2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases

doi:10.1002/art.41191

Practice Guideline

. 2020 Apr;72(4):529-556.

doi: 10.1002/art.41191. Epub 2020 Feb 23.

2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases

Lisa R Sammaritano¹, Bonnie L Bermas², Eliza E Chakravarty³, Christina Chambers⁴, Megan E B Clowse⁵, Michael D Lockshin¹, Wendy Marder⁶, Gordon Guyatt⁷, D Ware Branch⁸, Jill Buyon⁹, Lisa Christopher-Stine¹⁰, Rachelle Crow-Hercher¹¹, John Cush¹², Maurice Druzin¹³, Arthur Kavanaugh⁴, Carl A Laskin¹⁴, Lauren Plante¹⁵, Jane Salmon¹, Julia Simard¹³, Emily C Somers⁶, Virginia Steen¹⁶, Sara K Tedeschi¹⁷, Evelyne Vinet¹⁸, C Whitney White¹⁹, Jinoos Yazdany²⁰, Medha Barbhaiya¹, Brittany Bettendorf²¹, Amanda Eudy⁵, Arundathi Jayatilleke¹⁵, Amit Aakash Shah²², Nancy Sullivan²³, Laura L Tarter¹⁷, Mehret Birru Talabi²⁴, Marat Turgunbaev²², Amy Turner²², Kristen E D'Anci²³

Affiliations

¹ Weill Cornell Medicine, Hospital for Special Surgery, New York, New York.
² University of Texas Southwestern Medical Center, Dallas.
³ Oklahoma Medical Research Foundation, Oklahoma City.
⁴ University of California, San Diego.
⁵ Duke University Medical Center, Durham, North Carolina.
⁶ University of Michigan School of Medicine, Ann Arbor.
⁷ McMaster University, Hamilton, Ontario, Canada.
⁸ University of Utah, Salt Lake City.
⁹ New York University School of Medicine, New York, New York.
¹⁰ John Hopkins Medicine, Baltimore, Maryland.
¹¹ Shelby Township, Michigan.
¹² Baylor Research Institute, Dallas, Texas.
¹³ Stanford Medicine, Stanford, California.
¹⁴ University of Toronto, Toronto, Ontario, Canada.
¹⁵ Drexel University College of Medicine, Philadelphia, Pennsylvania.
¹⁶ Georgetown University Medical Center, Washington, DC.
¹⁷ Brigham and Women's Hospital, Boston, Massachusetts.
¹⁸ McGill University Health Center, Montreal, Quebec, Canada.
¹⁹ University of Mississippi, Jackson.
²⁰ University of California San Francisco.
²¹ University of Iowa, Iowa City.
²² American College of Rheumatology, Atlanta, Georgia.
²³ ECRI Institute, Plymouth Meeting, Pennsylvania.
²⁴ University of Pittsburgh, Pittsburgh, Pennsylvania.

PMID: 32090480
DOI: 10.1002/art.41191

Free article

Practice Guideline

2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases

Lisa R Sammaritano et al. Arthritis Rheumatol. 2020 Apr.

Free article

. 2020 Apr;72(4):529-556.

doi: 10.1002/art.41191. Epub 2020 Feb 23.

Authors

Affiliations

¹ Weill Cornell Medicine, Hospital for Special Surgery, New York, New York.
² University of Texas Southwestern Medical Center, Dallas.
³ Oklahoma Medical Research Foundation, Oklahoma City.
⁴ University of California, San Diego.
⁵ Duke University Medical Center, Durham, North Carolina.
⁶ University of Michigan School of Medicine, Ann Arbor.
⁷ McMaster University, Hamilton, Ontario, Canada.
⁸ University of Utah, Salt Lake City.
⁹ New York University School of Medicine, New York, New York.
¹⁰ John Hopkins Medicine, Baltimore, Maryland.
¹¹ Shelby Township, Michigan.
¹² Baylor Research Institute, Dallas, Texas.
¹³ Stanford Medicine, Stanford, California.
¹⁴ University of Toronto, Toronto, Ontario, Canada.
¹⁵ Drexel University College of Medicine, Philadelphia, Pennsylvania.
¹⁶ Georgetown University Medical Center, Washington, DC.
¹⁷ Brigham and Women's Hospital, Boston, Massachusetts.
¹⁸ McGill University Health Center, Montreal, Quebec, Canada.
¹⁹ University of Mississippi, Jackson.
²⁰ University of California San Francisco.
²¹ University of Iowa, Iowa City.
²² American College of Rheumatology, Atlanta, Georgia.
²³ ECRI Institute, Plymouth Meeting, Pennsylvania.
²⁴ University of Pittsburgh, Pittsburgh, Pennsylvania.

PMID: 32090480
DOI: 10.1002/art.41191

Abstract

Objective: To develop an evidence-based guideline on contraception, assisted reproductive technologies (ART), fertility preservation with gonadotoxic therapy, use of menopausal hormone replacement therapy (HRT), pregnancy assessment and management, and medication use in patients with rheumatic and musculoskeletal disease (RMD).

Methods: We conducted a systematic review of evidence relating to contraception, ART, fertility preservation, HRT, pregnancy and lactation, and medication use in RMD populations, using Grading of Recommendations Assessment, Development and Evaluation methodology to rate the quality of evidence and a group consensus process to determine final recommendations and grade their strength (conditional or strong). Good practice statements were agreed upon when indirect evidence was sufficiently compelling that a formal vote was unnecessary.

Results: This American College of Rheumatology guideline provides 12 ungraded good practice statements and 131 graded recommendations for reproductive health care in RMD patients. These recommendations are intended to guide care for all patients with RMD, except where indicated as being specific for patients with systemic lupus erythematosus, those positive for antiphospholipid antibody, and/or those positive for anti-Ro/SSA and/or anti-La/SSB antibodies. Recommendations and good practice statements support several guiding principles: use of safe and effective contraception to prevent unplanned pregnancy, pre-pregnancy counseling to encourage conception during periods of disease quiescence and while receiving pregnancy-compatible medications, and ongoing physician-patient discussion with obstetrics/gynecology collaboration for all reproductive health issues, given the overall low level of available evidence that relates specifically to RMD.

Conclusion: This guideline provides evidence-based recommendations developed and reviewed by panels of experts and RMD patients. Many recommendations are conditional, reflecting a lack of data or low-level data. We intend that this guideline be used to inform a shared decision-making process between patients and their physicians on issues related to reproductive health that incorporates patients' values, preferences, and comorbidities.

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Comment in

A guide to managing reproductive health in rheumatology.
Tincani A, Andreoli L. Tincani A, et al. Nat Rev Rheumatol. 2020 Aug;16(8):411-412. doi: 10.1038/s41584-020-0443-z. Nat Rev Rheumatol. 2020. PMID: 32518414 No abstract available.

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References

1. Smyth A, Oliveira GH, Lahr BD, Bailey KR, Norby SM, Garovic VD. A systematic review and meta-analysis of pregnancy outcomes in patients with systemic lupus erythematosus and lupus nephritis. Clin J Am Soc Nephrol 2010;5:2060-8.
1. Smith CJ, Förger F, Bandoli G, Chambers CD. Factors associated with preterm delivery among women with rheumatoid arthritis and women with juvenile idiopathic arthritis. Arthritis Care Res (Hoboken) 2019;71:1019-27.
1. Langen ES, Chakravarty EF, Liaquat M, El-Sayed YY, Druzin ML. High rate of preterm birth in pregnancies complicated by rheumatoid arthritis. Am J Perinatol 2014;31:9-13.
1. Chakravarty EF, Nelson L, Krishnan E. Obstetric hospitalizations in the United States for women with systemic lupus erythematosus and rheumatoid arthritis. Arthritis Rheum 2006;54:899-907.
1. Bharti B, Lee SJ, Lindsay SP, Wingard DL, Jones KL, Lemus H, et al. Disease severity and pregnancy outcomes in women with rheumatoid arthritis: results from the Organization of Teratology Information Specialists Autoimmune Diseases in Pregnancy Project. J Rheumatol 2015;42:1376-82.

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[1] Smyth A, Oliveira GH, Lahr BD, Bailey KR, Norby SM, Garovic VD. A systematic review and meta-analysis of pregnancy outcomes in patients with systemic lupus erythematosus and lupus nephritis. Clin J Am Soc Nephrol 2010;5:2060-8.

[2] Smyth A, Oliveira GH, Lahr BD, Bailey KR, Norby SM, Garovic VD. A systematic review and meta-analysis of pregnancy outcomes in patients with systemic lupus erythematosus and lupus nephritis. Clin J Am Soc Nephrol 2010;5:2060-8.

[3] Smith CJ, Förger F, Bandoli G, Chambers CD. Factors associated with preterm delivery among women with rheumatoid arthritis and women with juvenile idiopathic arthritis. Arthritis Care Res (Hoboken) 2019;71:1019-27.

[4] Smith CJ, Förger F, Bandoli G, Chambers CD. Factors associated with preterm delivery among women with rheumatoid arthritis and women with juvenile idiopathic arthritis. Arthritis Care Res (Hoboken) 2019;71:1019-27.

[5] Langen ES, Chakravarty EF, Liaquat M, El-Sayed YY, Druzin ML. High rate of preterm birth in pregnancies complicated by rheumatoid arthritis. Am J Perinatol 2014;31:9-13.

[6] Langen ES, Chakravarty EF, Liaquat M, El-Sayed YY, Druzin ML. High rate of preterm birth in pregnancies complicated by rheumatoid arthritis. Am J Perinatol 2014;31:9-13.

[7] Chakravarty EF, Nelson L, Krishnan E. Obstetric hospitalizations in the United States for women with systemic lupus erythematosus and rheumatoid arthritis. Arthritis Rheum 2006;54:899-907.

[8] Chakravarty EF, Nelson L, Krishnan E. Obstetric hospitalizations in the United States for women with systemic lupus erythematosus and rheumatoid arthritis. Arthritis Rheum 2006;54:899-907.

[9] Bharti B, Lee SJ, Lindsay SP, Wingard DL, Jones KL, Lemus H, et al. Disease severity and pregnancy outcomes in women with rheumatoid arthritis: results from the Organization of Teratology Information Specialists Autoimmune Diseases in Pregnancy Project. J Rheumatol 2015;42:1376-82.

[10] Bharti B, Lee SJ, Lindsay SP, Wingard DL, Jones KL, Lemus H, et al. Disease severity and pregnancy outcomes in women with rheumatoid arthritis: results from the Organization of Teratology Information Specialists Autoimmune Diseases in Pregnancy Project. J Rheumatol 2015;42:1376-82.

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2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases

Affiliations

2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases

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