Copyright American Medical Association. Many rheumatic diseases affect women of childbearing age, and the medications used to treat these diseases may affect conception, pregnancy, fetal development, and lactation. Physicians who care for these women need to be aware of the potential adverse effects of these medications, and which medications can be used safely prior to conception and during pregnancy and lactation. Although reviews of individual classes of medications are available, there is no practical and comprehensive review that summarizes all of this Hydroxychloroquine and low sperm count, and includes anticoagulant drugs and 2 recently approved drugs for rheumatoid arthritis.
Women who take cytotoxic drugs should be informed of the risks of impaired fertility and congenital malformations, and must use effective methods of contraception. During pregnancy, nonsteroidal anti-inflammatory agents may be used until the last 6 weeks, and low to moderate doses of corticosteroids are safe throughout pregnancy.
Among the disease-modifying agents, sulfasalazine and hydroxychloroquine treatment may be maintained. Cytotoxic drugs may be used after the first trimester to treat life-threatening disease. During lactation, prednisone, sulfasalazine, and hydroxychloroquine may be used cautiously.
Women using heparin for treatment of antiphospholipid antibody syndrome should take measures to prevent bone loss. Men taking methotrexate, sulfasalazine, cyclosporine, azathioprine, or leflunomide should be apprised of the possibilities of infertility and teratogenicity. Rheumatic diseases such as systemic lupus erythematosus SLErheumatoid arthritis RAscleroderma, and antiphospholipid antibody syndrome are common in women of childbearing age.
Virtually all the medications used to treat rheumatic diseases may affect conception, fetal development, pregnancy, and breastfeeding infants. Most drugs, however, are not tested in pregnant women, and are not labeled for use during pregnancy. The lack of readily available information presents a problem for both Hydroxychloroquine and low sperm count physician and the woman, who, once counseled to avoid pregnancy altogether, is now considering motherhood.
Physicians who care for these patients need to be aware of the potential adverse effects of these medications, and of which medications can be used safely prior to conception and during pregnancy and lactation. Although reviews of individual classes of medications are available, there is no practical and comprehensive review that summarizes all of this information. We have summarized the literature on Hydroxychloroquine and low sperm count effects of anti-inflammatory, immunosuppressive, and anticoagulant drugs on fertility, pregnancy, and lactation, and provided guidelines for safe use of these therapeutic agents.
The use of aspirin for rheumatoid arthritis has decreased markedly since the introduction of various NSAIDs; however, aspirin remains among the most frequently ingested drugs during pregnancy. Aspirin can cross the placenta and cause congenital anomalies in animals, but these are rare in humans.
Several large prospective studies failed to confirm a significant increase in cleft palate or congenital anomalies. Mothers taking aspirin regularly were more anemic and had a prolonged gestation, more complicated deliveries, and an increased incidence of both antepartum and postpartum hemorrhage. There are possible benefits of low-dose aspirin for patients at risk for the development of pregnancy-induced hypertension and preeclampsia, and in fetuses with intrauterine growth retardation, but studies do not yet adequately define the risk-benefit ratio of such therapy.
Possible premature closure of the ductus arteriosus in the fetus is a concern, and has been postulated to occur in some cases Hydroxychloroquine and low sperm count stillbirth associated with chronic or intermittent use of high-dose aspirin.
The presence of substantial serum salicylate levels have been demonstrated in breastfed neonates, which raises concerns about metabolic acidosis, bleeding, altered pulmonary circulation, and Reye syndrome.
After a single aspirin dose of to mg, 0.
However, with chronic maternal intake of anti-inflammatory doses and immature neonatal metabolism, the infant can potentially develop salicylate intoxication and bleeding problems.
Further, the infant can absorb free salicylic acid from the cleavage of salicylphenolic glucuronide in milk. Anti-inflammatory doses of aspirin should be avoided during the last 4 to 8 weeks of pregnancy to avoid prolonged gestation and labor, increased maternal and fetal bleeding during delivery, and possible premature closure of the ductus arteriosus. Some possible uses Hydroxychloroquine and low sperm count for low-dose aspirin therapy as an antiplatelet agent, especially for women with recurrent fetal loss.
Nursing mothers should avoid large doses of aspirin. These drugs are not known to be teratogenic in humans, and prophylactic cessation of therapy is not necessary. Possible effects on the mother include prolonged gestation and labor, increased peripartum blood loss, and increased anemia.
As with aspirin, the potential adverse effects of NSAIDs on the fetus include increased cutaneous and intracranial bleeding, premature closure of the ductus arteriosus, pulmonary hypertension, impaired renal function, a reduction in urine output, and reduced amniotic fluid volume. These effects have been demonstrated for indomethacin, naproxen, ketoprofen, and ibuprofen, and may also occur with other prostaglandin synthesis inhibitors.
The dose, Hydroxychloroquine and low sperm count, and period of gestation are important determinants of these effects.
It is believed that these effects are uncommon with cessation of therapy 6 to 8 weeks before delivery. Although most NSAIDs do not achieve high concentrations in breast milk, they should be used with caution by nursing mothers. Trace amounts of naproxen, piroxicam, ibuprofen, and diclofenac have been reported in milk. Because most NSAIDs displace bilirubin, they can increase the risk of kernicterus and are contraindicated in the jaundiced neonate. The American Academy of Pediatrics considers ibuprofen, indomethacin, and naproxen to be compatible with breastfeeding.
When administered to the pregnant patient, NSAIDs should be given in the lowest effective dose, intermittently if possible, and treatment should be discontinued at least 6 to 8 weeks prior to expected delivery. Hydroxychloroquine and low sperm count published studies suggest that in selected patients, an NSAID with a short half-life and inactive metabolites, such as flurbiprofen, diclofenac, or ibuprofen, may be used more safely.
Corticosteroids are potent anti-inflammatory drugs that are used in many patients with rheumatic diseases, and they are often the mainstay of therapy in pregnant patients.
When glucocorticoids are needed to treat fetal conditions such as immature lungs, fluorinated preparations such as dexamethasone and betamethasone are preferred because they are less well metabolized by the placenta and greater doses are available to Hydroxychloroquine and low sperm count fetus. These glucocorticoids are preferred for the treatment of maternal disorders.
Other than the impact of the underlying maternal disease, the use of corticosteroids prior to Hydroxychloroquine and low sperm count does not seem to adversely impact fertility Table 1. Corticosteroids in high doses have caused cleft palate in experimental animal models and low birth weight in humans.
The FDA risk categories are: Drugs should be given only if the potential benefit justifies the potential risk to the fetus; [D] there is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk [eg, if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective]; and [X] studies in animals or human beings have demonstrated fetal abnormalities or there is evidence of fetal risk based on human experience or both, and the risk of the use of the drug in pregnant women clearly outweighs any potential benefit.
The drug is contraindicated in Hydroxychloroquine and low sperm count who are or may become pregnant.
A large retrospective study of corticosteroid-treated pregnant patients with asthma failed to show an increased incidence of birth defects compared with the general population. Most women were receiving low-dose prednisone mean daily dose of 8 mg and were taking glucocorticoids at the time of conception.
The complications associated with the use of corticosteroids in a pregnant patient are the same as in those that may occur in nonpregnant patients, including immunosuppression, avascular necrosis of bone, osteopenia, hypertension, hyperglycemia, cataracts, and striae.
However, there may be pregnancy-specific complications such as premature rupture of the membranes and exacerbation of gestational diabetes and hypertension. Effects of high-dose pulse therapy during pregnancy have not been determined, although it has been reported that fetal movements are transiently decreased following the administration of high-dose fluorinated steroids. Fortunately the incidence of adrenal suppression and infection seems to be quite low.
Small amounts of glucocorticoids can be present in the breast milk of women taking these medications. However, no adverse effects have been reported, and the American Academy of Pediatrics has declared prednisone and prednisolone safe and compatible with breast-feeding. The routine use of oral calcium and vitamin D supplements is recommended to help prevent osteoporosis.
The lowest possible dose needed to control disease activity should be used, and a patient who has been treated with corticosteroids during pregnancy should be given "stress doses" of hydrocortisone for any emergency surgery, cesarean section, or prolonged labor and delivery. Neonates should be monitored for evidence of adrenal insufficiency and infection. Women who choose to breastfeed while taking high doses of glucocorticoids could wait 4 hours after ingesting a dose to resume breastfeeding, a strategy that will decrease the amount of glucocorticoid in Hydroxychloroquine and low sperm count milk.
The risk of amenorrhea is greatest in women older than 31 years. However, it is during the earliest follicular phase that young follicles are being recruited, and this strategy alone is not likely to be sufficient. Other options include the use of oral contraceptives or gonadotropin-releasing hormone agonists, which inhibit ovulation and are believed to protect ovarian follicle viability.
If time permits, another alternative is cryopreservation of oocytes. Patients undergoing therapy with cyclophosphamide must be counseled to avoid pregnancy and to use adequate contraception. Teratogenicity, impaired growth, bone marrow suppression, infection, hemorrhage, and the long-term effects on the fetal Hydroxychloroquine and low sperm count are of concern.
Both normal and malformed newborns have been reported after the use of cyclophosphamide in pregnancy. The reported malformations involve the skeleton, palate, limbs, Hydroxychloroquine and low sperm count eye, and are often difficult to detect prenatally.
Except in a few individual cases, long-term studies on fetuses exposed to cyclophosphamide during the second trimester, the period of neuroblast multiplication, have not been conducted.
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Cyclophosphamide is found in substantial concentrations in human breast milk. Cyclophosphamide is generally contraindicated for treatment of rheumatic diseases during pregnancy and lactation.