Breast Feeding and Multiple Sclerosis

Section 1- Introduction  

MS is a disease where the immune system attacks the myelin, which covers the nerve fibres causing communication problems between the brain and the rest of the body. MS is a disease that potentially disables the brain and spinal cord. It is a permanent disease of the nervous system that people can experience at different periods of their life, therefore there is no general pattern. Men and women may experience the same early MS symptoms and indicators.  
 
A vision impairment called optic neuritis is one of the more noticeable early indicators of multiple sclerosis. This is frequently because, in contrast to more vague sensations like tingling and numbness, it is more obvious when someone has vision issues. 

Typical signs and symptoms of multiple sclerosis are listed below, but not everyone experiences all MS symptoms, which include:  

• vision issues 

• fatigue, tingling, and numbness  

• lack of balance and light-headedness  

• stiffness or convulsions  

• pain  

• bladder issues  

• intestinal issues (MS Society, 2014). 

Mood swings, bladder and bowel issues, and overall difficulty with coordination are also common. Many women with MS can breastfeed successfully, though some challenges exist. Postpartum relapses may be more common, but exclusive breastfeeding might help reduce relapse risk. Some MS medications are not safe during breastfeeding, so adjustments may be needed. Fatigue from MS can make breastfeeding tiring, though it typically doesn’t impact milk supply directly. With support from healthcare providers and lactation consultants, breastfeeding is often achievable while managing MS.

MS can impact breastfeeding in several ways. However, many women with MS can successfully breastfeed. It is important to consider how the medications used to manage MS symptoms may affect breastfeeding. Safe options include Glatiramer Acetate (Copaxone) and Interferon beta, which pass into breast milk in small amounts but are not harmful to the nursing infant. However, some disease-modifying therapies introduced for MS in recent years have limited data regarding their safety during breastfeeding. While some may be considered safe, others may not be recommended. This blog presents two proposals outlining how MS can be managed while breastfeeding. 

How is it diagnosed? 

Diagnostic procedures for MS involve lumbar puncture, MRI scanning and an assessment of how symptoms may be affecting a patient’s life.  

An MRI scanner uses a powerful magnetic field to provide a finely detailed image of the inside of the brain and spinal cord. It is highly precise and can identify the exact position and extent of any damage, inflammation, or lesions. More than 90% of MS patients have MRI scans to confirm their diagnosis.  

Lumbar punctures involve using a needle to take a sample of spinal fluid from near the spinal cord in the patient’s lower back. Antibodies in this fluid are almost always present in MS patients. Your immune system has been active in your brain and spinal cord if you have antibodies in your spinal fluid because it means the body is trying to remove something that is damaged or not supposed to be in the body. Antibodies in this fluid are typically absent in people without multiple sclerosis because there is no damage in the nerves for the body to try to correct (MS Society, 2014).  

Neurologists have indicated that the chance of a woman experiencing a multiple sclerosis (MS) relapse decreases during pregnancy, particularly in the third trimester, and rises in the first 3–6 months postpartum. 

The impact of nursing on postpartum relapses is not clear; although some research suggests some advantages, others do not. To lower the risk of an MS recurrence, women may be encouraged to resume taking their disease-modifying drugs (DMD) shortly after giving birth. Breastfeeding is recommended during the first six months of a baby’s life but many mothers with MS may be concerned about DMDs affecting breast milk (Confavreux et al., 1998). 

Types of MS 

According to The Multiple Sclerosis Society of Ireland, there are four main types of MS in the country (MS Society, 2021). Their characteristics and symptoms are outlined in the table below.  

Table 1. Main types of multiple sclerosis in Ireland.

Why does MS affect more women than men? 

In the West, 1 in 1000 people suffer from multiple sclerosis, mostly women of reproductive age. Although there have been few studies and some have come to differing results, it is believed that the recurrence rate decreases during pregnancy and increases during the postpartum period (after a woman has a baby) (Confavreux et al., 1998). The ratio that makes women more vulnerable to MS varies across surveys, but in population studies, it is close to 2:1, so two women will be diagnosed for every man. Males are more likely than females to experience a progressive course from the outset of the disease however, and their average age of onset is around a year or two later. If MS begins before the age of 16, the female majority is more noticeable, affecting 3 girls for every boy (Sadovnick and Ebers, 1993). 

Women generally have stronger immune responses than men, which might contribute to the development of autoimmune diseases like MS. Given the significant differences observed between males and females in a variety of diseases, MS is no exception when it comes to men and women experiencing the disease differently. For example, women are 80% more likely than men to develop autoimmune diseases such as MS. Compared to men, women often exhibit more powerful innate and adaptive immune responses. In addition to making women more susceptible to inflammatory and autoimmune illnesses, this causes them to remove germs more quickly, so having a strong immune system is not necessarily a negative for women (Klein and Flanagan, 2016). These factors may explain why women are more likely than men to develop MS, but more research is needed.  

Limitations in Treatment 

The main limitation seen in the progression of novel treatments for pregnant/ lactating women is the lack of representation seen across most clinical trials. As the risk to newborns is unknown, pregnant women are often excluded from clinical trials conducted for MS using disease- modifying therapies (DMTs). The risks of adverse pregnancy and delivery outcomes must be considered when deciding treatment plans. When managing pregnant women, the risk/ benefit analysis of their needs must be considered. The lack of consistent data and guidance has led to variations between clinicians in the management of pregnancy in women with MS. This in turn affects the adequate guidance on how to best manage patients of childbearing age living with the disease (Edith L. G. et. al., 2024). These limitations lead to healthcare providers having to rely on limited data when advising pregnant women with MS about treatment and management options. 

Section 2- MS, Pregnancy and Postpartum Care

Hormonal Changes and MS Activity during pregnancy

Pregnancy introduces unique challenges for patients managing MS, mainly due to the hormonal fluctuations that occur during the stages of pregnancy. Several studies, such as that of (Ysrraelit et.al 2018) have outlined a correlation between the heightened oestrogen and progesterone levels during the third trimester and MS relapse rates. Oestrogen has a substantial impact on the immune function of a patient by promoting an anti-inflammatory response which in turn leads to a suppression of T-Cell mediated immune responses and the growth of T-Reg cells (Ysrraelit et.al 2018). These shift in conventional hormonal levels lead to a temporary remission of MS symptoms which can be observed in many late-stage pregnancies (Celius et.al 2020).  

However, after delivery, the hormonal environment rapidly shifts, often resulting in an increase in relapse rates. This trend in relapses post-delivery is well documented with studies suggesting that women with MS face a 20-40% increased risk of relapse within the first three months post-delivery (Wang et.al 2023). The sudden drop in progesterone and oestrogen levels disrupt the immune and hormone balance within the body, contributing to an inflammatory response.  

Preconception, Pregnancy and Postpartum Management Strategies  

Due to the added complexity of conceiving a child while managing MS, preconception counselling is a critical step of patient care. Women with MS are advised to consult regularly with their healthcare providers while planning to conceive. Treatment plans offered currently often contain disease-modifying therapies (DMTs) which allows for management of the disease while providing the lowest risk to the foetus (Miller et.al 2014). Two common DMTs currently in use are interferon- beta and glatiramer acetate, which have demonstrated a marked reduction in relapse rates while reducing any potential risk to the foetus (Miller et.al 2014).  

During the duration of pregnancy, it is recommended that the patient undertake various lifestyle changes to help reduce the risk of MS relapse. For example, vitamin D supplementation is recommended for pregnant women suffering from MS due to its effect on the immune system and studies suggesting a lower relapse rate associated with supplementation of the diet with vitamin D (Miller et.al 2014).. Furthermore, vitamin D also plays a large part in several of the immune response pathways which help offset some pro-inflammatory mechanisms associated with MS (Sadovnick et.al 1993).  

It is recommended that patients breastfeed post childbirth due to the potential protective effect against postpartum relapse. Some DMTs including interferon-beta are considered compatible with breastfeeding and can be continued if postpartum relapse is high (Celius et.al 2020).  

Postpartum Relapse Management 

 The risk of postpartum relapse poses significant challenges for patients suffering from MS due to the risk of relapse. The relapse rate for patients suffering from MS post childbirth is between 30-40% driven by the sudden decline in pregnancy related hormones (Wang et.al 2023). Given the risk posed to patients, proactive treatment is essential, and many healthcare professionals recommend the continuance of DMTs to help reduce the risk of relapse (Miller et.al 2014)..  

The Protective role of breastfeeding on MS Postpartum relapse.  

The postpartum period poses an increased risk of relapse with studies suggesting that 30-40% of women within the first 3-6 months following childbirth (Wang et.al 2023). This increased risk of relapse is largely attributed to the sharp change in hormone levels related with postpartum recovery, particularly oestrogen and progesterone which cause an anti-inflammatory effect (Celius et.al 2020). Breastfeeding appears to aid in mitigation of the risk posed to pregnant women with several studies indicating as much in comparison to those who did not breastfeed.  

Studies such as that by (Wang et.al 2023) suggest that women who breastfeed exclusively for at least the first 2 months had a significant lower risk of relapse compared to those who opted to not breastfeed exclusively or had a combination of breastfeeding and formula feeding. This reduced risk of relapse is suggested to be due to a more stable hormonal environment aided by the decrease in fluctuations of oestrogen levels combined with the suppression of ovulation that occurs in postpartum patients. Furthermore, the increased secretion of the hormone prolactin, the hormone responsible for inducting lactation, has also been linked to an immunomodulatory role within patients which aids in the reduction of relapse rated.  

Finally, as outlines in (Ysrraelit et.al 2018), exclusive breastfeeding can be linked to the reduction in expression of pro-inflammatory cytokines such as IL-6 and THF-alpha, which are known to contribute to MS disease activity (Ysrraelit et.al 2018). By shifting the immune system responses away from pro-inflammatory pathways, we can see a marked decrease in the relapse rates of patients which is attributed to an increase in the stability of the hormonal levels of the patient and an increase in the stability in the immune system of the patient.

Clinical Information Related to MS and Breast Feeding 

In the case of multiple sclerosis (MS) and breastfeeding, clinical information refers to medically relevant data and knowledge gathered through clinical practice, research, and patient care. This information aids healthcare providers in diagnosing, treating, and managing health conditions. The clinical information would include;

Research Findings: Effects of Breastfeeding on MS Progression, Postpartum Health, and Relapse Rates

Multiple sclerosis (MS) can impact breastfeeding in many ways, as the physical demands of breastfeeding may lead to certain challenges, including muscle weakness, coordination issues and sensory disruptions: Numbness, and tingling making breast feeding more challenging (NCBI, 2020).  

Figure 1. Infographic illustration of the main symptoms of multiple sclerosis. 

Recent studies reviewed a noticeable reduced rate of postpartum multiple sclerosis relapses was observed in women who were breastfeeding compared with those who were not breastfeeding (Langer-Gould et al., 2020).

Guidelines for Managing Multiple Sclerosis Medications During Breastfeeding: Disease-Modifying Therapies

Disease-modifying therapies (DMTs) work by altering or suppressing certain aspects of the immune response, aiming to reduce these attacks on myelin and prevent further damage (Bergamaschi. R et.al, 2016), as illustrated in Figure 2. 

Figure 2. Relapse rate on average 30% during breast feeding (Villaverde-González, 2022), and on medication DMT relapse rate reduced by 70%. 

Others DMTs specifically target immune cells, such as B-cells or T-cells, which are involved in the autoimmune response, reducing their numbers or altering their activity (Mohseni et al., 2025). This decrease in myelin attacks helps reduce relapses and slows the accumulation of disability and symptoms over time.  Some therapies act by blocking immune cells from crossing the blood-brain barrier, which can help by; 

• Reducing overall inflammation  

• Prevent the damage that contributes to disability.  

• DMTs also work to decrease the frequency of relapses illustrated in Figure 2. 

 While DMTs cannot cure MS, they are effective in managing symptoms, improving quality of life, and slowing the disease's progression, offering a valuable approach to long-term MS management. DMTs come in various forms, including injections, oral pills, and infusions, as illustrated in Figure 3. 

Figure 3. Medication types and modes of administration of these forms of medications  

DMTs used for MS are sometimes taken with caution in breastfeeding mothers, as the safety and effectiveness of these treatments in this context depend on the specific DMT being used (Mitsikostas & Goodin, 2017). Some DMTs have minimal presence in breast milk, which may make them safer for breastfeeding, while others can transfer more readily into breast milk and might require alternative approaches (Dobson & Hellwig, 2021). DMTs such as glatiramer acetate (Copaxone) and interferon-beta have shown limited transfer into breast milk, making them relatively safer options for breastfeeding mothers (Krysko et al, 2021). These therapies can be effective in maintaining disease stability postpartum without significantly impacting the breastfed infant. 

Guidelines for Selecting Medication for Patients

• For mothers with MS to work closely with their healthcare providers 

• Discuss and choose a treatment plan that balances disease control with breastfeeding safety. 

• Choose safe management of MS during breastfeeding that focuses on selecting DMTs with minimal milk transfer, allowing mothers to continue symptom control with a lower risk to their infants.   

Oher DMTs, particularly certain oral medications and monoclonal antibodies like natalizumab (Tysabri) or fingolimod (Gilenya), are more likely to pass into breast milk, posing a potential risk for the infant. In such cases, women may be advised either to avoid breastfeeding or to temporarily halt DMTs (Khan et al., 2023). This is where the controlled, monitored, and managed intake of medications for MS is observed during breastfeeding. 

Management of Medication for Multiple Sclerosis while Breast Feeding. 

MS during breastfeeding requires a careful balance between maintaining maternal health and ensuring infant safety, as some DMTs can transfer into breast milk. Practically, MS management during breastfeeding involves a collaborative approach between the mother, neurologist, and paediatrician, with consideration for both disease activity and the chosen DMT’s safety profile. For mothers with milder MS or stable disease, the approach may involve pausing DMTs temporarily while breastfeeding, particularly if they had low disease activity before pregnancy. This allows for exclusive breastfeeding without exposing the infant to medication, as long as the mother’s MS remains stable. Some women experience a rapid reduction of MS relapses during pregnancy and breast feeding as illustrated in Figure 4. 

Figure 4. Average MS Relapse Rates in Scenarios.  

In these cases, close monitoring of the mother’s symptoms is essential. If signs of disease activity appear, treatment can be reconsidered in consultation with her healthcare team. For mothers with more active MS who need ongoing treatment, safer DMTs like glatiramer acetate (Copaxone) or interferon-beta are often chosen due to their minimal transfer into breast milk (Sportiello et al., 2023). These medications can help control MS symptoms while minimizing risk to the infant. Regular paediatric checkups are also advised to ensure that the infant is developing well and showing no adverse effects.  

Some mothers may also choose a mixed feeding approach, supplementing with formula while using certain DMTs to minimize infant exposure. Another practical approach involves timing DMT administration, typically after breastfeeding or before a long sleep period, to help reduce the amount of medication in breast milk by the time of the next feeding. However, timing can only partially limit exposure, so it’s more relevant for DMTs with shorter half-lives or minimal milk transfer.  

     What should Patients Consider when Managing Medication for MS? 

• Throughout this period, frequent check-ins with healthcare providers, and symptom monitoring.  

• Discussing MS management and medication safety is crucial. 

• Tailoring the treatment approach allows mothers to prioritize breast-feeding, when possible, while still addressing MS symptoms effectively. 

3. Patient Observations 

Symptom Relief During Pregnancy: Many MS patients experience a decrease in disease activity during pregnancy, likely due to hormonal changes, particularly the increase in oestrogen, which can have an immune-modulating effect. Some women report fewer relapses and milder symptoms during pregnancy.

After giving birth, particularly within the first three to six months, the risk of relapse often increases as hormone levels fluctuate and the immune system returns to its baseline (Langer-Gould et al., 2020). This risk is a significant consideration for MS patients during the breastfeeding period, as illustrated in Figure 5.

    Figure 5. Relapse rates during trimesters of pregnancy (Confavreux 1998, NEJM).

Emotional and psychological impacts are noticed in patients, followed by symptom fluctuations. This can impact the adjustment of taking medication.

Pharmacological Management During Breastfeeding 

For female patients suffering with MS, the choice to breastfeed is made more difficult due to the treatment pathways that are often involved for patients suffering with MS. The most common treatment pathway is the use of DMTs to control the risk of relapse, which can often cause interfere with lactation and can harm the young child. Therefore, careful consideration must be taken by care providers and by patients to ensure that treatment can continue without risk to the child.  

Interferon-beta and glatiramer acetate are two DMTs that are generally regarded as low-risk options for breastfeeding mothers with MS (Miller et.al 2014). Research has shown that while these drugs are excreted in small amounts in breast milk, the level in which they are secreted is not likely to reach levels that would harm a nursing baby. Therefore, care providers view these as safe treatments while breastfeeding, especially to patients suffering from severe disease activity who would be prone to relapse post birth. The study conducted by (Miller et.al 2014) demonstrated the combinational treatment using both Interferon-beta and glatiramer acetate can decrease the risk of relapse while also slowing down the progression of the disease, making them an extremely effect tool in the treatment and management of MS for female patients.  

Treatments such as fingolimod, teriflunomide, and natalizumab are not recommended for breastfeeding patients due to the impact that they could potentially cause to the nursing baby. Drugs such as Fingolimod tends to bind to fats which might accumulate in breastmilk and be passed to the nursing baby while drugs such as Teriflunomide have a lengthy half-life which due to the prolonged presence in the mother's body has a higher chance of being passed onto the nursing baby.  

In cases where a mother is not able to breastfeed, it is recommended that the mother weans early. This is done to ensure that the patient can resume disease treatment with DMTs and reduce the period of the disease being untreated. The significance of this is outlined in (Wang et.al 2023) where they state the need to preconception counselling between the patient and their primary care provider to ensure the optimum treatment of the baby and mother.  

Challenges and Considerations in Breastfeeding for Women with MS 

Despite the potential benefits posed by breastfeeding, for patients suffering with MS, there are often physical limitations caused by their disease. Issues such as fatigue, muscle weakness and mobility issues due to MS can create unique challenges for breastfeeding patients. This often results in the patient being referred to caregivers or lactation specialist to help establish a manageable breastfeeding schedule. Furthermore, due to the disruption in sleep and fatigue posed by MS, breastfeeding schedules can often worsen fatigue, affecting a mother’s capability to combat the disease (Sadovnick et.al 1993).  

Furthermore, psychological factors are also important in the decision to breastfeed as woman suffering with MS often must balance the concerns of nursing an infant and managing a chronic illness. (Sadovnick et.al 1993) emphasized the need for and importance of social and emotional support for Mothers suffering with MS.

Impact of Breastfeeding on Long-Term MS Outcomes 

Breastfeeding not only affects the risk of postpartum relapse by decreasing the risk, but also may have an impact on long-term management of MS in female patients.  Despite the limited research on the long-term effects of breastfeeding on MS management, studies such as that conducted by (Wang et.al 2023) indicate that breastfeeding is linked to slower disease progression and a possible reduction in relapse rates to the stabilized immune benefits that come with breastfeeding. Additionally, breastfeeding my also lessen inflammation demethylation in MS by delaying the relapses and building immune tolerance. However, despite the promising results found in (Wang et.al 2023), the long-term effects of breastfeeding on MS are still in the process of being studies and additional research is required to understand the effect that it has on disease progression.  

Section 3- Proposals for Treatment in MS and Breastfeeding

Proposal 1: Cannabis-derived treatments for MS 

 “The leaves of this plant cure flatus – some people squeeze the fresh (seeds) for use in earaches. I believe that it is used in chronic pains” - Galen, speaking about cannabis as a medical treatment in the 2nd century A.D. (Hill et al., 2012) 

While DMDs are helpful, some MS patients may benefit from complimentary or holistic therapies, and breastfeedingmothers are no exception. One complimentary therapy that some MS patients find helpful is cannabis and treatments derived from it. 

Proposal for treatment 2: MicroRNA (miRNAs) and Their Potential

MiRNAs are a class of non-coding RNAs that play important roles in regulating gene-expression (O’brien, J. et. Al., 2018). They exhibit high stability in body fluids such as serums, plasma, and Cerebral spinal fluid (CSF) samples. The use of miRNAs facilitates non-invasive techniques which, for breastfeeding mothers, are favoured for treatment. Potential applications of these miRNAs should focus on their therapeutic potential to develop strategies for promoting neurorepair and reducing neuroinflammation in MS (Zabalza A et. al., 2024). Alongside advantages of miRNAs in MS treatment it is also crucial to understand negative effects that they may have on patients. 

The miRNA miR-219 is known to regulate oligodendrocyte maturation. Oligodendrocytes are highly specialized neural cells involved in the myelination of axons on the central nervous system (CNS) (Miron, V.E. Et. Al., 2011). The absence of this miRNA has been recognised as a potential biomarker for MS. In a recent study completed, three cohorts of multiple sclerosis patients and controls revealed that the absence of miR-219 detections in CSF were consistently associated with MS (Bruinsma I.B. et. Al., 2017). In neurological diseases such as MS the lack of oligodendrocytes and demyelination align with axonal degeneration and neurological decline (Trapp, B.D. et. Al., 1999). Gaps in the myelin cause the formation of ‘Nodes of Ranvier’, axonal segments in which the sodium channels that regulate electrical impulses are aggregated (Miron, V.E. Et. Al., 2011). Recovery in MS can reflect Myelin repair (remyelination), which is the default spontaneous process by which demyelinated axons undergo ensheathment with new myelin sheaths leading to functional recovery (Liebetanz, D. and Merkler, D., 2006). New myelin sheath may act as a protective physical barrier to damaging inflammatory molecules or restore trophic support to the axon. A potential treatment for breastfeeding mothers could be the expression of this miRNA to aid in the regulation in oligodendrocyte maturation, in turn leading to remyelination and reparation of neurons. 

Figure 1. Remyelination Diagram Created in BioRender.com. 

The strategic use of miRNAs for potential therapeutic applications in pregnant or breastfeeding women has the potential to reduce the amount of DMDs and DMTs being consumed, therefore the possible negative effects in breastmilk are avoided. Ectopic expression is the abnormal gene expression in a cell type, tissue type or developmental stage in which the gene is not usually expressed (Cox, T.C. et. Al, 2014). The ectopic expression of certain miRNAs such as miR-219 or miR-155 should be studied further. 

It has been identified that the inhibition of miRNA miR-155 is a mechanism utilized by macrophages to maintain an ‘M2’ state. The anti-inflammatory M2 state of a macrophage plays a role in tissue repair and regeneration. miR-155 is involved in blood- brain barrier (BBB) disruption via down- regulation of key junctional proteins under inflammatory conditions. And drives demyelination processes (Maciak, K. et. al., 2021). Frances Nally conducted a study in which the fact that macrophages are heterogeneous innate immune cells that are capable of adopting either a pro or anti-inflammatory phenotype is highlighted. In MS patients, miR-155 inhibition may favourably modulate the macrophage population to an ‘M2’ or pro-repair phenotype, reducing inflammation and alleviation disease progression through delivery of an anti-miRNA oligonucleotide (AMO) (Nally, F. et.al., 2012). Optimising macrophage uptake could offer a novel therapeutic approach for MS treatment. 

In a study completed by Elkhodiry, Zamzam and El Tayebi the role of miR-155 in regulating CD8+ T-cell activity in patients with RRMS was investigated. The study focused on its role in cell movement, specifically regarding intracellular adhesion molecule-1 (ICAM1) and integrin subunit β2 (ITGB2), as well as its effects on cytotoxic proteins like perforin and granzyme B. The findings concluded that increasing miR-155 led to a lasting decrease in the expression of all genes related to CD8+ T-cell activation, which positively correlated with the Expanded Disability Status Scale in patients. These findings may indicate that miR-155 contributes to reduced immune function. However, the study also highlights the miRNA’s potential as a therapeutic target and diagnostic marker, suggesting it could have beneficial uses in managing the disease (Elkhodiry et. Al., 2023).

Figure 2: The Expanded Disability Status Scale (EDSS) (Kurtzke, 1983) Image source: https://my-ms.org/ms_progression.htm).  

Proposal for treatment 3: Neuromodulation 

Neuromodulation is a technology that directly influences nerve activity. It involves the modulation or alteration of nerve function through the delivery of electrical impulses or pharmaceutical agents to a specific area. 

Devices for neurostimulation apply electrodes to various areas such as the brain, spinal cord, or peripheral nerves. These electrodes are strategically placed and connected to a pulse generator via an extension cable, which provides the necessary electrical stimulation. A low-voltage current travels from the generator to the nerve, either blocking pain signals or generating neural impulses where they were previously lacking. 

For pharmacological agents delivered via implanted pumps, the advantage lies in administering smaller doses. Since the drug bypasses the need for metabolism throughout the body before reaching its target, doses can be as small as 1/300 of a standard oral dose. This approach often results in fewer side effects, greater patient comfort and an overall improved quality of life (QOL) (International Neuromodulation Society, 2014). Due to the lowering of the dosage, the combination of existing DMTs alongside neuromodulation could potentially allow for an expansion of the use of treatment in pregnant women. 

While immune-modulating therapies have historically dominated MS research, recent advancements in DMTs suggest that focusing on neuromodulation and functional restoration could prove hugely beneficial. Studies indicate that techniques such as the intrathecal baclofen (ITB) pump and functional electrical stimulation can improve spasticity and motor function in MS patients. Additionally, deep brain stimulation has shown promise in alleviating MS- related tremors and trigeminal neuralgia, while spinal cord stimulation is effective for managing MS- related pain and bladder dysfunction. Sacral neuromodulation and posterior tibial nerve stimulation are also beneficial for bladder overactivity (Abboud et al., 2017). ITB pumps are surgically implanted into the subcutaneous tissue in the abdomen and is connected to a catheter ending in the thoracic intrathecal space. Baclofen is a muscle relaxant drug that orally is only recommend to pregnant women if the benefit outweighs the risk to the foetus. Despite concerns, delivering baclofen to pregnant women using devices such as the ITB pump seem to be safe in pregnant women and can drastically improve their QOL (Dalton et al., 2008). 

Figure 3. Intrathecal baclofen pump created in BioRender.com.