Relapse activity during pregnancy and the postpartum year is associated with accelerated disability progression in multiple sclerosis

Management of multiple sclerosis (MS) presents unique challenges during pregnancy, particularly regarding disease-modifying therapies (DMT) and the risk of postpartum relapses. We investigated DMT exposure and further clinical and radiological parameters to identify predictors of relapse and disability progression during pregnancy and the postpartum year. We identified 112 pregnancies in 70 women with MS followed between 2010 and 2023. After excluding pregnancies lasting <22 weeks, 96 pregnancies in 66 women, primarily with relapsing-remitting MS (RRMS), were included in the analysis. 77 pregnancies (80.2 %) developed during DMT exposure, with natalizumab, injectables, and fumarates being the most common. Relapse during pregnancy or the postpartum year occurred in 33 pregnancies, with 39.5 % happening during pregnancy and 60.5 % in the postpartum year, peaking in the first postpartum trimester. Women with pregnancies complicated by relapses during pregnancy or the postpartum year had lower rates of DMT exposure (66.7 % vs. 87.3 %, p = 0.016) and a non-significant trend toward higher baseline disability at conception. Disability progression within the first postpartum year was more frequent in the relapse group (25.8 % vs. 5.5 %, p = 0.010), with sustained differences in EDSS at two years postpartum. Postpartum MRI showed higher lesion load and more contrast-enhancing lesions in the relapse group. Spinal lesions at diagnosis and prior to conception were associated with significant higher risk of relapse during pregnancy and the postpartum year. Subgroup analysis of pregnant women treated with natalizumab indicated a lower relapse risk when natalizumab was continued into the third trimester. Pregnancy outcomes were mostly favorable, with 95.4 % term births and no significant differences in delivery mode or neonatal outcomes between women with versus without relapses during pregnancy. Our findings emphasize the importance of DMT management, particularly the potential benefits of sustained natalizumab therapy for high-risk pregnancies. These results highlight the need for tailored treatment strategies to minimize postpartum relapses and long-term disability progression for women with MS.