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

...reatmen...

Recommendations...

Contraceptio...

All RMD

...men with RMD who have neither SLE nor positive aP...

...effective methods, we conditionally reco...

We strongly recommend discussing use of emerge...

...E patien...

...with stable or low disease activity wh...

...onditionally recommend the highly effective I...

...ditionally recommend against use of th...

...strongly recommend progestin-only or IUD contrac...

...tiphospholipid antibody–positive patient...

...strongly recommend against combined estrogen-p...

...rongly recommend IUDs (levonorgestrel or copper)...

...special RMD situations...

...are the most effective contraceptive opt...

...women with RMD who are at increased risk...

...ditionally recommend that women wit...

...ed reproductive technology...

...trongly recommend proceeding with ART if n...

SLE patient...

...ecommend deferring ART procedures in patients w...

...tionally recommend against an empiric dosage inc...

...pid antibody–positive patients...

...fertile patients with RMD who desire pregn...

...lly recommend prophylactic anticoagulation th...

...ecommend prophylactic anticoagulation with hep...

...ongly recommend therapeutic anticoagul...

Embryo and oocyte cryopreser...

...ngly recommend continuation of necessary immunos...

...reservation with cyclophosphamide...

...preservation in women with RMD treated with CYCTo...

...ervation in men with RMD treated with CYCW...

...ause sperm cryopreservation prior to treatme...

...hormone replacement therapy...

...est as good practice the use of HRT in postmen...

...E patients...

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

...ositive patient...

...en with asymptomatic aPL, we condit...

...ongly recommend against use of HRT i...

...nally recommend against HRT use in patients...

...y recommend consideration of HRT, if desired, in...

...ncy: general assessment, counseling, and manageme...

...rd good practice, we strongly suggest counseli...

...omen with RMD planning pregnancy who...

...ith RMD who are currently pregnant and have...

...ommend testing for anti-Ro/SSA and anti-La/SSB o...

...elative persistence and unchanged t...

...s with scleroderma renal crisi...

...y recommend use of angiotensin-conve...

...E patien...

...SLE who are considering pregnancy or ar...

...ecommend that all women with SLE take hydroxy...

...t taking HCQ, we conditionally recommend star...

...ditionally recommend treating SLE patie...

...use active disease affects materna...

...iphospholipid antibody–positive patie...

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

...rongly recommend combined low-dose...

...with OB APS, we further strongly recommend treatin...

...nt women with thrombotic APS, we strongly...

...nally recommend against using the combination...

...conditionally recommend against treatment with...

...e strongly recommend against adding prednis...

...lly recommend the addition of HCQ to pro...

...n pregnant women with positive aPL who do not...

...o/SSA and/or anti-La/ SSB antibodies in pr...

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

...with a prior infant with CHB or other N...

...ally recommend treating all women who are positi...

...r pregnant women with anti-Ro/SSA and...

...hout other cardiac inflammation) is present, we c...

...cation use...

...al medication use...

...strongly recommend against use of CYC and...

...MD who are planning to father a pregnancy...

...MD who are planning to father a pregnan...

...itionally recommend continuation of anakin...

Maternal medication u...

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

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

For women treated with leflunomide, we s...

...e conditionally recommend treatment with CYC f...

...tially teratogenic medications are discont...

...with inadvertent exposure to teratogenic medicati...

...ommend HCQ, azathioprine/6-mercaptopur...

...ally recommend calcineurin inhibitors...

...ionally recommend discontinuation of N...

...strongly recommend against use of NSAIDs i...

...ionally recommend nonselective NSAIDs over cycloox...

...nditionally recommend continuing l...

...ngly recommend tapering higher dose...

...re only minimal data regarding prolonged treatm...

...ditionally recommend continuing tumo...

...ngly recommend continuation of certolizumab th...

...nally recommend continuing treatment with anakin...

...e conditionally recommend continuing treatment wi...

...ion use during breastfeedi...

We suggest as standard good practice that women...

...n, we suggest that disease control be...

...e strongly recommend treatment with HCQ,...

...also recommend prednisone...

but strongly recommend that with doses of predniso...

...conditionally recommend treatment wi...

...ongly recommend against use of CYC, leflunomide...

...nditionally recommend against use of MTX...


...oductive health care in patients wit...

...raception...

All RMD

...ion/pregnancy discussion early and...

Use barrier methods if unable to use...

...emergency contraception if necessary....

...eceiving immunosuppressive medications: Use intrau...

...for osteoporosis: Avoid depot medroxypr...

...ceiving mycophenolate mofetil (MMF): Use IUD or...

...thout systemic lupus erythematosus...

...ghly effective methods preferred to effect...

SLE

...gative aPL and low/stable disease activity: Use h...

...ghly effective methods preferred to e...

...id transdermal estrogen-progestin patch. [2...

...h negative aPL and moderate-to-high disease ac...

...itive aPL ...

...se combined estrogen-progestin contraceptives. [...

...ssisted reproductive technology...

...Stable diseas...

...itro fertilization if pregnancy-compati...

...cryopreservation: Continue medications ex...

...Defer assisted reproductive technology until di...

...LE

...e SLE: Defer assisted reproductive techno...

...or patients undergoing assisted reprodu...

...tive aPL

...assisted reproductive technology in patient...

...d reproductive technology patients w...

...ssisted reproductive technology patients with...

...tility preservation...

...Use gonadotropin-releasing hormone agonist the...

...m cryopreservation pre–CYC treatment...

...gonadotropin-releasing hormone agonist therapy...

...ormone replacement therapy...

All R...

...SLE or aPL: Treat with hormone repl...

SLE

...and negative aPL: Treat with hormone replacemen...

...itive aP...

...f no prior thrombosis or OB APS: Do not treat wit...

...iters negative, treat with hormone replaceme...

...rombosis or OB APS and not receiving anticoagulat...

...rent titers negative, do not treat with hormone...

...bosis or OB APS and receiving antic...

...regnancy

...l RMD...

...unseling: Outcomes improved with pregnancy...

...e-pregnancy: Change to pregnancy-compatibl...

...disease during pregnancy: Initiate pre...

If SLE or SLE-like disease, Sjögren’s s...

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

SLE

...LE or SLE-like disease: Test once (ear...

...ue hydroxychloroquine (HCQ) during preg...

...not taking HCQ, start HCQ during pregna...

...tor laboratory values at least onc...

...with low-dose aspirin starting in...

...tive aPL ...

...ive aPL only: If no prior thrombosis or OB APS, tr...

...ive aPL only: Do not treat with combinat...

...ly: Do not treat with HCQ. [44A] (Conditional)7070...

...thrombosis but meet OB APS criteria, treat with...

...not treat with combination therapeutic hep...

...S: Do not treat with addition of IV...

...Do not treat with addition of prednisone. [51]...

...with addition of HCQ for combination heparin...

...th prophylactic anticoagulation during post...

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

...ic-APS: Treat with addition of HCQ for the...

...anti-Ro/SSA with or without anti-La/SSB...

...uring pregnancy. [69, 70] (Conditional)7070...

...or history of neonatal lupus: Serial (int...

...history of neonatal lupus: Weekly fetal echocard...

...ormal fetal echocardiography: If first-or second-d...

...isolated third-degree heart block (and no o...

...edication 

...nal medication ...

...lanning to father a child: Discuss medica...

...ntinue CYC and thalidomide. [133, 139] ()Strong...

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

...unomide, MMF, nonsteroidal anti-inflammatory dru...

...aternal medicat...

...anning pregnancy: Discuss medication use i...

...and exposed to teratogenic medications: Di...

...NSAIDs if difficulty conceiving. [86] (Conditiona...

...void NSAIDs in third trimester. [87] (Strong)7070...

...e rather than cyclooxygenase 2 (COX-2)–specif...

...tinue methotrexate (MTX), MMF, thalidom...

...for life-threatening disease only in sec...

...nue leflunomide 24 months prior to conceptio...

...tinue HCQ, sulfasalazine, azathioprine (AZ...

...porine and tacrolimus. [127, 131]...

...certolizumab. [156] (Strong)7070...

...liximab, etanercept, adalimumab, go...

...en pregnancy confirmed: rituximab, belimum...

...imab for organ-or life-threatening dise...

...recommendations for tofacitinib, baricitinib, a...

...ar low-dose prednisone. [201] (Conditional...

...r high-dose prednisone with addition of pregnan...

...-dose steroid at delivery. Do not treat for vagi...

...reastfeeding 

...astfeeding and maintain disease control with comp...

Compatible medicatio...

...ximab, etanercept, adalimumab, golimumab...

...ulfasalazine, colchicine, AZA, cyclospori...

...ne or nonfluorinated steroid equi...

...or prednisone ≥20 mg daily, disc...

...treat with leflunomide, MMF, CYC, thalidomide...

...ot treat with MTX. [106] (Conditional)7070...

...a Recommendation numbers, shown in brackets, all...


...2. Safety and efficacy of various contrace...


...endations regarding medication use for men...

...oprine/6-mercaptopurine Colchicine H...

...Cyclooxygenase 2 inhibitors Cyclosporine...

...sphamide (discontinue 12 weeks prior to...

...iscontinue 4 weeks prior to attemp...

...t Apremilast Baricitinib Belimum...


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


...Recommendations and good practice stat...


...mendations for use of assisted reprodu...


...ecommendations and GPS for HRT use in postmeno...


...e 4. Recommendations and GPS for pregnancy coun...