Neuromyelitis optica (NMO): treatment during pregnancy

Background: NMO is a demyelinating autoimmune disorder of the CNS which affects the optic nerves and the spinal cord. Method: review based on papers from 2016 to 2020. Platforms used: MEDLINE and Pubmed. The descriptors: “NMO” AND “Treatment”. Objective: to review therapeutic approaches and restrictions for NMO during pregnancy. Case report: G.V.L, 17 years, 23 weeks pregnant, diagnosis of NMO in Dec/2020, with progressive loss of visual acuity and limbs paresthesia. The patient received intravenous methylprednisolone pulses 1g/5 days, followed by 7 sessions of plasmapheresis (PLEX), showing partial symptoms remission, prednisone 60 mg was maintained. March/2021: she presented symptoms reissue, cranial MRI w/o: nerves signal alteration, chiasma and bilateral optical tracts. Spine MRI w/o: slight signal alteration in the dorsal root of the spinal cord, which extends from C1 to C4. Other 5 sessions of PLEX were attempted, without improvement. Results: during pregnancy, intravenous glucocorticoid, Rituximab and Eculizumab proved to be safe in the treatment of NMO. PLEX is indicated in cases of remissions resistant to medications. The therapy with immunosuppressants, such as methotrexate, mycophenolate mofetil and mitoxantrone, isn’t recommended. These immunosuppressants can cause miscarriage or pose a risk to the fetus. However, the immunosuppressant azathioprine has a safety profile in pregnancy; furthermore, it is considered the most appropriate maintenance treatment in combination with prednisone. Conclusion: due to the risk of miscarriage and teratogenicity, NMO treatment during pregnancy is restrict to intravenous glucocorticoids, rituximab and eculizumab, and in specific cases PLEX.