Pregnancy planning in women with rheumatic diseases: an integrated framework for risk stratification and multidisciplinary management

Pregnancy planning in patients with rheumatic diseases (RD) is a multifaceted public health issue that includes complex strategies targeting underlying disease activity and reproductive potential. Patients with autoimmune diseases, including those with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Sjögren syndrome, systemic sclerosis (SSc), and spondyloarthritis, present with heightened risks of adverse maternal and fetal outcomes, including miscarriage, fetal growth restriction, preeclampsia, preterm birth, and increased utilization of assisted reproductive technologies. Available evidence suggests that conception during sustained disease remission, alongside tailored drug therapies, enhances maternal-fetal outcomes. Critical determinants of obstetric prognosis include disease-specific activity indices, serologic markers, organ involvement, and prior gonadotoxic exposures which compromise ovarian reserve. Structured preconception counseling that integrates contraception strategies, fertility preservation, ovarian reserve assessment, and multidisciplinary follow-up is essential to mitigate these risks. Current management paradigms advocate the continuation of pregnancy-compatible disease-modifying antirheumatic drugs (DMARDs), while strictly avoiding teratogenic therapies. Despite these advances, substantial unmet needs exist in early risk stratification, patient education, and systematic integration of reproductive health counselling into routine RD management. This review synthesizes contemporary evidence, delineates existing gaps, and provides a strategic framework for optimizing pregnancy planning and reproductive outcomes in women with RDs. The review addresses the key domains, including preconception risk stratification, disease-specific considerations, fertility assessment, ovarian reserve evaluation, and optimization of drug therapies. A multidisciplinary, treat-to-target approach is essential to improve pregnancy outcomes and long-term maternal health in this high-risk population.