Management of Multiple Sclerosis During Pregnancy and the Reproductive Years in 2026: An Expert Clinical Review.

Women's neurology and obstetrics/gynecology experts convened to consolidate the best available evidence on multiple sclerosis (MS) management in reproductive-aged women, especially regarding the use of MS disease-modifying therapies (DMTs) surrounding pregnancy and lactation. To update 2014 clinical recommendations, an expert clinical review informed by a systematic literature search of PubMed, LactMed, and ClinicalTrials.gov was conducted utilizing keywords "multiple sclerosis" and "pregnancy." A total of 774 papers were screened for inclusion. To provide updated guidelines, two reviewers prioritized studies according to strength of evidence and relevance to validating/updating our clinical management recommendations. To provide updated information about pregnancy and lactation safety of available MS DMTs, an additional reviewer synthesized all available studies. All authors then reviewed data to craft consensus guidelines. We encourage collaborative care models to optimize symptom control, social support, and maternal wellbeing before, during, and after pregnancy. In most cases, MS is not associated with increased risks of adverse pregnancy outcomes, although some studies have reported slightly elevated risks of lower birthweight, preterm birth, and operative delivery. With appropriate monitoring, MS disease activity can often be minimized throughout the childbearing period by continuation or strategic timing of many DMTs to optimize maternal disease control while minimizing fetal risk. The postpartum period represents a period of increased medical and psychological risk, and close follow-up is recommended. After childbearing is complete, gynecological care can shift to prevention and management of gynecological complications (DMT-associated infections and risk of cervical dysplasia) and of the menopausal transition.