Multiple Sclerosis – Management and Disease Modulation in Pregnancy

This review explores the evolving approach to managing multiple sclerosis (MS) in pregnancy, highlighting current evidence on disease-modifying therapies (DMT), clinical monitoring, and postpartum care. Given the unique immunologic changes of pregnancy and the increasing number of patients on DMTs at conception, there is a growing need to clarify treatment goals, safety profiles, and counseling strategies for this population.

Emerging data suggest pregnancy is a protective state against MS disease activity, particularly in the second and third trimesters. However, the postpartum period carries a heightened risk of relapse, promoting careful planning for DMT resumption and postpartum monitoring. Safety data now support continued or early-pregnancy use of glatiramer acetate, interferon beta, and several monoclonal antibodies. In contrast, fingolimod, teriflunomide, and mitoxantrone remain contraindicated due to potential fetal risks.

MS should not be considered a contraindication to pregnancy. With appropriate counseling and coordination, most patients can anticipate low-intervention pregnancies. When clinically indicated, certain DMTs may be continued through conception or resumed postpartum with minimal fetal or infant risk. Treatment decisions should be guided by disease severity, DMT pharmacokinetics, and pregnancy timing. Delivery planning, anesthesia considerations, and peripartum care require multidisciplinary coordination, emphasized by shared decision-making throughout the pregnancy continuum.