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ACR Announces Draft Guidelines for Reproductive Health Management
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CHICAGO — Researchers have issued draft clinical practice guidelines for the management of reproductive issues among patients with rheumatic diseases. Prompted by a summit on reproductive health held by the American College of Rheumatology in 2014, experts have been studying a breadth of topics based on common and important questions surrounding these issues.
“Our patients, fortunately, are pursuing pregnancy more and more, and because of that reproductive issues have become of increasing interest over the last year,” Lisa R. Sammaritano, MD, associate professor of clinical medicine at Hospital for Special Surgery-Weill Cornell Medicine in New York and principal investigator and voting panel leader of the Core Oversight Team of experts who oversaw the development of the new guideline, said during a press conference. “Plus, obstetrics and gynecology has had changes in their guidelines/recommendations, and it’s not something we necessarily keep up with.”
She added, “Finally, we have had an explosion of new therapies over the past 10 to 20 years in rheumatology. It’s been wonderful to have so many options, but it raises questions about what we do with therapies in pregnancy and planning.”
In 2017, a team of researchers gathered to compile a list of common and/or important questions regarding reproductive issues in patients with rheumatic diseases. They identified 370 PICO questions, which generated a literature search that returned 12,000 abstracts; the systematic review included more than 300 patients. A grading system was used to assess the evidence, which included information from a 12-patient panel and experts in clinical rheumatology and obstetrics and gynecology. A voting panel compiled the recommendations.
Important topics that are addressed in the guidelines include the use of contraception in women with rheumatic diseases, as well as the use of low-dose aspirin and hydroxychloroquine during pregnancy to improve outcomes for both mother and baby.
According to Sammaritano, during the development process, researchers determined there is an opportunity to help educate both rheumatologists and obstetricians/gynecologists, especially regarding the options for contraception in these patients. Specifically, Sammaritano noted that some members of the voting panel were unaware that intrauterine devices (IUDs) are considered quite safe and are recommended as first-line contraception. At the same time, obstetricians/gynecologists could benefit from more information from their rheumatology colleagues.
“One of the things we learned is that our patients really expect us to be involved in this way, at least from the patients we spoke to,” she said. “I think that’s an important message to get across and hopefully something to adopt as part of our routine rheumatology follow-up: to not ignore this very important area of a woman — or a man’s — life.”
The guidelines are currently under review; no publication date has been announced. – by Stacey L. Adams
Disclosure: Healio Rheumatology was unable to confirm Sammaritano’s relevant financial disclosures at the time of publication.
Reference :
Sammaritano LR. Presentation of the new ACR reproductive guidelines. Presented at ACR/ARHP Annual Meeting, Oct. 20-24, 2018; Chicago.
Perspective
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Ellen M. Field, MD
We as rheumatologists are challenged with how to appropriately counsel our female patients of childbearing years regarding sexual health and contraception, family planning and the use of medication during pregnancy and postpartum.
Half of all pregnancies are unplanned. We need to use guidelines to provide our patients with pathways to ensure good outcomes for the pregnant mother and fetus, which include education about contraception, impact of fertility with cytotoxic agents, as well as safety in medication management throughout pregnancy and postpartum.
Recommendations for pregnancy management should offer a team approach with the obstetrician-gynecologist, pediatrician, rheumatologist, and maternal fetal medicine specialist particularly in those patients at high risk for poor outcomes due to active disease, including inflammatory arthritis, lupus, and antiphospholipid antibody syndrome. Medication safety around conception, during pregnancy and postpartum — including lactation — are of high importance in the management of this subpopulation. Consideration for paternal medication is needed as well.
The care team approach with education for clinicians and patients is crucial to ensuring disease control before, during, and after pregnancy, to minimize potential risks to the pregnant mother and child, while maximizing good outcomes. Women with autoimmune diseases are a unique population requiring special attention throughout the reproductive period and postmenopause, including potential use of hormone therapy and osteoporosis prevention and treatment. Rheumatologists must play an active role in the implementation of these guidelines to ensure the best outcomes possible in caring for patients with autoimmune disease.
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