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
Treatmen...
...ommendationsÂ...
Contracepti...
All R...
...women with RMD who have neither SLE nor pos...
...effective methods, we conditionally recommend th...
...strongly recommend discussing use of emergency...
...E patients...
...LE patients with stable or low disease activity...
...conditionally recommend the highly effect...
...ly recommend against use of the transdermal estro...
...mmend progestin-only or IUD contraceptives o...
...ntiphospholipid antibody–positive patients
...mmend against combined estrogen-progestin co...
...rongly recommend IUDs (levonorgestrel or...
...special RMD situati...
...IUDs are the most effective contraceptive option...
...en with RMD who are at increased risk for osteopor...
...onally recommend that women with R...
...d reproductive technolo...
...mmend proceeding with ART if needed...
...patients...
...trongly recommend deferring ART procedures...
...e conditionally recommend against an...
...id antibody–positive patients
...bfertile patients with RMD who desire...
...onally recommend prophylactic anticoagulation...
...ngly recommend prophylactic anticoagulation wi...
...nd we strongly recommend therapeutic anti...
...oocyte cryopreservation...
...commend continuation of necessary immunosuppressi...
...rtility preservation with cyclophosphamide...
...ty preservation in women with RMD treated with CYC...
...lity preservation in men with RMD treat...
...cryopreservation prior to treatment preserves a m...
...e and hormone replacement th...
...gest as good practice the use of HRT in postmenop...
...LE patient...
...nts without positive aPL who desire HRT due to s...
aPL-positive patients
...with asymptomatic aPL, we conditionall...
...strongly recommend against use of HRT in women...
...onally recommend against HRT use in pa...
...ally recommend consideration of HRT, if desired, i...
...ncy: general assessment, counseling, and...
...standard good practice, we strongly suggest cou...
...women with RMD planning pregnancy who are...
In women with RMD who are currently pregn...
...strongly recommend testing for anti-Ro/SSA and a...
...tive persistence and unchanged titer...
...with scleroderma renal crisis...
...gly recommend use of angiotensin-c...
...LE patients
...with SLE who are considering pregnancy or are p...
...mend that all women with SLE take hydroxy...
...is not taking HCQ, we conditionally recom...
...ditionally recommend treating SLE patien...
...tive disease affects maternal and pregnancy outc...
...pid antibody–positive patients...
...n pregnant women with positive aPL who do not m...
...ongly recommend combined low-dose aspirin and pro...
...APS, we further strongly recommend treati...
In pregnant women with thrombotic APS, we stro...
...nditionally recommend against using...
...ly recommend against treatment with...
...trongly recommend against adding p...
...onditionally recommend the addition of HCQ...
...omen with positive aPL who do not meet criteria fo...
...ti-Ro/SSA and/or anti-La/ SSB antib...
...women with anti-Ro/SSA and/or anti-La/SSB antibod...
...with a prior infant with CHB or oth...
...ditionally recommend treating all women w...
...egnant women with anti-Ro/SSA and/or an...
...f CHB ( without other cardiac inflammation)...
Medication u...
...l medication use
...recommend against use of CYC and th...
...RMD who are planning to father a preg...
...with RMD who are planning to father a pregnancy,...
We conditionally recommend continuation o...
...al medication use...
...good practice, we suggest discussing medicatio...
...MF, CYC, and thalidomide are known...
...eated with leflunomide, we strongly re...
...ally recommend treatment with CYC for...
...lly teratogenic medications are discontinued pr...
...n with inadvertent exposure to teratogenic m...
...recommend HCQ, azathioprine/6-mercapto...
...y recommend calcineurin inhibitors (tacrolimus and...
...ionally recommend discontinuation of NSAID...
...e strongly recommend against use of NSA...
...lly recommend nonselective NSAIDs over...
...nditionally recommend continuing low-dose glucoc...
...strongly recommend tapering higher doses o...
...though there are only minimal data regar...
...nditionally recommend continuing tumor necro...
...ngly recommend continuation of certolizumab therap...
...tionally recommend continuing treatment with anak...
...e conditionally recommend continuing...
...ation use during breastfeeding
...uggest as standard good practice that women w...
..., we suggest that disease control be...
...gly recommend treatment with HCQ,...
...recommend prednisone...
...ut strongly recommend that with dose...
...lly recommend treatment with azathioprine/6-merc...
...ecommend against use of CYC, leflunomide...
...ditionally recommend against use of MTX...
...1. Reproductive health care in patients with R...
...ontracepti...
All R...
...n/pregnancy discussion early and r...
...thods if unable to use other methods. (GPS)70...
...ency contraception if necessary. [6...
...immunosuppressive medications: Use intrauterine...
...t risk for osteoporosis: Avoid depo...
...n receiving mycophenolate mofetil (MMF):...
...systemic lupus erythematosus (SLE) or ant...
...ighly effective methods preferred t...
...LE...
...ative aPL and low/stable disease a...
...ective methods preferred to effective methods. [...
Avoid transdermal estrogen-progest...
...ith negative aPL and moderate-to-high dise...
...sitive aPLÂ ...
...not use combined estrogen-progestin contracepti...
...ted reproductive technology ...
...l RMD Stabl...
...fertilization if pregnancy-compatible med...
...opreservation: Continue medications...
...ive disease: Defer assisted reproductive technolog...
...LE...
...LE: Defer assisted reproductive technology unti...
...s undergoing assisted reproductive tec...
...ositive aPL...
...ed reproductive technology in patients with asymp...
...ed reproductive technology patients with no...
...r assisted reproductive technology p...
...tility preservatio...
Women: Use gonadotropin-releasing h...
...erm cryopreservation pre–CYC trea...
...gonadotropin-releasing hormone agonist therapy d...
...enopause/hormone replacement therapy...
...ll RM...
RMD without SLE or aPL: Treat with hormon...
...LE...
...nd negative aPL: Treat with hormone repla...
Positive a...
...thrombosis or OB APS: Do not treat...
...ters negative, treat with hormone replac...
...prior thrombosis or OB APS and not receiving anti...
...s negative, do not treat with hormone...
...ior thrombosis or OB APS and receiving anticoag...
...gnancy
...ll RM...
...Outcomes improved with pregnancy...
...e-pregnancy: Change to pregnancy-c...
...ctive disease during pregnancy: In...
...or SLE-like disease, Sjögren’s syndrom...
...d renal crisis during pregnancy: Trea...
...LE
...r SLE-like disease: Test once (early) for a...
...ontinue hydroxychloroquine (HCQ) d...
...taking HCQ, start HCQ during pregnancy i...
...tor laboratory values at least once pe...
...with low-dose aspirin starting in first...
...sitive aPLÂ
...sitive aPL only: If no prior thrombosis or...
...only: Do not treat with combination prop...
...ve aPL only: Do not treat with HCQ. [44A] (...
...hrombosis but meet OB APS criteria, treat with com...
...S: Do not treat with combination therapeutic hepa...
...B-APS: Do not treat with addition of IV immunogl...
...not treat with addition of prednison...
...S: Treat with addition of HCQ for combi...
...-APS: Treat with prophylactic antico...
...tic-APS: If prior thrombosis (meet...
...APS: Treat with addition of HCQ for therapeutic h...
...ti-Ro/SSA with or without anti-L...
...with HCQ during pregnancy. [69, 7...
...prior history of neonatal lupus: Serial (int...
...history of neonatal lupus: Weekly fe...
...ormal fetal echocardiography: If firs...
If isolated third-degree heart block (and n...
...dicationÂ
...ternal medicatio...
...planning to father a child: Discuss medic...
...YC and thalidomide. [133, 139] ()Strong/Conditiion...
...inue HCQ, AZA, infliximab, etanercep...
...unomide, MMF, nonsteroidal anti-inflamm...
Maternal medication...
...ing pregnancy: Discuss medication u...
...regnant and exposed to teratogenic...
...nue NSAIDs if difficulty conceiving. [...
...in third trimester. [87] (Strong)7070...
...ctive rather than cyclooxygenase 2 (COX-2)â€...
...nue methotrexate (MTX), MMF, thalidomide,...
...life-threatening disease only in seco...
...tinue leflunomide 24 months prior to conception...
...e HCQ, sulfasalazine, azathioprine (A...
...closporine and tacrolimus. [127, 131] (Conditiona...
...e certolizumab. [156] (Strong)7...
...imab, etanercept, adalimumab, golim...
...top when pregnancy confirmed: rituximab, belimuma...
...or organ-or life-threatening disease du...
No recommendations for tofacitinib, barici...
...gular low-dose prednisone. [201] (Conditiona...
...high-dose prednisone with addition of preg...
...oid at delivery. Do not treat for vag...
...stfeedingÂ...
...astfeeding and maintain disease control with comp...
Compatible medicati...
HCQ, infliximab, etanercept, adalimumab...
...Ds, sulfasalazine, colchicine, AZA, cyclosporine,...
...nonfluorinated steroid equivalent...
...‰Ą20 mg daily, discard breast milk...
...with leflunomide, MMF, CYC, thalidomid...
...with MTX. [106] (Conditional)7070...
...a Recommendation numbers, sho...
...able 2. Safety and efficacy of variou...
...e 3. Recommendations regarding medic...
...ioprine/6-mercaptopurine Colchic...
...nakinra Cyclooxygenase 2 inhibito...
...hosphamide (discontinue 12 weeks prior to atte...
...discontinue 4 weeks prior to attempte...
...Abatacept Apremilast Baricitini...
...Maternal medication use: overview of medication...
...1. Recommendations and good practice statements...
...igure 2. Recommendations for use of assisted...
...e 3. Recommendations and GPS for HRT u...
...mendations and GPS for pregnancy counselin...