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
...reatment
...commendation...
...traception
...l RMD...
...n fertile women with RMD who have n...
...g effective methods, we conditionally recommen...
...gly recommend discussing use of emergenc...
...patients...
...with stable or low disease activity who...
...onally recommend the highly effective...
...conditionally recommend against use of the transd...
...ecommend progestin-only or IUD contr...
...ospholipid antibody–positive pa...
...strongly recommend against combined...
...ecommend IUDs (levonorgestrel or copper) or t...
...ecial RMD situations...
...the most effective contraceptive options, we s...
...n with RMD who are at increased risk for oste...
...conditionally recommend that women with RM...
...ted reproductive technolo...
...mmend proceeding with ART if needed in wo...
...patients...
...commend deferring ART procedures in...
...itionally recommend against an empiri...
...ipid antibody–positive patients...
...patients with RMD who desire pregn...
...conditionally recommend prophylactic anti...
...y recommend prophylactic anticoagulati...
...gly recommend therapeutic anticoagulatio...
...oocyte cryopreservation...
...recommend continuation of necessary...
...eservation with cyclophosphamide
...ertility preservation in women with RMD treated...
...ertility preservation in men with RMD treated...
...use sperm cryopreservation prior to treat...
...and hormone replacement therapy...
...ly suggest as good practice the use...
...E patients...
...SLE patients without positive aPL who desire...
...positive patients...
...men with asymptomatic aPL, we conditionally recom...
...recommend against use of HRT in women with...
We conditionally recommend against...
...onditionally recommend consideration of...
...al assessment, counseling, and manageme...
...ood practice, we strongly suggest counsel...
...RMD planning pregnancy who are receiving medi...
...omen with RMD who are currently pregnant and h...
...commend testing for anti-Ro/SSA and a...
...iven the relative persistence and unchanged ti...
...th scleroderma renal crisis...
...trongly recommend use of angiotensin-converting en...
...E patients...
...with SLE who are considering pregnancy or are pr...
...e recommend that all women with SLE tak...
...is not taking HCQ, we conditionally recomm...
...e conditionally recommend treating SLE patients...
...ecause active disease affects maternal and pr...
...ospholipid antibody–positive pat...
...women with positive aPL who do not mee...
...ngly recommend combined low-dose aspir...
...women with OB APS, we further strongly re...
...men with thrombotic APS, we strongly recommend t...
...nditionally recommend against using the combin...
...ionally recommend against treatmen...
...ly recommend against adding prednisone to p...
...itionally recommend the addition of HCQ to prop...
...nt women with positive aPL who do not mee...
Anti-Ro/SSA and/or anti-La/ SSB antibodies in preg...
...men with anti-Ro/SSA and/or anti-La/SSB...
...th a prior infant with CHB or other NLE we cond...
...conditionally recommend treating all wo...
...omen with anti-Ro/SSA and/or anti-La/SSB antibodie...
...t other cardiac inflammation) is present, we cond...
...cation use...
...nal medication use...
...ngly recommend against use of CYC and t...
In men with RMD who are planning to fathe...
...men with RMD who are planning to father a...
...lly recommend continuation of anakinra and r...
...ernal medication use
...ood practice, we suggest discussing medication...
..., and thalidomide are known teratogens. We st...
For women treated with leflunomide, we str...
...ionally recommend treatment with CYC for life-thre...
...tially teratogenic medications are disconti...
...inadvertent exposure to teratogenic...
...recommend HCQ, azathioprine/6-mercap...
...lly recommend calcineurin inhibitor...
...onally recommend discontinuation of NSAIDs...
...ommend against use of NSAIDs in the third t...
...itionally recommend nonselective NSAID...
...recommend continuing low-dose glucocort...
...ommend tapering higher doses of nonfluorinated g...
...though there are only minimal data regarding prol...
...e conditionally recommend continuing tumor nec...
...ommend continuation of certolizumab therapy...
...lly recommend continuing treatment...
...tionally recommend continuing treatment w...
...dication use during breastf...
...gest as standard good practice that wome...
...we suggest that disease control be maintain...
...y recommend treatment with HCQ, colchicine, s...
...also recommend prednisone...
...gly recommend that with doses of prednisone ≥...
...ly recommend treatment with azathioprine/6-merc...
...recommend against use of CYC, leflunomide,...
...conditionally recommend against use of MTX whil...
...ctive health care in patients with...
...ntraceptio...
All RMD
...regnancy discussion early and regularl...
...methods if unable to use other metho...
...ency contraception if necessary. [6] (S...
...immunosuppressive medications: Use int...
...r osteoporosis: Avoid depot medroxyprog...
...n receiving mycophenolate mofetil (MMF): U...
...ut systemic lupus erythematosus (SLE) or antiph...
...ghly effective methods preferred to effective me...
...LE
...negative aPL and low/stable disease...
...effective methods preferred to effective...
...ransdermal estrogen-progestin patch. [2B] (Con...
...negative aPL and moderate-to-high disease act...
...tive aPLÂ ...
...t use combined estrogen-progestin contrac...
Assisted reproductive technology...
...fertilization if pregnancy-compatible med...
...ryopreservation: Continue medications except cy...
...e disease: Defer assisted reproductive tech...
SLE
...SLE: Defer assisted reproductive technology...
...undergoing assisted reproductive tec...
Positive aPL
...productive technology in patients with as...
...eproductive technology patients with no...
...reproductive technology patients with prior thro...
...rtility preserva...
...: Use gonadotropin-releasing hormone agonis...
...perm cryopreservation pre–CYC treatment. (GPS)70...
...en: Do not use gonadotropin-releasi...
...se/hormone replacement ther...
All RM...
...E or aPL: Treat with hormone replacement therapy...
...LE...
...gative aPL: Treat with hormone replacement...
...sitive aPL...
...or thrombosis or OB APS: Do not treat with hormone...
...titers negative, treat with hormone replace...
...rior thrombosis or OB APS and not rec...
...urrent titers negative, do not treat with...
...hrombosis or OB APS and receiving anticoagulatio...
...regnan...
All R...
...eling: Outcomes improved with pregnancy planning,...
...pregnancy: Change to pregnancy-compa...
...isease during pregnancy: Initiate pregnancy-compat...
...or SLE-like disease, Sjögren’s syn...
If SSc and renal crisis during pregnancy:...
SLE
...r SLE-like disease: Test once (early) for aP...
...ntinue hydroxychloroquine (HCQ) during pregnancy....
...f not taking HCQ, start HCQ during pregnancy...
...nitor laboratory values at least once...
Treat with low-dose aspirin starting in firs...
...tive aPLÂ ...
...ly: If no prior thrombosis or OB APS, treat w...
...ve aPL only: Do not treat with comb...
...y: Do not treat with HCQ. [44A] (Conditional)7070...
...thrombosis but meet OB APS criteria, treat with...
...t treat with combination therapeutic hepar...
...PS: Do not treat with addition of...
...Do not treat with addition of prednisone. [51]...
...eat with addition of HCQ for combination hep...
...with prophylactic anticoagulation during post...
...hrombotic-APS: If prior thrombosis (meeting o...
...mbotic-APS: Treat with addition of...
...e anti-Ro/SSA with or without an...
...th HCQ during pregnancy. [69, 70] (Conditiona...
...ior history of neonatal lupus: Serial (int...
...r history of neonatal lupus: Weekly fet...
...l fetal echocardiography: If first-or sec...
...d third-degree heart block (and no ot...
...dication...
...ternal medicat...
...ng to father a child: Discuss medication use...
...C and thalidomide. [133, 139] ()Strong/Co...
...Q, AZA, infliximab, etanercept, adalimumab, goli...
...tinue leflunomide, MMF, nonsteroidal...
...ernal medication ...
...egnancy: Discuss medication use including...
...exposed to teratogenic medications: Dis...
...IDs if difficulty conceiving. [86] (C...
...s in third trimester. [87] (Strong...
...se nonselective rather than cyclooxygenase 2 (...
...thotrexate (MTX), MMF, thalidomide...
...life-threatening disease only in second and third...
...leflunomide 24 months prior to conception or...
...ontinue HCQ, sulfasalazine, azathioprine (AZA), co...
...sporine and tacrolimus. [127, 131] (Condit...
...olizumab. [156] (Strong)7070...
...infliximab, etanercept, adalimumab,...
...pregnancy confirmed: rituximab, belimumab, an...
...imab for organ-or life-threatening disease d...
...tions for tofacitinib, baricitinib, apremilast du...
...inue regular low-dose prednisone. [201] (Condi...
...dose prednisone with addition of pregnancy-...
...tress-dose steroid at delivery. Do...
BreastfeedingÂ...
...ncourage breastfeeding and maintain disease co...
...tible medications:...
...iximab, etanercept, adalimumab, golimumab, ce...
...AIDs, sulfasalazine, colchicine, AZA, cyclospor...
...nfluorinated steroid equivalent...
...ednisone ≥20 mg daily, discard br...
...ot treat with leflunomide, MMF, CYC, thalidomide....
...ith MTX. [106] (Conditional)7070...
...a Recommendation numbers, shown i...
...2. Safety and efficacy of various contraceptive me...
...Recommendations regarding medicatio...
...rine/6-mercaptopurine Colchicine...
Anakinra Cyclooxygenase 2 inhibitors...
...hamide (discontinue 12 weeks prior to attempted...
...halidomide (discontinue 4 weeks prio...
...Apremilast Baricitinib Belimumab S...
...rnal medication use: overview of m...
...igure 1. Recommendations and good...
...ure 2. Recommendations for use of a...
...ommendations and GPS for HRT use in postmenopa...
...ommendations and GPS for pregnancy counseling, as...