Treatment Guidelines Issued for Reproductive Health in Rheumatic and Musculoskeletal Diseases

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The treatment of rheumatic and musculoskeletal diseases presents some unique considerations for female patients considering becoming pregnant.

Women with rheumatic and musculoskeletal diseases have a higher risk of having pregnancy complications, such as gestational diabetes, preeclampsia, infection, preterm premature rupture of membranes, small for gestational age infants and preterm deliveries, according to Frauke Förger, M.D., in a study published July 2018 in the journal Rheumatology.

In terms if treatment, taking certain medications increases the risk of negatively affecting the fetus or newborn infant. But without medication, they risk having a dangerous flare-up.

This week, the American College of Rheumatology issued treatment guidelines for the management of reproductive health in rheumatic and musculoskeletal diseases. The guidelines, which are based on a systemic view of evidence, addresses contraception, assisted reproductive technologies, fertility preservation with gonadotoxic therapy, use of menopausal hormone replacement therapy, pregnancy assessment and management, and medication use in patients with rheumatic and musculoskeletal disease.

The guidelines include 12 ungraded good practice statements and 131 graded recommendations for all female patients considering becoming pregnant, except in cases when care is strictly indicated for women with systemic lupus erythematosus, those positive for antiphospholipid antibody, and those positive for anti‐Ro/SSA and/or anti‐La/SSB antibodies.

Although many of the recommendations are conditional due to the lack of data on a given subject, they are intended to inform the decision-making process between doctor and patient. The recommendations center on the use of safe and effective contraception to prevent unplanned pregnancy, pre‐pregnancy counseling to encourage conception when disease is inactive and counseling when receiving pregnancy‐compatible medications.

"It is difficult to avoid use of medication during pregnancy in patients with rheumatic and musculoskeletal diseases. Not all medications are safe for pre‐conception use by men and women or during pregnancy and lactation, but uncontrolled systemic inflammatory disease is itself associated with poor pregnancy outcomes," wrote Lisa R. Sammaritano, M.D., and colleagues in the new set of guidelines which were published on Sunday in Arthritis and Rheumatology.

There has been little research in this area to determine the extent of risks for both mother and child. Most data are derived from case reports, small series, and observational studies instead of randomized controlled trials, but still, doctors should counsel their patients about contraception, pregnancy and lactation, assisted reproductive technology, fertility preservation, and hormone replacement therapy, the authors wrote. They should also be prepared to collaborate with specialists in obstetrics‐gynecology, maternal‐fetal medicine, and reproductive endocrinology and infertility.

For the complete list of recommendations, see:  "2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases,"Arthritis & Rheumatology, February 23, 2020. DOI 10.1002/art.41191