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
...reatme...
...mmendationsÂ...
...traception...
All R...
...men with RMD who have neither SLE nor p...
...ong effective methods, we conditionally r...
...ommend discussing use of emergency contracep...
...patients...
...tients with stable or low disease activ...
...conditionally recommend the highly effec...
...onditionally recommend against use of the tra...
...gly recommend progestin-only or IUD co...
...d antibody–positive patients...
...ngly recommend against combined estro...
...ommend IUDs (levonorgestrel or copper) or the p...
...ecial RMD situations...
...Ds are the most effective contraceptiv...
...RMD who are at increased risk for osteo...
...nditionally recommend that women with...
...eproductive technology...
...recommend proceeding with ART if needed in wome...
...E patients...
We strongly recommend deferring ART procedu...
...ly recommend against an empiric dosage in...
...lipid antibody–positive patients...
...patients with RMD who desire pregnancy, have...
...ionally recommend prophylactic anticoa...
...y recommend prophylactic anticoagulation wi...
...trongly recommend therapeutic anticoag...
...and oocyte cryopreservation...
...rongly recommend continuation of n...
...preservation with cyclophosphamide...
...preservation in women with RMD treated with...
...ty preservation in men with RMD treated with C...
...perm cryopreservation prior to treatment pres...
...and hormone replacement therapy...
...rongly suggest as good practice the u...
...E patients...
...nts without positive aPL who desire HR...
aPL-positive patien...
...women with asymptomatic aPL, we cond...
...y recommend against use of HRT in wome...
...nditionally recommend against HRT use in pat...
...y recommend consideration of HRT, if desired, in...
Pregnancy: general assessment, counselin...
...dard good practice, we strongly suggest counselin...
...n women with RMD planning pregnanc...
...with RMD who are currently pregnant...
...e strongly recommend testing for anti-Ro...
...relative persistence and unchanged titer...
...ents with scleroderma renal c...
...ecommend use of angiotensin-converting enzyme...
...LE patient...
...omen with SLE who are considering pregnancy...
We recommend that all women with S...
...aking HCQ, we conditionally recommend starting...
...e conditionally recommend treating SLE...
...ecause active disease affects maternal...
...olipid antibody–positive patients...
...nt women with positive aPL who do not me...
...recommend combined low-dose aspirin and prophylac...
...OB APS, we further strongly recommend tr...
...egnant women with thrombotic APS, w...
...conditionally recommend against using the combina...
...ally recommend against treatment with intraven...
...gly recommend against adding predniso...
...y recommend the addition of HCQ to prophylactic-d...
...regnant women with positive aPL who do not mee...
...d/or anti-La/ SSB antibodies in pregn...
In pregnant women with anti-Ro/SSA...
...women with a prior infant with CHB or other N...
...nditionally recommend treating all wom...
...women with anti-Ro/SSA and/or anti-La/...
...hout other cardiac inflammation) is present, we...
...dication use...
...l medication use
...y recommend against use of CYC and...
...men with RMD who are planning to father a...
...th RMD who are planning to father...
...ly recommend continuation of anakinr...
Maternal medication u...
...standard good practice, we suggest dis...
...and thalidomide are known teratogens. We strongl...
...men treated with leflunomide, we strongly...
...tionally recommend treatment with C...
When potentially teratogenic medications ar...
...men with inadvertent exposure to teratogenic medi...
...ly recommend HCQ, azathioprine/6-mercap...
...tionally recommend calcineurin inhibitors...
...recommend discontinuation of NSAIDs p...
...ommend against use of NSAIDs in the thi...
...onally recommend nonselective NSAID...
...conditionally recommend continuing low-dose gl...
...gly recommend tapering higher doses of nonfluorin...
...there are only minimal data regarding prolonged tr...
...itionally recommend continuing tumor necrosis...
...strongly recommend continuation of certo...
...nally recommend continuing treatment with...
...recommend continuing treatment with ritu...
...use during breastfeeding...
...est as standard good practice that w...
...on, we suggest that disease control be maintained...
...strongly recommend treatment with HCQ, co...
...also recommend predn...
...ut strongly recommend that with doses o...
...ditionally recommend treatment with azathiop...
...strongly recommend against use of CYC, leflun...
...ly recommend against use of MTX while breastfeedi...
...ctive health care in patients with RMD...
...ontracepti...
...ll RM...
...tion/pregnancy discussion early and regular...
...er methods if unable to use other methods. (GPS)7...
...contraception if necessary. [6] (Strong...
...immunosuppressive medications: Use i...
...k for osteoporosis: Avoid depot med...
...eiving mycophenolate mofetil (MMF): Use I...
...t systemic lupus erythematosus (SLE)...
...effective methods preferred to effective methods...
...LE
...with negative aPL and low/stable diseas...
...ive methods preferred to effective...
Avoid transdermal estrogen-progestin pa...
SLE with negative aPL and moderate-t...
...sitive aPLÂ ...
Do not use combined estrogen-progest...
...isted reproductive technology ...
...Stable...
...n vitro fertilization if pregnancy-compat...
...reservation: Continue medications...
...sease: Defer assisted reproductive tec...
...LE...
...ive SLE: Defer assisted reproductiv...
...tients undergoing assisted reproductive te...
...itive aP...
...sted reproductive technology in patients with asym...
...ed reproductive technology patient...
...assisted reproductive technology patients w...
...tility preservatio...
...gonadotropin-releasing hormone agonist...
...m cryopreservation pre–CYC treatment. (GPS)70...
...o not use gonadotropin-releasing hormone agoni...
...ormone replacement therapy
...l RMD...
...SLE or aPL: Treat with hormone replacement...
...LE
...ive aPL: Treat with hormone replacement th...
...sitive aPL...
...mbosis or OB APS: Do not treat with hormone...
...titers negative, treat with hormo...
...prior thrombosis or OB APS and not receiving...
...ent titers negative, do not treat with hormone...
If prior thrombosis or OB APS and receivi...
...regnan...
...l RMD
...ng: Outcomes improved with pregnancy planning...
...pregnancy: Change to pregnancy-compatible medicati...
...isease during pregnancy: Initiate pre...
...f SLE or SLE-like disease, Sjögren...
...renal crisis during pregnancy: Treat with...
SLE
...SLE-like disease: Test once (early) for aPL (ant...
...roxychloroquine (HCQ) during pregna...
...CQ, start HCQ during pregnancy if no contraind...
...nitor laboratory values at least once...
...ith low-dose aspirin starting in first tri...
...sitive aPLÂ...
...ly: If no prior thrombosis or OB AP...
...ositive aPL only: Do not treat with combinati...
...ly: Do not treat with HCQ. [44A] (Conditional)...
...o thrombosis but meet OB APS criteria, tr...
...t treat with combination therapeutic heparin or...
...ot treat with addition of IV immunogl...
...not treat with addition of predniso...
...APS: Treat with addition of HCQ for...
...with prophylactic anticoagulation during post pa...
Thrombotic-APS: If prior thrombosis (...
...: Treat with addition of HCQ for th...
...Ro/SSA with or without anti-La/SSB...
...h HCQ during pregnancy. [69, 70] (Conditional)...
...or history of neonatal lupus: Serial (in...
...tory of neonatal lupus: Weekly fetal echocardi...
...echocardiography: If first-or secon...
...ted third-degree heart block (and no other cardia...
...ication ...
...nal medication ...
...f planning to father a child: Discuss...
...tinue CYC and thalidomide. [133, 139] ()Stro...
..., AZA, infliximab, etanercept, adalimumab...
...flunomide, MMF, nonsteroidal anti-inflamm...
...l medication ...
...planning pregnancy: Discuss medication use includ...
...exposed to teratogenic medications:...
...ontinue NSAIDs if difficulty conceiving. [86...
Avoid NSAIDs in third trimester. [87] (Strong)70...
...nonselective rather than cyclooxygenase 2...
...nue methotrexate (MTX), MMF, thalidomide,...
...or life-threatening disease only in secon...
...lunomide 24 months prior to conception...
...lfasalazine, azathioprine (AZA), colchicin...
...e cyclosporine and tacrolimus. [127, 131] (Conditi...
...ontinue certolizumab. [156] (Strong)...
...liximab, etanercept, adalimumab, gol...
...hen pregnancy confirmed: rituximab,...
...se rituximab for organ-or life-threatenin...
...ecommendations for tofacitinib, baricitinib, a...
...ontinue regular low-dose prednisone. [20...
...igh-dose prednisone with addition of pregnancy-...
...eroid at delivery. Do not treat for vagina...
...tfeeding ...
...ourage breastfeeding and maintain disease con...
...atible medicatio...
..., etanercept, adalimumab, golimumab, c...
...sulfasalazine, colchicine, AZA, cyclosporine, tac...
...one or nonfluorinated steroid equivalent...
...prednisone ≥20 mg daily, discar...
...eat with leflunomide, MMF, CYC, thalidomide. [113...
...t treat with MTX. [106] (Conditional)7...
...a Recommendation numbers, shown in...
.... Safety and efficacy of various contracep...
...3. Recommendations regarding medication...
...e/6-mercaptopurine Colchicine Hyd...
...akinra Cyclooxygenase 2 inhibito...
...phamide (discontinue 12 weeks prior to attempted...
...idomide (discontinue 4 weeks prior to...
...Apremilast Baricitinib Belimumab S...
Table 4. Maternal medication use: overview of...
...1. Recommendations and good practice s...
...gure 2. Recommendations for use of assisted repr...
...gure 3. Recommendations and GPS for...
...4. Recommendations and GPS for pregnancy co...