Pregnancy Planning and Management in Multiple Sclerosis: A Clinical Conversation with Ingrid Loma-Miller, MD

The Neuroimmunology and Pregnancy Clinic within the UPMC Multiple Sclerosis Center, led by Ingrid Loma-Miller, MD, assistant professor of neurology at the University of Pittsburgh School of Medicine and assistant chief of the Division of Neuroimmunology/MS, provides specialized, longitudinal care to women living with neuroimmunologic conditions who wish to become or who are pregnant.

The complexities of caring for this patient population are such that a dedicated clinic like the one created by Dr. Loma-Miller is not a ‘nice to have’ but a necessary construct to ensure the health of the woman and baby – before, during, and immediately after pregnancy.

In the interview that follows, Dr. Loma-Miller discusses some of the complexities that arise between pregnancy and neuroimmunologic conditions and the care dynamics in the clinic to help educate the physician community.

How has Pregnancy Management in Multiple Sclerosis Changed in Recent Years?

Dr. Loma-Miller:

Pregnancy management in MS and related conditions now hinges on maintaining disease control while planning optimal treatment timing around conception, pregnancy, and the postpartum period. Rather than approaching pregnancy as a time when therapy must be avoided, clinicians increasingly focus on how medication pharmacology, disease activity, and relapse risk intersect across the different stages of pregnancy.

In the past, women with MS were often told to stop therapy if they wanted to become pregnant, and that meant accepting a higher risk of relapse. Maintaining disease control during pregnancy is critically important, and we have more information that allows us to do that safely.

For many patients, this means entering pregnancy with stable disease and a defined treatment plan rather than making adjustments after conception, if at all possible. Decisions may include continuing therapy until pregnancy is confirmed, timing medication dosing to reduce exposure later in pregnancy, or planning postpartum treatment resumption in advance to reduce relapse risk after delivery. These decisions depend on both the underlying disease course and the characteristics of individual therapies, which differ in how long they remain active and when fetal exposure is most likely to occur.

This shift has changed counseling conversations with patients. Discussions now focus on planning across the entire pregnancy timeline, including preconception stability and postpartum relapse prevention, rather than treating pregnancy as a separate period from ongoing disease management.

We spend a lot of time helping patients understand that pregnancy itself is not harmful for MS. The challenge is managing treatment around pregnancy so that patients remain stable before, during, and after delivery.

What Are the Most Important Considerations Before Conception for Patients With MS or Related Neuroimmunology Disorders?

Dr. Loma-Miller:

The biggest thing is making sure patients are stable before they become pregnant. If someone goes into pregnancy with active disease, their risk of relapse after delivery is higher, so we try to make treatment decisions ahead of time rather than after pregnancy has already started. Ideally, patients want to be stable and relapse-free for at least a year before becoming pregnant. That stability decreases the risk of relapse after delivery, which is the period we worry about the most. A lot of the preconception work in the clinic is planning. We are looking at what therapies they are on, how long it stays active, and whether we need to adjust timing so they can stay controlled through pregnancy and into the postpartum period.

As an example, women with MS may have a higher risk for infertility compared to the general population. The research on this is evolving but what I would say is that women with MS who are having trouble with conception may want to seek fertility consultations earlier than what would typically occur with someone having difficult becoming pregnant.

We also spend time talking about fertility and pregnancy timing because those decisions affect treatment planning. Some patients are pursuing fertility treatments, and that adds another layer of coordination around when medications are given and how we monitor them. It is easier to do that before conception than once someone is already pregnant.

Vitamin D comes up frequently because patients ask what they can do ahead of pregnancy to reduce risk. There is data suggesting vitamin D deficiency is associated with an increased risk for the baby to develop MS later in life, so we check levels and correct deficiency as part of overall pregnancy preparation.

A lot of what we’re doing in that stage is helping patients understand the timeline. What happens before pregnancy, what changes during pregnancy, and what the plan is after delivery so that there aren’t unexpected decisions later on.

How do Treatment Decisions Change During Pregnancy?

Dr. Loma-Miller:

Once a patient becomes pregnant, the discussion shifts to how medication exposure changes across the pregnancy itself. Different therapies behave differently during pregnancy, and timing becomes important because fetal exposure is not the same in early pregnancy as it is later on. A lot of our decision-making is based on understanding when medications cross the placenta and how that affects both maternal disease control and fetal risk.

One thing patients are often surprised by is that placental transfer of many medications is limited early in pregnancy because the fetus has yet to develop receptors for these agents. That means, for some patients, continuing a therapy into early pregnancy may be appropriate, depending on the medication and their disease history. Those decisions are individualized, and they’re usually part of the plan that was established before conception.

We also talk about what happens if symptoms change or if a relapse occurs during pregnancy. Most patients do well neurologically during pregnancy. In fact, the risk of a relapse has been shown to decrease, but relapses can still happen, and patients want to know ahead of time how those situations would be managed and what effect it would have on their developing baby. Having that discussion early helps avoid urgent decisions later and gives patients a clear understanding of what to expect.

Another part of management during pregnancy is coordination with obstetrics and maternal fetal medicine (MFM). Questions about imaging, medication adjustments, and symptom management often come up, and those decisions are made in the context of both neurologic and obstetric considerations.

The goal is to allow pregnancy to proceed normally while continuing to monitor for neurologic changes and preparing for the transition into the postpartum period, when relapse risk increases again. For example, there are no known contraindications with the usual forms of anesthesia given during the birth process. However, if a patient needs and MRI for any reason, they absolutely must not receive it with contrast due to possible fetal effects. We also know that women with MS have a slight increase in risk for preterm births, but we do not see increases in risk or incidence for things like preeclampsia, chorioamnionitis, or postpartum hemorrhage.

Fortunately, at UPMC we have access to and collaborate closely with our obstetrics and MFM providers at UPMC Magee-Womens Hospital who are some of the very best in the country at managing challenging pregnancy dynamics. It is very much a team effort when it comes to neuroimmunology disease and pregnancy.

What Happens After Delivery, and How Does Postpartum Management Differ as a Distinct Temporal Period for Women with MS and Other Similar Conditions?

Dr. Loma-Miller:

The postpartum period is when we pay the closest attention from a neurologic standpoint because relapse risk increases after delivery. The risk for relapse is most acute during the first several months and can also be affected by younger age, the number of relapses before and during pregnancy, and many other factors.

We talk ahead of time about when therapy will be restarted and how that fits with a patient’s plans for breastfeeding. Some medications are compatible with breastfeeding, while others require different timing or a change in therapy, so those discussions usually happen before delivery rather than afterward. That allows patients to make informed decisions about feeding plans and treatment without feeling rushed during the postpartum period

Fatigue, sleep disruption, and recovery after delivery can also make it harder for patients to recognize early neurologic symptoms, so we encourage close follow-up during that time. The goal is to identify changes early and restart or adjust treatment in a way that reduces the likelihood of relapse while allowing patients to recover from delivery and adjust to caring for a newborn.

A lot of reassurance is also part of these visits. Patients often worry that pregnancy will permanently worsen their MS, and we spend time explaining that the concern is really about timing — understanding that risk temporarily increases after delivery and having a plan in place to manage that period safely.

How Does Research and Collaboration Continue to Inform and Evolve the Care of Women with MS During Pregnancy?

Dr. Loma-Miller:

A lot of what we know about managing MS during pregnancy comes from observational data rather than randomized trials, so collaboration across centers is important. Individual clinics may only see a limited number of pregnancies each year, and larger registries allow us to better understand medication exposure, relapse risk, and long-term outcomes over time. That’s part of the reason we participate in collaborative efforts like NEU-RING, where data from multiple centers can be combined to improve how we counsel patients, conduct studies, and create new treatment guidelines using the latest evidence-based medicine.

Patients are often interested in contributing to that work because many of the recommendations we use today exist as a result of prior patients who agreed to share their outcomes and participate in research. Continuing to collect that information helps refine treatment decisions and allows counseling to become more precise for future patients.

It also helps us address what are known gaps in care in this patient population. We know that certain unrepresented groups like black and Hispanic women have significant disparities in terms of pregnancy outcomes in general. Layer into that a diagnosis of MS or another neuroimmunology condition and it becomes more challenging because the research shows these population tens to have more aggressive MS with higher relapse rates. Understanding these kinds of dynamics that exist can help us prepare for them, treat them more aggressively, and work to put into place safeguards for mitigating the downstream consequences to whatever degree possible.

How Does the MS and Pregnancy Clinic Work with Referring Neurologists and Obstetric Providers?

Dr. Loma-Miller:

Most patients continue seeing their primary neurologist throughout pregnancy. The goal of our clinic isn’t to replace that relationship, but to provide additional guidance during a period when treatment decisions become much more complex for the mother and baby. Pregnancy introduces questions around medication exposure, relapse risk, and postpartum planning that many neurologists may not encounter frequently.

Communication between providers becomes especially important when treatment adjustments are being considered. Decisions around medication timing, imaging, or relapse management often involve input from multiple specialties, and part of our clinic’s role is helping align those decisions, so patients receive consistent guidance.

After the pregnancy and postpartum period, patients generally transition fully back to their usual neurologic care. The goal is to support patients during a defined period when subspecialized guidance is helpful, while maintaining continuity with the physicians who manage their long-term care.

For Referring Physicians: Contact Information for Referrals and Consultations

For physicians who have patients considering pregnancy or who are already pregnant and have questions about management, referrals can be made for consultation during pregnancy planning, pregnancy itself, or the postpartum period. The goal is to provide guidance during that time and coordinate care with the patient’s existing neurologist and obstetric team.

For more information, visit the UPMC Multiple Sclerosis Center or contact the center for referrals and consultation at 412-641-6600.