Progress in the management of pregnancy in patients with neuromyelitis optica spectrum disorder

Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune astrocytopathy characterized by autoantibodies against aquaporin-4 (AQP) that predominantly affecting women of childbearing potential. Unlike multiple sclerosis, NMOSD poses a higher risk of severe and irreversible postpartum relapse, making pregnancy a significant concern in affected women. Historically, in Japan, immunosuppressive treatments were contraindicated in women who could become pregnant, leading many to discontinue therapy before conception. This often resulted in relapse and sometimes required pregnancy termination or abandonment. At present, immunosuppressants such as azathioprine, tacrolimus, and cyclosporine are considered beneficial during pregnancy. Five monoclonal antibody therapies have now been approved and are covered by national insurance for the treatment of NMOSD. These developments have expanded treatment options, enabling safer pregnancies and allowing more women with NMOSD to consider childbirth. To ensure optimal outcomes, individualized, evidence-based treatment plans are essential. Shared decision-making between patients and healthcare providers is critical, particularly when evaluating the safety of monoclonal antibody therapies during pregnancy and their potential impact on fetal development. This review outlines recent insights into the impact of NMOSD on patients of childbearing age, including family planning, postpartum management, and breastfeeding. It emphasizes the importance of balancing disease control with reproductive goals through informed and collaborative care strategies that also encompass AQP4-antibody-negative NMOSD and myelin oligodendrocyte glycoprotein antibody-associated disease.