Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases

Publication Date: February 23, 2020

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

...Treatment...

...Recommendations ...

...Contraception...

...All RMD...

...fertile women with RMD who have neith...

...g effective methods, we conditional...

...trongly recommend discussing use of emergency...

...SLE patients...

...with stable or low disease activit...

...onally recommend the highly effective I...

...ly recommend against use of the transder...

...ecommend progestin-only or IUD contraceptives...

...Antiphospholipid...

...trongly recommend against combined estrogen-pro...

...ly recommend IUDs (levonorgestrel or cop...

...Other spec...

...ce IUDs are the most effective contracepti...

...RMD who are at increased risk for osteoporosi...

...itionally recommend that women with RMD taking...

...Assisted reprod...

...y recommend proceeding with ART if needed...

...SLE patients...

...ly recommend deferring ART procedures...

...ditionally recommend against an empiric dosage inc...

...Antip...

...bfertile patients with RMD who desire...

...itionally recommend prophylactic antic...

...trongly recommend prophylactic anticoagulation wit...

...rongly recommend therapeutic anticoagulation...

...Embryo and ooc...

...strongly recommend continuation of necess...

Fertilit...

...ty preservation in women with RMD t...

...y preservation in men with RMD trea...

...ecause sperm cryopreservation prior to treatm...

...Menopause and...

...e strongly suggest as good practice the use of HRT...

...SLE patients...

...n SLE patients without positive aPL who des...

...aPL-positive...

...en with asymptomatic aPL, we condi...

...strongly recommend against use of HRT in women...

...e conditionally recommend against HR...

...ly recommend consideration of HRT, if desired,...

...Pre...

...standard good practice, we strongly suggest coun...

...en with RMD planning pregnancy who are recei...

...men with RMD who are currently pregnant and hav...

...e strongly recommend testing for anti...

...tive persistence and unchanged tite...

...Pati...

...gly recommend use of angiotensin-converting en...

...SLE patients...

...SLE who are considering pregnancy o...

We recommend that all women with SLE take hyd...

...s not taking HCQ, we conditionally rec...

...ionally recommend treating SLE patie...

...ive disease affects maternal and pre...

...Antiphospholipid antib...

...ant women with positive aPL who do not meet cr...

We strongly recommend combined low-dose...

...omen with OB APS, we further strongly recommend tr...

...men with thrombotic APS, we strongly recommend...

...conditionally recommend against using t...

...y recommend against treatment with intrave...

...ommend against adding prednisone to prophylactic-d...

We conditionally recommend the addition of...

...nant women with positive aPL who do not...

...pregnant women with anti-Ro/SSA and/or a...

...ith a prior infant with CHB or other NLE we...

...ionally recommend treating all wom...

...t women with anti-Ro/SSA and/or anti-La...

...( without other cardiac inflammation) i...

...Medication us...

...Pat...

...recommend against use of CYC and thalidomide in m...

...D who are planning to father a pregnancy, we str...

...with RMD who are planning to father a...

...ionally recommend continuation of anakinra and...

...Maternal medication use...

...dard good practice, we suggest discussing medicati...

...MMF, CYC, and thalidomide are known tera...

...ated with leflunomide, we strongly recommend c...

...ditionally recommend treatment with CYC fo...

...y teratogenic medications are discontinued...

...omen with inadvertent exposure to...

...strongly recommend HCQ, azathioprine/...

...onditionally recommend calcineurin inhibit...

...tionally recommend discontinuation o...

...recommend against use of NSAIDs in th...

...ionally recommend nonselective NSAI...

...itionally recommend continuing low-dose...

...recommend tapering higher doses of nonfluorinat...

...gh there are only minimal data regardi...

...onditionally recommend continuing tumor nec...

...ommend continuation of certolizumab thera...

...nally recommend continuing treatment with ana...

...ally recommend continuing treatment with ritux...

...Medication use d...

...as standard good practice that women...

...ddition, we suggest that disease con...

...commend treatment with HCQ, colchici...

...lso recommend prednisone...

...rongly recommend that with doses of prednis...

...onally recommend treatment with azathioprine/6-me...

...gly recommend against use of CYC, leflu...

...nditionally recommend against use of MTX while b...


...Contrac...

...All RMD...

.../pregnancy discussion early and regu...

...hods if unable to use other methods. (GPS)70...

...contraception if necessary. [6] (Strong)7070...

...ng immunosuppressive medications: Use intrauter...

...sk for osteoporosis: Avoid depot med...

...ving mycophenolate mofetil (MMF): Use IU...

...MD without systemic lupus erythematosus...

...methods preferred to effective metho...

...ve aPL and low/stable disease activity: U...

Highly effective methods preferred to effe...

...ransdermal estrogen-progestin patch. [2B...

...ive aPL and moderate-to-high disease...

...Positi...

Do not use combined estrogen-progestin c...

...Assisted re...

All...

...vitro fertilization if pregnancy-compatible me...

...ocyte cryopreservation: Continue medications e...

...ase: Defer assisted reproductive technology unt...

...SLE...

...er assisted reproductive technology until diseas...

...nts undergoing assisted reproductive t...

...Posit...

...ed reproductive technology in patients with a...

...sisted reproductive technology patie...

...reproductive technology patients with prior th...

...Fertility pre...

...omen: Use gonadotropin-releasing hormone agoni...

...opreservation pre–CYC treatment. (GPS)7070...

...Do not use gonadotropin-releasing hormone agoni...

...Menopause/hormon...

...without SLE or aPL: Treat with hormone re...

...tive aPL: Treat with hormone replacement thera...

...Positive aPL...

...ombosis or OB APS: Do not treat with...

...titers negative, treat with hormon...

...ombosis or OB APS and not receiving anticoagul...

...ent titers negative, do not treat with hormo...

...mbosis or OB APS and receiving antic...

...Pregnan...

...: Outcomes improved with pregnancy planning...

...cy: Change to pregnancy-compatible medication an...

...ve disease during pregnancy: Initiate pregnancy-...

...f SLE or SLE-like disease, Sjögren’s syndro...

...renal crisis during pregnancy: Treat with a...

...SLE...

...disease: Test once (early) for aPL...

Continue hydroxychloroquine (HCQ) during...

...HCQ, start HCQ during pregnancy if no contr...

...ry values at least once per trimester. (GPS)707...

...eat with low-dose aspirin starting in first trime...

...Positive...

...L only: If no prior thrombosis or OB APS, treat wi...

...only: Do not treat with combination prophylactic...

...itive aPL only: Do not treat with HCQ. [44A]...

...hrombosis but meet OB APS criteria,...

...APS: Do not treat with combination...

...not treat with addition of IV immunoglo...

...t treat with addition of prednisone. [51] (Stron...

...: Treat with addition of HCQ for combination hepa...

...S: Treat with prophylactic anticoagulation...

...: If prior thrombosis (meeting or...

...botic-APS: Treat with addition of HC...

...Positive anti-...

...h HCQ during pregnancy. [69, 70] (C...

...rior history of neonatal lupus: Serial (interval...

...ory of neonatal lupus: Weekly fetal echoca...

...bnormal fetal echocardiography: If first-...

...olated third-degree heart block (and...

...Medica...

...Paternal me...

...father a child: Discuss medication use including...

...e CYC and thalidomide. [133, 139] ()Strong/Condit...

...nue HCQ, AZA, infliximab, etanercept, adali...

...nomide, MMF, nonsteroidal anti-inflammatory drugs...

...Maternal me...

...planning pregnancy: Discuss medication use in...

...exposed to teratogenic medications: Discont...

...SAIDs if difficulty conceiving. [86] (Condition...

...SAIDs in third trimester. [87] (Strong)7070...

...se nonselective rather than cyclooxygenase 2...

...iscontinue methotrexate (MTX), MMF, thal...

...life-threatening disease only in second and...

...leflunomide 24 months prior to concepti...

...HCQ, sulfasalazine, azathioprine...

Continue cyclosporine and tacrolimus. [127, 1...

...ontinue certolizumab. [156] (S...

...ue infliximab, etanercept, adalimumab, golim...

...pregnancy confirmed: rituximab, belim...

...for organ-or life-threatening disease dur...

...ations for tofacitinib, baricitinib, apremil...

...r low-dose prednisone. [201] (Conditio...

...prednisone with addition of pregnancy-compatible d...

...steroid at delivery. Do not treat for v...

...Breastfeeding...

...rage breastfeeding and maintain disease cont...

...ble medications:...

..., infliximab, etanercept, adalimumab...

...s, sulfasalazine, colchicine, AZA, cy...

...or nonfluorinated steroid equivalent...

...prednisone ≥20 mg daily, discard breast...

...eat with leflunomide, MMF, CYC, thali...

...reat with MTX. [106] (Conditional)7070...

...a Recommendation numbers, sh...


...Safety and efficacy of various contraceptive met...


...Table 3. Recomm...

...prine/6-mercaptopurine Colchicine Hydrox...

...a Cyclooxygenase 2 inhibitors Cyclosporine...

...e (discontinue 12 weeks prior to attempte...

...scontinue 4 weeks prior to attempted conc...

...pt Apremilast Baricitinib Belimumab...


...4. Maternal medication use: overview of medi...


...1. Recommendations and good practice statements (...


...e 2. Recommendations for use of assisted re...


...gure 3. Recommendations and GPS for HRT us...


...4. Recommendations and GPS for pregnancy couns...