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...
...commendation...
...traception...
All RM...
...omen with RMD who have neither SLE nor...
...ve methods, we conditionally recommend...
...recommend discussing use of emergency...
...LE patie...
...n SLE patients with stable or low disease acti...
...itionally recommend the highly effective...
...conditionally recommend against use of the tra...
...ngly recommend progestin-only or IUD contrac...
...ipid antibody–positive patient...
...recommend against combined estrogen-progestin con...
...ly recommend IUDs (levonorgestrel o...
...special RMD situations...
...e IUDs are the most effective contracept...
...th RMD who are at increased risk for o...
...ly recommend that women with RMD ta...
...ed reproductive techno...
...trongly recommend proceeding with ART if needed i...
...LE patients
...ecommend deferring ART procedures in patients with...
...itionally recommend against an empiric dosag...
...ntiphospholipid antibody–positive pat...
In subfertile patients with RMD who desir...
...conditionally recommend prophylact...
...mmend prophylactic anticoagulation with h...
...recommend therapeutic anticoagulat...
...yo and oocyte cryopreservation...
...recommend continuation of necessary im...
...rtility preservation with cycloph...
...rvation in women with RMD treated with CYCTo...
...ervation in men with RMD treated wit...
...cryopreservation prior to treatment preserv...
...ause and hormone replacement ther...
...e strongly suggest as good practice the u...
SLE patie...
In SLE patients without positive aPL who...
...itive patients...
...n with asymptomatic aPL, we conditionally...
...ecommend against use of HRT in women with...
...onditionally recommend against HRT use in...
...ditionally recommend consideration of HRT, if des...
...: general assessment, counseling, and...
...good practice, we strongly suggest coun...
...h RMD planning pregnancy who are receiving medic...
...omen with RMD who are currently pregnant...
...recommend testing for anti-Ro/SSA a...
...en the relative persistence and unchanged titers...
...ients with scleroderma renal crisi...
...ngly recommend use of angiotensin-converti...
SLE patien...
...women with SLE who are considering pregnan...
...at all women with SLE take hydroxychloroquine (...
...is not taking HCQ, we conditionally reco...
...ly recommend treating SLE patients with l...
...tive disease affects maternal and pregnan...
...id antibody–positive patients...
...women with positive aPL who do not meet c...
...commend combined low-dose aspirin and prophy...
...n with OB APS, we further strongly recommend treat...
...ant women with thrombotic APS, we stro...
...conditionally recommend against using the...
We conditionally recommend against treatment wi...
...recommend against adding prednisone...
...conditionally recommend the addition...
...t women with positive aPL who do not meet criteria...
...d/or anti-La/ SSB antibodies in pregna...
In pregnant women with anti-Ro/SSA and/or anti-La...
...h a prior infant with CHB or other NLE we conditio...
We conditionally recommend treating all women who...
...egnant women with anti-Ro/SSA and/or an...
...HB ( without other cardiac inflammation) is...
...dication use...
...rnal medication use...
...ly recommend against use of CYC and thali...
...with RMD who are planning to father a pregnan...
...RMD who are planning to father a pregnancy, we...
We conditionally recommend continuation...
...ternal medication...
...ndard good practice, we suggest discussing medic...
MTX, MMF, CYC, and thalidomide are known terato...
...ated with leflunomide, we strongly r...
We conditionally recommend treatment with CYC...
...tentially teratogenic medications a...
...omen with inadvertent exposure to tera...
...recommend HCQ, azathioprine/6-mercaptopurine, col...
...conditionally recommend calcineurin inhibi...
...e conditionally recommend disconti...
...ly recommend against use of NSAIDs in the third...
...ly recommend nonselective NSAIDs over cyclooxyg...
...onditionally recommend continuing low-d...
...ommend tapering higher doses of non...
...ere are only minimal data regarding prolonged trea...
We conditionally recommend continuing tumor ne...
...ly recommend continuation of certoli...
...ally recommend continuing treatment with a...
...conditionally recommend continuing treatm...
...use during breastfeeding...
...standard good practice that women with R...
...dition, we suggest that disease control be main...
...strongly recommend treatment with HCQ, colch...
...also recommend prednisone...
...ly recommend that with doses of prednisone ≥20...
...e conditionally recommend treatmen...
...y recommend against use of CYC, leflunomide, MMF...
...y recommend against use of MTX whil...
...1. Reproductive health care in patients wi...
...raception...
All RMD
...ption/pregnancy discussion early and regu...
...e barrier methods if unable to use other m...
...se emergency contraception if necessary. [6] (S...
...receiving immunosuppressive medica...
...men at risk for osteoporosis: Avoid depot medroxyp...
...g mycophenolate mofetil (MMF): Use...
...hout systemic lupus erythematosus (SLE) or anti...
...e methods preferred to effective methods....
...LE
...ative aPL and low/stable disease activity...
...ghly effective methods preferred to effec...
...id transdermal estrogen-progestin patch....
...ve aPL and moderate-to-high disease...
...itive aPLÂ ...
...use combined estrogen-progestin contracep...
...productive technology ...
...St...
...lization if pregnancy-compatible medications....
...servation: Continue medications except...
...e: Defer assisted reproductive technology un...
SL...
...Defer assisted reproductive technology until...
...undergoing assisted reproductive technology,...
...ositive aPL
...productive technology in patients with asym...
...reproductive technology patients with no prior thr...
...d reproductive technology patients with pr...
...rtility preservati...
...gonadotropin-releasing hormone agonist therapy...
...yopreservation pre–CYC treatment. (GPS)7070...
...Do not use gonadotropin-releasing hor...
...rmone replacement therapy...
...ll RMD
...ut SLE or aPL: Treat with hormone replacem...
SLE
...negative aPL: Treat with hormone replacement th...
...tive aPL...
...prior thrombosis or OB APS: Do not treat wi...
...s negative, treat with hormone replacement...
...sis or OB APS and not receiving anti...
...rrent titers negative, do not treat with ho...
...rior thrombosis or OB APS and receiving ant...
...gnancy...
All R...
...g: Outcomes improved with pregnancy planning, s...
...: Change to pregnancy-compatible medication and o...
...isease during pregnancy: Initiate pregnancy-comp...
...or SLE-like disease, Sjögren’s s...
...f SSc and renal crisis during pregn...
SLE
...r SLE-like disease: Test once (earl...
...oxychloroquine (HCQ) during pregnancy. [57]...
...taking HCQ, start HCQ during pregnanc...
...or laboratory values at least once per trimes...
...ow-dose aspirin starting in first tri...
...tive aPLÂ
Positive aPL only: If no prior thrombosis or...
...aPL only: Do not treat with combinatio...
...only: Do not treat with HCQ. [44A] (C...
...If no thrombosis but meet OB APS criteria,...
...B-APS: Do not treat with combination therapeuti...
...reat with addition of IV immunoglobulin (IVIG). [...
...PS: Do not treat with addition of prednisone. [51]...
...PS: Treat with addition of HCQ for combination...
...at with prophylactic anticoagulation durin...
...: If prior thrombosis (meeting or not m...
...Treat with addition of HCQ for therape...
.../SSA with or without anti-La/SSB...
...with HCQ during pregnancy. [69, 70] (...
...no prior history of neonatal lupus: Seria...
...r history of neonatal lupus: Weekly fetal e...
Abnormal fetal echocardiography: If...
...isolated third-degree heart block (a...
...ication ...
...rnal medication ...
...father a child: Discuss medication use includ...
...scontinue CYC and thalidomide. [133,...
Continue HCQ, AZA, infliximab, etanerc...
...leflunomide, MMF, nonsteroidal anti-inflamma...
...l medication ...
...gnancy: Discuss medication use inclu...
...d exposed to teratogenic medications: Discontin...
...NSAIDs if difficulty conceiving. [86] (Condit...
...third trimester. [87] (Strong)7070...
...elective rather than cyclooxygenase 2 (COX-2)â€...
...ontinue methotrexate (MTX), MMF, tha...
...life-threatening disease only in second and...
...tinue leflunomide 24 months prior to conception...
...tinue HCQ, sulfasalazine, azathioprine (AZA)...
Continue cyclosporine and tacrolimus. [1...
...certolizumab. [156] (Strong)7070...
...ue infliximab, etanercept, adalimumab, golimu...
...when pregnancy confirmed: rituximab,...
...mab for organ-or life-threatening disease during...
...dations for tofacitinib, baricitin...
...nue regular low-dose prednisone. [20...
...ose prednisone with addition of pregnancy-compatib...
...tress-dose steroid at delivery. Do not treat fo...
Breastfeed...
...ge breastfeeding and maintain disease contr...
...tible medications...
...ab, etanercept, adalimumab, golimu...
...alazine, colchicine, AZA, cyclosporine,...
...onfluorinated steroid equivalent
...isone ≥20 mg daily, discard breast milk...
...reat with leflunomide, MMF, CYC, thali...
...with MTX. [106] (Conditional)7070...
...a Recommendation numbers, sho...
...ble 2. Safety and efficacy of variou...
...3. Recommendations regarding medication use...
...Azathioprine/6-mercaptopurine Colchicine...
...Anakinra Cyclooxygenase 2 inhibito...
...hamide (discontinue 12 weeks prior to att...
...de (discontinue 4 weeks prior to attempted conce...
...Apremilast Baricitinib Belimumab...
...aternal medication use: overview of medicat...
...e 1. Recommendations and good practice...
...ure 2. Recommendations for use of assis...
...igure 3. Recommendations and GPS for HRT u...
...re 4. Recommendations and GPS for pregna...