In February 2020 the American College of Rheumatology (ACR) issued a guideline for the management of reproductive health in people with rheumatic and musculoskeletal diseases (RMDs). Following the publication of this guideline, medwireNews speaks to lead author Lisa Sammaritano, from the Hospital for Special Surgery in New York, USA, about why reproductive health is particularly important for this patient population, and what rheumatologists need to be aware of.
What’s new and what’s important in the ACR guideline?
Compared with previous iterations and other guidelines, the 2020 ACR guideline on reproductive health “is unique in two ways,” says Sammaritano.
“First, the guideline provides recommendations for the full spectrum of RMD patients, with additional focus on specific diagnoses that require more detailed recommendations such as systemic lupus erythematosus (SLE) and antiphospholipid syndrome ,” and “second, the guideline deals with the intersection of […] rheumatology and OB-GYN [obstetrics and gynecology],” she explains.
Sammaritano says that the guideline covers a number of “specific areas of reproductive health,” including “contraception, assisted reproductive technology (i.e. fertility therapies), preservation of fertility during treatment with cyclophosphamide, hormone replacement therapy, pre-pregnancy assessment, pregnancy management, and medication use before, during and after pregnancy.”
Why rheumatologists need to know about reproductive health
“The management of reproductive health issues for patients with [RMDs] differs from that of the general population,” says Sammaritano.
“[A]s a result, rheumatologists and other clinicians caring for these patients must often discuss with and counsel their patients about disease-specific issues that impact this important aspect of overall health.”
For instance, the guideline advises that pregnant women with RMDs may experience maternal or fetal complications, with the risks dependent on diagnosis, medication use, disease activity, and the presence of antiphospholipid, anti‐Ro/SSA, and anti‐La/SSB antibodies.
Sammaritano discusses kidney function as an example of how RMDs may impact physiology in pregnant women, noting that “the expected and necessary increase in glomerular filtration rate […] during pregnancy may not occur in a patient who starts her pregnancy with reduced kidney function due to prior kidney inflammation and this may impact both maternal and pregnancy outcome.” Indeed, a meta-analysis found that the presence of active lupus nephritis was associated with an increased risk for maternal hypertension and preterm birth among women with SLE, and a systematic review of studies investigating maternal deaths in women with lupus nephritis found that all deaths occurred in those with active disease.
Conversely, “changes that are normal in pregnancy [can also] impact RMD,” says Sammaritano. For example, a US cohort study that followed up SLE patients from 1987 to 2015 found that the risk for flare was increased during pregnancy and for 3 months postpartum, with hydroxychloroquine treatment mitigating this risk. And on the other hand, evidence from several studies points to an improvement of rheumatoid arthritis disease activity during pregnancy, with an increased risk for flare after delivery.
Sammaritano points out that while rheumatologists are experts in caring for their patients with RMDs, “not all are familiar with OB-GYN care that, like all aspects of medicine, is constantly evolving.” She explains that rheumatologists and their patients “may not be aware of current thinking about the potentially complex interactions” between chronic disease and reproductive health, highlighting the need for specialist guidance.
Indeed, she stresses that one of the main goals of the ACR guideline is “to increase rheumatologists’ knowledge about reproductive health care for RMD patients, including the specific clinical challenges for some of these disorders [and] to provide guidance in addressing these challenges.”
And the other primary goals of the guideline relate to communication. Sammaritano says that the recommendations aim to “increase discussion and collaboration between rheumatologists and OB-GYNs, and also between rheumatologists and their patients.”
Early discussions, planning, and communication are key
So who should initiate discussions about reproductive health and when should this be done?
Sammaritano stresses that “rheumatologists should introduce the topic of reproductive health and family planning at an initial or early visit, and periodically thereafter” with their patients, noting that this is “an important guiding principle” in the ACR guideline based on input from a patient focus group.
And she adds that “planning ahead for pregnancy is another important message of the guideline,” requiring regular discussion between patients and rheumatologists “since planning for pregnancy may take a significantly longer time for RMD patients than for those without RMD.”
For patients who wish to conceive, Sammaritano recommends that pregnancy should ideally be planned “for a time when underlying RMD is controlled on pregnancy-compatible medications” to benefit “both patient and pregnancy outcomes.” And for those who are not actively trying to conceive, she says that “safe and effective contraception should be discussed and tailored to the patient’s specific clinical and personal situation.” Sammaritano advocates long-acting reversible contraception such as an intrauterine device as “usually the most effective option,” but underlines that “the recommendations will vary based on the underlying diagnosis.”
“Importantly, estrogen-containing contraceptives are contraindicated in antiphospholipid-positive patients,” she notes.
Sammaritano emphasizes that “all aspects of reproductive health care should be coordinated between rheumatology, OB-GYN, and other relevant professionals, with ongoing discussion with the patient.”
Noting that “the potential issues are numerous,” Sammaritano stresses “the key point is that ongoing communication among specialists is needed to be sure that the many complex interactions are noted and addressed.”
Gaps in knowledge
While the ACR guideline brings together all the latest information and contains some strong recommendations on reproductive health in rheumatology patients, particularly regarding contraception and pregnancy planning, Sammaritano says that “there are many gaps in this area.”
“Although over 12,000 abstracts were initially pulled in the systematic literature review that was the foundation for this guideline, less than 400 full length articles were felt to contain relevant information,” she explains.
Moreover, she cautions that “many of the recommendations are conditional, suggesting that physician-patient discussion about risks and benefits is important, as [the available] data are not adequate to justify strong recommendations.”
Although “studies extrapolating from non-RMD patients were helpful in formulating the recommendations,” Sammaritano says that “studies in RMD patients are still needed,” particularly to investigate medication use during pregnancy.
Looking ahead, she believes “there is much to be learned,” and recommends that “future research should include safety and efficacy of hormonal contraceptives in RMD patients, optimal assisted reproductive medicine practices in RMD patients, monitoring and therapy for anti-Ro and/or anti-La patients to prevent development of neonatal lupus and congenital heart block, and safety of new RMD medications before, during and after pregnancy.”
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