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
...Treatment...
...Recommendations ...
...Contr...
...All...
...rtile women with RMD who have neither S...
...fective methods, we conditionally recommend t...
...rongly recommend discussing use of em...
...SLE p...
...LE patients with stable or low disease acti...
...nditionally recommend the highly ef...
...y recommend against use of the transdermal...
...gly recommend progestin-only or IUD contracep...
Antiphosp...
...commend against combined estrogen-...
...y recommend IUDs (levonorgestrel or copper) or t...
...Other special RM...
...the most effective contraceptive options, w...
...women with RMD who are at increased risk for...
...onditionally recommend that women with RMD taki...
...Assisted reproductive t...
...rongly recommend proceeding with ART if n...
...SLE patient...
...mmend deferring ART procedures in patien...
...conditionally recommend against an em...
...Antiphospholipi...
...rtile patients with RMD who desire pr...
...tionally recommend prophylactic anticoagulation t...
...gly recommend prophylactic anticoagu...
...rongly recommend therapeutic anticoagulation...
...Em...
...ly recommend continuation of necess...
...Fertility p...
...servation in women with RMD treated with CYCTo pr...
...rvation in men with RMD treated with CYCWe...
...ecause sperm cryopreservation prior...
...Meno...
...trongly suggest as good practice th...
...SLE patients...
...E patients without positive aPL who desire HRT...
...aPL-po...
...asymptomatic aPL, we conditionally...
...ommend against use of HRT in women with obste...
...ly recommend against HRT use in patients with APS...
We conditionally recommend considerati...
...Pregnancy: ge...
...practice, we strongly suggest counseling women...
...RMD planning pregnancy who are receivin...
...D who are currently pregnant and have active dise...
...recommend testing for anti-Ro/SSA and ant...
...ative persistence and unchanged titers of t...
...Patien...
...rongly recommend use of angiotensin...
...SLE patients...
...LE who are considering pregnancy or are pregn...
...hat all women with SLE take hydroxy...
...she is not taking HCQ, we conditionally reco...
...e conditionally recommend treating...
Because active disease affects maternal and preg...
...Antiphospholipid...
...n pregnant women with positive aPL who do...
...commend combined low-dose aspirin and prophyl...
...APS, we further strongly recommend...
In pregnant women with thrombotic...
...onally recommend against using the combination of...
...ionally recommend against treatment wit...
...ly recommend against adding prednisone...
...itionally recommend the addition of HCQ to prophyl...
...ant women with positive aPL who do...
...Anti-Ro/SSA and/or...
...regnant women with anti-Ro/SSA and/or anti-La/SSB...
...th a prior infant with CHB or other NLE we condi...
...ly recommend treating all women wh...
...nt women with anti-Ro/SSA and/or ant...
...other cardiac inflammation) is present, w...
...Medicatio...
...Paternal medicati...
...y recommend against use of CYC and thalidomi...
...en with RMD who are planning to father a pr...
...men with RMD who are planning to fath...
...itionally recommend continuation o...
...Maternal medication...
...d practice, we suggest discussing medications...
...and thalidomide are known teratogens. We strongl...
...eated with leflunomide, we strongly r...
...nally recommend treatment with CYC f...
...potentially teratogenic medications are d...
...inadvertent exposure to teratogenic medicatio...
...ngly recommend HCQ, azathioprine/6-mercaptopurine...
...e conditionally recommend calcineuri...
...nditionally recommend discontinuation of...
...recommend against use of NSAIDs in the...
...nally recommend nonselective NSAIDs...
...recommend continuing low-dose glucocorticoi...
...trongly recommend tapering higher...
...here are only minimal data regarding pr...
...conditionally recommend continuing tumor nec...
...ommend continuation of certolizumab therapy p...
...y recommend continuing treatment with anakin...
...y recommend continuing treatment with rituximab...
...Medication use dur...
...uggest as standard good practice th...
...we suggest that disease control be mai...
...ecommend treatment with HCQ, colchicine...
...e also recommend predni...
...ommend that with doses of prednisone â‰...
...lly recommend treatment with azathioprine/6...
...ngly recommend against use of CYC,...
...nally recommend against use of MTX...
...Table 1. Reproductive health...
...Contraception...
...All RMD...
...eption/pregnancy discussion early and re...
...barrier methods if unable to use other met...
...se emergency contraception if necessary....
...immunosuppressive medications: Use intrauter...
...k for osteoporosis: Avoid depot me...
...ng mycophenolate mofetil (MMF): Use IU...
...emic lupus erythematosus (SLE) or antiphosphol...
...y effective methods preferred to effective...
...SLE...
...th negative aPL and low/stable disease activity:...
...ighly effective methods preferred to effective...
...al estrogen-progestin patch. [2B] (Cond...
...gative aPL and moderate-to-high disease...
...Positive...
...mbined estrogen-progestin contraceptives. [3] Use...
...Assisted reproduct...
...All RMDSta...
...vitro fertilization if pregnancy-compatibl...
...ervation: Continue medications except cyclophosph...
...Defer assisted reproductive technology until...
...S...
Active SLE: Defer assisted reproductive...
...ients undergoing assisted reproductive tech...
...Positive aPL...
...sisted reproductive technology in patie...
...isted reproductive technology patients with...
...sisted reproductive technology patients with pr...
...Fertility preservat...
...nadotropin-releasing hormone agonist therapy...
...preservation pre–CYC treatment. (GPS)7070...
...ot use gonadotropin-releasing hormone agonist...
...Menopause/hormone r...
...All RMD...
...E or aPL: Treat with hormone replacement...
...SLE...
...egative aPL: Treat with hormone re...
...Positiv...
...no prior thrombosis or OB APS: Do not tr...
...s negative, treat with hormone replacement ther...
...mbosis or OB APS and not receiving anticoa...
...titers negative, do not treat with hormone replac...
...f prior thrombosis or OB APS and receiving...
...Pregnancy...
...All...
...: Outcomes improved with pregnancy planning, stabl...
...egnancy: Change to pregnancy-compatible medicat...
If active disease during pregnancy: In...
...or SLE-like disease, Sjögren’s syndr...
...nal crisis during pregnancy: Treat wi...
...E or SLE-like disease: Test once (early) for aPL...
...xychloroquine (HCQ) during pregnancy. [57] (Stron...
...king HCQ, start HCQ during pregnan...
...ratory values at least once per trimester. (GPS)70...
...reat with low-dose aspirin starting in first trime...
...Positive aPLÂ ...
...aPL only: If no prior thrombosis or OB APS,...
...PL only: Do not treat with combination...
...ive aPL only: Do not treat with HCQ. [4...
...If no thrombosis but meet OB APS crit...
...reat with combination therapeutic heparin or L...
...not treat with addition of IV immunog...
...-APS: Do not treat with addition of prednis...
...with addition of HCQ for combination hepa...
...Treat with prophylactic anticoagulation durin...
...: If prior thrombosis (meeting or not meetin...
...Treat with addition of HCQ for ther...
...Positive anti-R...
...with HCQ during pregnancy. [69, 70] (...
...ory of neonatal lupus: Serial (interval u...
...f prior history of neonatal lupus: Weekly feta...
...ormal fetal echocardiography: If first-or...
...isolated third-degree heart block (and no other...
...Medication ...
...Paternal me...
...planning to father a child: Discuss medication u...
Discontinue CYC and thalidomide. [133, 13...
...ue HCQ, AZA, infliximab, etanercept, adalimumab,...
...flunomide, MMF, nonsteroidal anti-inf...
...Maternal m...
...nancy: Discuss medication use incl...
...nt and exposed to teratogenic medica...
...ontinue NSAIDs if difficulty conceiving. [...
...IDs in third trimester. [87] (Strong)7070...
...nonselective rather than cyclooxygenase 2 (COX...
...thotrexate (MTX), MMF, thalidomide, CYC prior...
...ife-threatening disease only in second and...
...iscontinue leflunomide 24 months prior to...
...ntinue HCQ, sulfasalazine, azathiopri...
Continue cyclosporine and tacrolimu...
...certolizumab. [156] (Strong)7070...
...ntinue infliximab, etanercept, adalimumab,...
...p when pregnancy confirmed: rituximab, bel...
...imab for organ-or life-threatening...
...mmendations for tofacitinib, baric...
...gular low-dose prednisone. [201] (Con...
...ose prednisone with addition of pregnancy-compat...
...eroid at delivery. Do not treat for vaginal...
...Breastfeeding...
...ncourage breastfeeding and maintain disease...
...mpatible medications...
...ab, etanercept, adalimumab, golimumab, cer...
...lfasalazine, colchicine, AZA, cyclosporine, tacrol...
...sone or nonfluorinated steroid equi...
...dnisone ≥20 mg daily, discard br...
...reat with leflunomide, MMF, CYC, thalid...
...t with MTX. [106] (Conditional)707...
...a Recommendation numbers, shown i...
...fety and efficacy of various contraceptive meth...
...Table 3....
...ioprine/6-mercaptopurine Colchicine...
...nakinra Cyclooxygenase 2 inhibi...
...mide (discontinue 12 weeks prior to at...
...idomide (discontinue 4 weeks prior to attempted c...
...t Apremilast Baricitinib Belimumab...
...4. Maternal medication use: overview of med...
...igure 1. Recommendations and good practice st...
...re 2. Recommendations for use of assisted...
...3. Recommendations and GPS for HRT use in...
...4. Recommendations and GPS for pregnancy...