Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases
Key Points
Key Points
- Pregnancy in women with rheumatic and musculoskeletal diseases (RMD) may lead to serious maternal or fetal adverse outcomes. Accordingly, contraception, tailored to the individual patient with emphasis on safety and efficacy, should be discussed and encouraged.
- Because risk for pregnancy complications depends on diagnosis, disease activity and damage, medications, and the presence of anti-Ro/SSA, anti-La/SSB, and antiphospholipid (aPL) antibodies, pre-pregnancy assessment is critical to informing pregnancy management, therapy, and outcomes.
- In addition, patients are vulnerable to disease flare postpartum, and medications for RMD must be screened for safety while breastfeeding.
- Minimizing risk of gonadal insufficiency in the setting of cyclophosphamide therapy is important. Patients with RMD may require assisted reproductive technology and therefore a discussion about oocyte preservation and in vitro fertilization should also be part of the management of patients contemplating parenthood.
Treatment
Treatm...
...mmendationsÂ...
Contracept...
All R...
...e women with RMD who have neither SLE nor positiv...
...tive methods, we conditionally rec...
...ly recommend discussing use of emergency c...
...E patients...
...E patients with stable or low disease act...
...nditionally recommend the highly effective...
...ionally recommend against use of the tran...
...trongly recommend progestin-only or IUD cont...
...tiphospholipid antibody–positive pati...
...ommend against combined estrogen-progestin con...
...ongly recommend IUDs (levonorgestrel or c...
Other special RMD si...
...IUDs are the most effective contrac...
...th RMD who are at increased risk for osteoporosis...
We conditionally recommend that women...
...isted reproductive techn...
...ommend proceeding with ART if need...
SLE pati...
...strongly recommend deferring ART pro...
...recommend against an empiric dosage increase of p...
Antiphospholipid antibody–positive patien...
...fertile patients with RMD who desire pregnanc...
...conditionally recommend prophylactic anticoag...
...rongly recommend prophylactic anticoagula...
...ly recommend therapeutic anticoagulation in wo...
...bryo and oocyte cryopreservati...
...e strongly recommend continuation of necessary...
...servation with cyclophosphamide...
...tility preservation in women with RMD tr...
...ty preservation in men with RMD treat...
...ecause sperm cryopreservation prior to treatme...
Menopause and hormone replacement...
...y suggest as good practice the use of HRT...
...E patients...
...ients without positive aPL who desire HRT due to...
...positive patient...
...h asymptomatic aPL, we conditionally re...
...mmend against use of HRT in women with obstetric a...
...nally recommend against HRT use in patien...
...conditionally recommend consideration of...
...al assessment, counseling, and manag...
...andard good practice, we strongly suggest counseli...
In women with RMD planning pregnancy who a...
...h RMD who are currently pregnant and...
...recommend testing for anti-Ro/SSA and...
...relative persistence and unchanged titers of these...
...s with scleroderma renal crisis...
...trongly recommend use of angiotensin-con...
...patients...
In women with SLE who are considering...
...that all women with SLE take hydroxy...
...ot taking HCQ, we conditionally recommend sta...
...itionally recommend treating SLE patien...
...disease affects maternal and pregnancy outcome,...
...phospholipid antibody–positive patie...
...nant women with positive aPL who do not meet cr...
...e strongly recommend combined low-dose asp...
...n with OB APS, we further strongly recomme...
...regnant women with thrombotic APS, we strongly...
...ionally recommend against using the combinati...
...e conditionally recommend against treatment with...
...recommend against adding prednisone to prophy...
...onally recommend the addition of HC...
...pregnant women with positive aPL who do not meet...
...nti-Ro/SSA and/or anti-La/ SSB antibodies in...
...n pregnant women with anti-Ro/SSA and/or anti-L...
...women with a prior infant with CHB or ot...
...conditionally recommend treating all women...
...women with anti-Ro/SSA and/or anti-L...
...HB ( without other cardiac inflammat...
Medication use
...al medication use...
...ommend against use of CYC and thalidomide in m...
...th RMD who are planning to father a pregnan...
...n men with RMD who are planning to fathe...
...nally recommend continuation of anakinra and...
...ernal medication use
...standard good practice, we suggest discus...
...TX, MMF, CYC, and thalidomide are known teratog...
...or women treated with leflunomide, we strongly rec...
...y recommend treatment with CYC for life-threa...
...tentially teratogenic medications are dis...
...inadvertent exposure to teratogenic medications w...
...commend HCQ, azathioprine/6-mercaptopurine, colchi...
...ally recommend calcineurin inhibitors (tacrolimu...
We conditionally recommend discontinuation of NS...
...ommend against use of NSAIDs in the t...
...tionally recommend nonselective NSA...
...ionally recommend continuing low-dose glucocor...
...ly recommend tapering higher doses of...
...though there are only minimal data regardi...
...tionally recommend continuing tumor n...
...recommend continuation of certolizumab...
...nditionally recommend continuing treatment with...
...ly recommend continuing treatment with rituximab...
...ication use during breas...
...uggest as standard good practice that women wi...
...we suggest that disease control be maint...
...ongly recommend treatment with HCQ, colchicine,...
...e also recommend prednis...
...trongly recommend that with doses of pr...
...y recommend treatment with azathioprin...
...e strongly recommend against use of CYC, lef...
...conditionally recommend against use...
...ductive health care in patients with RMD:...
...ntracepti...
All RMD
...on/pregnancy discussion early and regularly: Choo...
...r methods if unable to use other met...
...contraception if necessary. [6] (Str...
...receiving immunosuppressive medications: U...
...at risk for osteoporosis: Avoid depot med...
...ng mycophenolate mofetil (MMF): Use IUD or...
...t systemic lupus erythematosus (SLE) or ant...
...ffective methods preferred to effective methods....
SL...
...E with negative aPL and low/stable dise...
...ve methods preferred to effective me...
...transdermal estrogen-progestin pa...
...ith negative aPL and moderate-to-high d...
Positive aPLÂ
...ombined estrogen-progestin contraceptives....
...isted reproductive technologyÂ...
All RMD...
...ization if pregnancy-compatible medica...
...yopreservation: Continue medicatio...
...: Defer assisted reproductive technology until...
SL...
...fer assisted reproductive technolo...
...dergoing assisted reproductive technology...
...ositive aPL
For assisted reproductive technology in patient...
...reproductive technology patients wit...
...ed reproductive technology patients...
...ty preservation...
...men: Use gonadotropin-releasing hormone ag...
...Sperm cryopreservation pre–CYC treatment....
...Do not use gonadotropin-releasing hormone...
...ause/hormone replacement therapy...
...ll RMD
...E or aPL: Treat with hormone replacement therapy i...
...LE...
...ve aPL: Treat with hormone replacement t...
...ositive aPL
If no prior thrombosis or OB APS: Do not tre...
...rrent titers negative, treat with ho...
...prior thrombosis or OB APS and not r...
...current titers negative, do not treat with hormon...
...f prior thrombosis or OB APS and r...
...gnancy
...l RMD...
...g: Outcomes improved with pregnancy...
...-pregnancy: Change to pregnancy-compa...
...tive disease during pregnancy: Initiate pr...
...SLE-like disease, Sjögren’s syndrome (...
...enal crisis during pregnancy: Treat wit...
SLE
...LE-like disease: Test once (early)...
...hydroxychloroquine (HCQ) during pregnancy. [57] (...
...t taking HCQ, start HCQ during pregnancy if no...
...ratory values at least once per trimester. (GPS...
...low-dose aspirin starting in first trimester....
...sitive aPL...
Positive aPL only: If no prior thrombosis or OB...
...itive aPL only: Do not treat with combina...
...aPL only: Do not treat with HCQ....
...: If no thrombosis but meet OB APS c...
...o not treat with combination therape...
...t treat with addition of IV immunoglobul...
...not treat with addition of prednisone. [51]...
...S: Treat with addition of HCQ for combination he...
...Treat with prophylactic anticoagul...
...ic-APS: If prior thrombosis (meeting or...
...: Treat with addition of HCQ for therapeutic hepa...
...ti-Ro/SSA with or without anti-La/SSB...
...during pregnancy. [69, 70] (Conditional)70...
...ior history of neonatal lupus: Serial...
...prior history of neonatal lupus: Weekl...
...al fetal echocardiography: If first-or s...
...third-degree heart block (and no oth...
...cation ...
...ernal medicationÂ
...father a child: Discuss medication use including...
...iscontinue CYC and thalidomide. [133, 139] ()...
...Q, AZA, infliximab, etanercept, adalimumab, goli...
...leflunomide, MMF, nonsteroidal anti-inflammatory...
...ernal medicatio...
...nancy: Discuss medication use including CYC. (G...
...and exposed to teratogenic medications: Discontinu...
...e NSAIDs if difficulty conceiving. [86]...
...void NSAIDs in third trimester. [87] (Strong)70...
...rather than cyclooxygenase 2 (COX-2)–specific N...
...continue methotrexate (MTX), MMF, thal...
...e CYC for life-threatening disease only in...
...ontinue leflunomide 24 months prior to conception...
Continue HCQ, sulfasalazine, azathiopri...
...ntinue cyclosporine and tacrolimus. [127, 131] (Co...
...e certolizumab. [156] (Strong)7070...
...e infliximab, etanercept, adalimumab, golimumab...
...when pregnancy confirmed: rituximab, belimumab, a...
...tuximab for organ-or life-threatening disease...
...ecommendations for tofacitinib, baricitinib, ap...
...tinue regular low-dose prednisone....
...aper high-dose prednisone with addition of...
Stress-dose steroid at delivery. Do not treat fo...
Breastfeedi...
...ncourage breastfeeding and maintain d...
...ompatible medications...
HCQ, infliximab, etanercept, adalimumab, golimu...
...Ds, sulfasalazine, colchicine, AZA, cyclospori...
...one or nonfluorinated steroid equivalen...
...≥20 mg daily, discard breast mil...
...th leflunomide, MMF, CYC, thalidomide. [113, 124,...
...ot treat with MTX. [106] (Condition...
a Recommendation numbers, shown in b...
...ety and efficacy of various contraceptive m...
Table 3. Recommendations regarding...
...ioprine/6-mercaptopurine Colchici...
...Cyclooxygenase 2 inhibitors Cyclosp...
...mide (discontinue 12 weeks prior to attempted c...
...mide (discontinue 4 weeks prior to a...
...ept Apremilast Baricitinib Belimuma...
...ternal medication use: overview of medication...
...ommendations and good practice statements (GPS...
...gure 2. Recommendations for use of...
...igure 3. Recommendations and GPS for...
...ecommendations and GPS for pregnancy counseling,...