Maternal disease control and pregnancy outcomes with anti-CD20 therapy versus natalizumab in multiple sclerosis: a systematic review.

Abdulaziz Altamimi; Bashayr Arif Almutairi; Mohammed Essam Shaybah; Leen Essam Almahmoud; Abdullah Al Mazyad; Ahmed Sami Afash; Nawaf Abdulrahman Obaid Alharbi; Nura Waleed Ghibban; Ruwaym Jaber Mohammed Alharbi; Mohammed Yousef Almohaimeed; Abdulrahman Hussain Ghazwani; Atif Eid Alrashidi; Abdullah Altamimi

doi:10.1007/s10072-026-09400-x

PubMed · 42730789

Maternal disease control and pregnancy outcomes with anti-CD20 therapy versus natalizumab in multiple sclerosis: a systematic review.

Abdulaziz Altamimi·Bashayr Arif Almutairi·Mohammed Essam Shaybah·Leen Essam Almahmoud·Abdullah Al Mazyad·Ahmed Sami Afash·Nawaf Abdulrahman Obaid Alharbi·Nura Waleed Ghibban·Ruwaym Jaber Mohammed Alharbi·Mohammed Yousef Almohaimeed·Abdulrahman Hussain Ghazwani·Atif Eid Alrashidi·Abdullah Altamimi

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Abstract

BACKGROUND: Management of multiple sclerosis (MS) during pregnancy requires balancing maternal disease control with fetal safety. Among high-efficacy disease-modifying therapies, anti-CD20 monoclonal antibodies and natalizumab are commonly used in women with active disease, yet their comparative effectiveness and safety during pregnancy remain incompletely defined. This systematic review evaluated maternal disease activity and pregnancy-related outcomes associated with anti-CD20 exposure compared with natalizumab in pregnant women with MS. METHODS: PubMed/MEDLINE, Web of Science, Scopus, and the Cochrane Library were searched from inception through February 2026. Eligible studies included pregnant women with MS exposed to anti-CD20 before or during pregnancy and reporting maternal disease activity compared to natalizumab. RESULTS: Seven studies were included, comprising six observational cohort studies and one pharmacovigilance disproportionality analysis. Across studies, anti-CD20 exposure was consistently associated with lower relapse activity than natalizumab, particularly in the postpartum period. Anti-CD20 strategies were also associated with markedly lower postpartum MRI activity and more favorable disability-related outcomes where reported. Meta-analysis of three studies demonstrated a significant reduction in postpartum MRI activity with anti-CD20 therapy compared with natalizumab (RR 0.06, 95% CI 0.02-0.24; I² = 0%). No clear increase in major congenital anomalies was identified, although some data suggested higher odds of small for gestational age and maternal antibiotic use with anti-CD20 exposure. CONCLUSIONS: Anti-CD20 therapy was associated with lower maternal disease activity than natalizumab during pregnancy, especially for relapse prevention and postpartum MRI suppression. However, evidence regarding fetal and neonatal safety remains limited, warranting cautious individualized treatment decisions and further comparative research.

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Humans Female Natalizumab Pregnancy Multiple Sclerosis Immunologic Factors Pregnancy Complications Pregnancy Outcome Antigens, CD20 Rituximab Anti-CD20 Meta-analysis Multiple sclerosis Systematic review Journal Article Systematic Review Review

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Abdulaziz Altamimi, Bashayr Arif Almutairi, Mohammed Essam Shaybah, Leen Essam Almahmoud, Abdullah Al Mazyad, Ahmed Sami Afash, Nawaf Abdulrahman Obaid Alharbi, Nura Waleed Ghibban, Ruwaym Jaber Mohammed Alharbi, Mohammed Yousef Almohaimeed, Abdulrahman Hussain Ghazwani, Atif Eid Alrashidi, Abdullah Altamimi. 2026-09-12. Maternal disease control and pregnancy outcomes with anti-CD20 therapy versus natalizumab in multiple sclerosis: a systematic review.. https://doi.org/10.1007/s10072-026-09400-x

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