Family planning and multiple sclerosis - part 2: Does real-world practice align with Swedish treatment guidelines?

Managing family planning and treatment in women with multiple sclerosis (MS) requires balancing disease control with medication safety. Despite guidelines, practice often adapts to individual needs, with clinicians adjusting disease-modifying therapies (DMTs) to protect maternal and fetal health. This study examines pregnancy-related MS treatment in Sweden.

We identified 130 women (153 pregnancies) from a 2021 online MS questionnaire and linked responses to the Swedish MS register to capture DMT use during three periods: 25 weeks before conception, pregnancy (≈40 weeks), and 25 weeks postpartum. DMTs were classified as "accepted," "discontinuation recommended"-requiring monitoring, or "not recommended" in planned pregnancy.

Before conception, among 153 pregnancies, 26% involved DMTs considered acceptable before and during pregnancy, while 55% involved DMTs for which discontinuation before conception is recommended-of which rituximab accounted for nearly half of all pregnancies (47%, n = 72). Three percent were exposed to ´not recommended´ DMTs, and 16% had no prior treatment. Overall, 29% discontinued DMTs before or shortly after conception, while 58% (n = 88) had ongoing or recent treatment exposure, defined as treatment administered within 6 months before conception or, in a minority of cases, after conception. Among these, 50% (n = 77) involved rituximab-and 13% remained untreated. Postpartum, 58% resumed treatment, 3% remained under long-lasting DMT effects, and 39% did not initiate DMT, likely due to breastfeeding.

Overall, real-world practice in Sweden broadly aligns with national recommendations, with widespread use of rituximab before pregnancy reflecting its perceived safety and durable effect, alongside some individualized deviations from discontinuation guidance.