steroids was complete, she was given the option of initiating a DMT. She wanted to have another baby within the next few years, and she was concerned about the possible effects of a DMT on a future pregnancy. Thus, she decided to postpone initiation of DMT treatment.
The patient returned after four months, at which time she was eight weeks pregnant. She had decided at the time of her diagnosis that she would not try to postpone a future pregnancy. There is a risk of Devic’s exacerbation during pregnancy, and experts suggest that immunosuppressive therapy is safe during pregnancy.2 Additionally, Devic disease can increase the risk of adverse pregnancy outcomes, such as miscarriages and and pre-term births.3
Nevertheless, the patient opted not to use a DMT during her pregnancy despite these risks. Near the end of her pregnancy, she began to experience a recurrence of paresthesias and visual changes. She opted not to use DMT or immunosuppressive therapy during the remainder of her pregnancy, and her symptoms did not worsen or resolve. Her pregnancy and delivery were otherwise uncomplicated. About three weeks after she delivered her healthy full-term baby boy, she was treated with a course of high dose steroids and experienced substantial improvement of her symptoms. She then opted to start using a DMT for treatment of Devic disease.
At a one-year follow up visit, she had not experienced any further symptoms or exacerbations and remained on her DMT.
• Pregnancy influences symptoms of MS and variants such as Devic disease.
• Treatment for MS is considered safe during pregnancy and can help prevent exacerbations.
• Women who are of childbearing age often base their decisions about DMTs and immunosuppressive therapies on their plans to become pregnant, and thus they may not follow medical advice.
1. Tong Y, Liu J, Yang T, et al. Influences of pregnancy on neuromyelitis optica spectrum disorders and multiple sclerosis. Mult Scler Relat Disord. 2018;25:61-65.
2. Wuebbolt D, Nguyen V, D'Souza R, Wyne A. Devic syndrome and pregnancy: A case series. Obstet Med. 2018;11:171-177.
3. Shi B, Zhao M, Geng T et al. Effectiveness and safety of immunosuppressive therapy in neuromyelitis optica spectrum disorder during pregnancy. J Neurol Sci. 2017;377:72-76.