Pregnancy management in women with Rheumatic and Musculoskeletal Disease

(Part 3)

This week, we will discuss how to manage pregnancy in women but this time, it is the male partner who is suffering from rheumatic and musculoskeletal disease (RMD).

There is some concern about pregnancy of a woman whose male partner is suffering from RMD. In this case, the script is flipped. It is a matter of managing the pregnancy when there is a concern about the effects of the medications being taken by a man with RMD.

When a man with RMD gets his female partner pregnant, the main concern is whether or not the male partner’s drugs are present in seminal fluid and could cause a transfer through vaginal mucosa, cross the placenta, and be teratogenic.

The fact is post-conception exposure of drugs to the embryo or fetus is more likely to be minimal.

No reports have been received about post-conception teratogenesis, that is attributable to drugs taken by a male partner who suffers from RMD.

In the event a man with RMD has his wife pregnant, reassurance in relation to low risk associated with the male partner’s RMD medication is generally warranted.

Due to the absence of adequate data regarding the male-side exposure for most drugs used for treating RMD, experts have developed guidelines on how to come about with the set of recommendations.

The recommendations will be based on some data on paternal exposure, accumulated clinical experience of paternal exposure help guide the recommendation, or there were no data on paternal exposure, but maternal exposure show some teratogenicity.

Experts do not express recommendations for new medications with there is no class-level or drug-specific data available.

Experts do not recommend the use of certain drugs, which include but not limited to thalidomide of cyclophosphamide (CYC) in males with RMD prior to the attempt to impregnate a woman.

The male partner’s use of CYC may lead to the impairment of spermatogenesis or be mutagenic for Deoxyribonucleic acid (DNA) and needs to be discontinued around 3 months if planning to have a baby.

Thalidomide can be detected in seminal fluid and is known to be strongly teratogenic when provided to pregnant women and the use of the drug should be discontinued at least a month prior to attempting to have a baby. Experts should also assess what other medications should be discontinued prior to the time when the partners are planning to have a baby.

In the case of men with RMD, experts recommend the use of hydroxychloroquine, azathioprine, 6-mercaptopurine, colchicine, and tumor necrosis factor inhibitors.

Experts conditionally recommend, using methotrexate (MTX) mycophenolate mofetil (MMF) leflunomide, sulfasalazine, calcineurin inhibitors, and nonsteroidal anti inflammatory drugs (NSAIDs).

While the general idea suggests discontinuation of MTX before planning to have a baby, there is no

evidence for mutagenesis or teratogenicity.

Expertscontinuation of anakinra and rituximab based on limited data.

Furthermore, experts suggest discussing medications before the partner plan to have a baby.

It is best to have some time to allow for appropriate changes and disease stability, usually a minimum of several months prior to the attempt to have a baby.

Have some time to discuss with the doctor which medications should be discontinued and how long should the waiting period be prior to conceive a baby.