Nav: Home

ACR releases reproductive health guideline for patients with rheumatic diseases

February 24, 2020

ATLANTA - Today, the American College of Rheumatology (ACR) published the 2020 Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. This is the first, evidence-based, clinical practice guideline related to the management of reproductive health issues for all patients with rheumatic diseases. With 131 recommendations, the guideline offers general precepts that provide a foundation for its recommendations and good practice statements.

"This guideline is paramount, because it is the first official guidance addressing the intersection of rheumatology and obstetrics and gynecology (OB-GYN)," said Lisa Sammaritano, MD, lead author of the guideline. "Rheumatic diseases affect many younger individuals; however, little education has been provided to rheumatology professionals on current OB-GYN practices. The guideline [and more detailed online appendices] presents vital background knowledge and recommendations for addressing reproductive health issues in the full spectrum of rheumatology patients, with additional focus on specific diagnoses that require more detailed recommendations such as systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS).

The guideline provides 12 ungraded good practice statements and 131 graded recommendations that are intended to guide care for rheumatology patients except where indicated as being for patients with specific conditions or antibodies present. Good practice statements are those in which indirect evidence is compelling enough that a formal vote was considered unnecessary; these are ungraded and are presented as suggestions rather than formal recommendations. The recommendations were separated into six categories: contraception, assisted reproductive technology (fertility therapies), fertility preservation with gonadotoxic therapy, menopausal hormone replacement therapy, pregnancy assessment and management, and medication use.

While some of the recommendations are strong, many of the recommendations presented are conditional due to a lack of data. Pregnant women are not generally enrolled in clinical studies; and few maternal health studies focus on rheumatology patients. A few notable recommendations from each category include:

  • Strong recommendation for women with rheumatic disease who do not have lupus or APS to use effective contraceptives with a conditional recommendation to preferentially use highly effective IUDs or a subdermal progestin implant.
  • Strong recommendation against using combined estrogen-progestin contraceptives in women who test positive for anti-phospholipid autoantibodies (aPL) or APS.

    Assisted Reproductive Technology (Fertility Therapies)
  • Strong recommendation for fertility therapy in women with uncomplicated rheumatic disease who are receiving pregnancy-compatible medications, whose disease is stable, and who test negative for aPL. Specific recommendations also address patients testing positive for aPL and suggest an anti-blood clotting procedure.
  • Conditional recommendation against increasing prednisone dosage during fertility therapy procedures in lupus patients.
Fertility Preservation
  • Conditional recommendation against testosterone co-therapy in men with rheumatic disease receiving cyclophosphamide (CYC) and a good practice suggestion to cryopreserve sperm before CYC treatment in men who desire it.
  • Conditional recommendation for monthly gonadotropin-releasing hormone agonist co-therapy for premenopausal women with rheumatic disease who are receiving monthly CYC injections/infusions to prevent premature ovarian insufficiency.
Pregnancy Assessment and Management
  • Strong good practice suggestion to counsel women with rheumatic disease, who are considering pregnancy, on the improved maternal and fetal outcomes associated with entering pregnancy during low disease activity.
  • Conditional recommendation to treat lupus patients with low-dose aspirin daily (81 to 100 mg) starting in the first trimester. For women testing positive for aPL who do not meet the criteria for obstetric or thrombotic APS, it is conditionally recommended to preventatively treat with a daily aspirin (81 to 100 mg) starting early in pregnancy and continuing through delivery.
Menopause and Hormone Replacement Therapy
  • A good practice suggestion to use hormone replacement therapy in postmenopausal women with rheumatic disease who do not have lupus or have a positive aPL test; and who have severe vasomotor symptoms, have no contraindications, and desire treatment.
  • A conditional recommendation for hormone replacement therapy in women with lupus and without aPL.
  • Conditionally recommend against treating with hormone replacement therapy for women with asymptomatic aPL, and strongly recommend against hormone replacement therapy for women with any form of APS.
Medication Use (Paternal and Maternal)
  • Strongly recommend against use of CYC and thalidomide in men prior to attempting conception.
  • Strong recommendation against the use of NSAIDs in the third trimester.
Individuals involved in the development of the new guideline included rheumatologists, obstetrician/gynecologists, reproductive medicine specialists, epidemiologists, and patients with rheumatic diseases. ACR guidelines are currently developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, which creates rigorous standards for judging the quality of the literature available and assigns strengths to the recommendations that are largely based on the quality of the available evidence.

"This guideline should open avenues of communication between the rheumatologist and the patient, as well as between the rheumatologist and the OB-GYN," said Dr. Sammaritano. "A better understanding of the risks and benefits of reproductive health options will enhance patient care by providing safe and effective contraception, improving pregnancy outcomes by conceiving during inactive disease periods, and allowing for continued control of rheumatic diseases during and after pregnancy with the use of well-suited medications."

A draft of the guideline was presented during the 2018 ACR/ARP Annual Meeting in Chicago. Since that time, the guideline team has condensed the original three-part draft into a single, concise manuscript, with detailed background and discussion now available online. The guideline development team also incorporated color-coded flow charts to highlight common decision-making points to make it user friendly.
The paper containing the full list of recommendations and supporting evidence is available at

About the American College of Rheumatology

The American College of Rheumatology (ACR) is an international medical society representing over 8,500 rheumatologists and rheumatology health professionals with a mission to empower rheumatology professionals to excel in their specialty. In doing so, the ACR offers education, research, advocacy and practice management support to help its members continue their innovative work and provide quality patient care. Rheumatologists are experts in the diagnosis, management and treatment of more than 100 different types of arthritis and rheumatic diseases. For more information, visit

Media Contact: Monica McDonald
Office - (404) 633-3777, ext. 332

American College of Rheumatology

Related Pregnancy Articles:

Are women using e-cigarettes during preconception and/or pregnancy?
A new study of 1,365 racially/ethnically diverse, low-income pregnant women found that 4% reported e-cigarette use.
A better pregnancy test for whales
To determine whale pregnancy, researchers have relied on visual cues or hormone tests of blubber collected via darts, but the results were often inconclusive.
Cannabis use during pregnancy
The large health care system Kaiser Permanente Northern California provides universal screening for prenatal cannabis use in women during pregnancy by self-report and urine toxicology testing.
Questions and answers about cannabis use during pregnancy
A new study shows that women have many medical questions about the use of cannabis both before and during pregnancy, and during the postpartum period while breastfeeding.
The effect of taking antidepressants during pregnancy
Exposure to antidepressants during pregnancy and the first weeks of life can alter sensory processing well into adulthood, according to research in mice recently published in eNeuro.
Is ivermectin safe during pregnancy?
Is it safe to give ivermectin to pregnant women? To answer this question, researchers from the Barcelona Institute for Global Health (ISGlobal), an institution supported by 'la Caixa,' conducted a systematic review and meta-analysis of studies that reported cases of accidental exposure to the drug among pregnant women.
Going to sleep on your back in late pregnancy
This study looked at whether going to sleep on your back in the third trimester of pregnancy was associated with average lower birth weights.
Opioid use disorder in pregnancy: 5 things to know
Opioid use is increasing in pregnancy as well as the general population.
Medical imaging rates during pregnancy
Researchers looked at rates of medical imaging (CT, MRI, conventional x-rays, angiography, fluoroscopy and nuclear medicine) during pregnancy in this observational study that included nearly 3.5 million pregnant women in the United States and Canada from 1996 to 2016.
New research on diet and supplements during pregnancy and beyond
The foods and nutrients a woman consumes while pregnant have important health implications for her and her baby.
More Pregnancy News and Pregnancy Current Events

Trending Science News

Current Coronavirus (COVID-19) News

Top Science Podcasts

We have hand picked the top science podcasts of 2020.
Now Playing: TED Radio Hour

Listen Again: Reinvention
Change is hard, but it's also an opportunity to discover and reimagine what you thought you knew. From our economy, to music, to even ourselves–this hour TED speakers explore the power of reinvention. Guests include OK Go lead singer Damian Kulash Jr., former college gymnastics coach Valorie Kondos Field, Stockton Mayor Michael Tubbs, and entrepreneur Nick Hanauer.
Now Playing: Science for the People

#562 Superbug to Bedside
By now we're all good and scared about antibiotic resistance, one of the many things coming to get us all. But there's good news, sort of. News antibiotics are coming out! How do they get tested? What does that kind of a trial look like and how does it happen? Host Bethany Brookeshire talks with Matt McCarthy, author of "Superbugs: The Race to Stop an Epidemic", about the ins and outs of testing a new antibiotic in the hospital.
Now Playing: Radiolab

Dispatch 6: Strange Times
Covid has disrupted the most basic routines of our days and nights. But in the middle of a conversation about how to fight the virus, we find a place impervious to the stalled plans and frenetic demands of the outside world. It's a very different kind of front line, where urgent work means moving slow, and time is marked out in tiny pre-planned steps. Then, on a walk through the woods, we consider how the tempo of our lives affects our minds and discover how the beats of biology shape our bodies. This episode was produced with help from Molly Webster and Tracie Hunte. Support Radiolab today at