Advertisement

Family Planning and Rheumatoid Arthritis

  • Nicole Hunt
  • Mehret Birru TalabiEmail author
Rheumatoid Arthritis (L Moreland, Section Editor)
  • 102 Downloads
Part of the following topical collections:
  1. Topical Collection on Rheumatoid Arthritis

Abstract

Purpose of Review

Patients with rheumatoid arthritis (RA) have special family planning considerations that require close coordination with health care providers. While this article focuses on issues inherent to female patients given their potential for pregnancy, we will review pertinent issues related to medication counseling for male patients.

Recent Findings

Some women with RA may experience subfertility. Disease activity may decrease for some, but not all pregnant women with RA. Preterm birth is more common among women with RA than among healthy women, which may be explained, in part, by disease activity and/or use of certain medications. Contraception is safe for women with RA.

Summary

RA is a chronic, female-predominant inflammatory disease that may affect women and men during their reproductive years. We describe some of these considerations herein and focus on strategies to help providers to clarify and support their patients’ reproductive goals.

Keywords

Rheumatoid arthritis Women’s health Family planning Pregnancy 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Golding A, Haque UJ, Giles JT. Rheumatoid arthritis and reproduction. Rheum Dis Clin N Am. 2007;33(2):319–43 vi-vii.CrossRefGoogle Scholar
  2. 2.
    Hargreaves ER. A survey of rheumatoid arthritis in West Cornwall; a report to the empire rheumatism council. Ann Rheum Dis. 1958;17(1):61–75.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Kay A, Bach F. Subfertility before and after the development of rheumatoid arthritis in women. Ann Rheum Dis. 1965;24:169–73.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Wallenius M, Skomsvoll JF, Irgens LM, Salvesen KA, Nordvag BY, Koldingsnes W, et al. Parity in patients with chronic inflammatory arthritides childless at time of diagnosis. Scand J Rheumatol. 2012;41(3):202–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Wallenius M, Salvesen KA, Daltveit AK, Skomsvoll JF. Secular trends of pregnancies in women with inflammatory connective tissue disease. Acta Obstet Gynecol Scand. 2015;94(11):1195–202.PubMedCrossRefGoogle Scholar
  6. 6.
    Katz PP. Childbearing decisions and family size among women with rheumatoid arthritis. Arthritis Rheum. 2006;55(2):217–23.PubMedCrossRefGoogle Scholar
  7. 7.
    Walldorf J, Brunne S, Gittinger FS, Michl P. Family planning in inflammatory bowel disease: childlessness and disease-related concerns among female patients. Eur J Gastroenterol Hepatol. 2018;30(3):310–5.PubMedGoogle Scholar
  8. 8.
    Skomsvoll JF, Ostensen M, Baste V, Irgens LM. Number of births, interpregnancy interval, and subsequent pregnancy rate after a diagnosis of inflammatory rheumatic disease in Norwegian women. J Rheumatol. 2001;28(10):2310–4.PubMedGoogle Scholar
  9. 9.
    Brouwer J, Hazes JM, Laven JS, Dolhain RJ. Fertility in women with rheumatoid arthritis: influence of disease activity and medication. Ann Rheum Dis. 2015;74(10):1836–41.PubMedCrossRefGoogle Scholar
  10. 10.
    Ostensen M. Rheumatoid arthritis: the effect of RA and medication on female fertility. Nat Rev Rheumatol. 2014;10(9):518–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Leroy C, Rigot JM, Leroy M, Decanter C, Le Mapihan K, Parent AS, et al. Immunosuppressive drugs and fertility. Orphanet J Rare Dis. 2015;10:136.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Clowse ME, Chakravarty E, Costenbader KH, Chambers C, Michaud K. Effects of infertility, pregnancy loss, and patient concerns on family size of women with rheumatoid arthritis and systemic lupus erythematosus. Arthritis Care Res. 2012;64(5):668–74.CrossRefGoogle Scholar
  13. 13.
    NCHS. Key statistics from the National Survey of Family Growth. In. Centers for Disease Control and Prevention: Atlanta; 2016.Google Scholar
  14. 14.
    Brouwer J, Laven JS, Hazes JM, Schipper I, Dolhain RJ. Levels of serum anti-Mullerian hormone, a marker for ovarian reserve, in women with rheumatoid arthritis. Arthritis Care Res. 2013;65(9):1534–8.CrossRefGoogle Scholar
  15. 15.
    • Brouwer J, Fleurbaaij R, Hazes JMW, Dolhain R, Laven JSE. Subfertility in women with rheumatoid arthritis and the outcome of fertility assessments. Arthritis Care Res (Hoboken). 2017;69(8):1142–9. While subfertility is an issue for some women with RA, this paper helps to demonstrate that assisted reproductive technologies are effective for these women. CrossRefGoogle Scholar
  16. 16.
    Ostensen M, Fuhrer L, Mathieu R, Seitz M, Villiger PM. A prospective study of pregnant patients with rheumatoid arthritis and ankylosing spondylitis using validated clinical instruments. Ann Rheum Dis. 2004;63(10):1212–7.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Barrett JH, Brennan P, Fiddler M, Silman AJ. Does rheumatoid arthritis remit during pregnancy and relapse postpartum? Results from a nationwide study in the United Kingdom performed prospectively from late pregnancy. Arthritis Rheum. 1999;42(6):1219–27.PubMedCrossRefGoogle Scholar
  18. 18.
    de Man YA, Dolhain RJ, van de Geijn FE, Willemsen SP, Hazes JM. Disease activity of rheumatoid arthritis during pregnancy: results from a nationwide prospective study. Arthritis Rheum. 2008;59(9):1241–8.PubMedCrossRefGoogle Scholar
  19. 19.
    de Man YA, Bakker-Jonges LE, Goorbergh CM, Tillemans SP, Hooijkaas H, Hazes JM, et al. Women with rheumatoid arthritis negative for anti-cyclic citrullinated peptide and rheumatoid factor are more likely to improve during pregnancy, whereas in autoantibody-positive women autoantibody levels are not influenced by pregnancy. Ann Rheum Dis. 2010;69(2):420–3.PubMedCrossRefGoogle Scholar
  20. 20.
    van den Brandt S, Zbinden A, Baeten D, Villiger PM, Ostensen M, Forger F. Risk factors for flare and treatment of disease flares during pregnancy in rheumatoid arthritis and axial spondyloarthritis patients. Arthritis Res Ther. 2017;19(1):64.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    Kahn DA, Baltimore D. Pregnancy induces a fetal antigen-specific maternal T regulatory cell response that contributes to tolerance. Proc Natl Acad Sci U S A. 2010;107(20):9299–304.PubMedPubMedCentralCrossRefGoogle Scholar
  22. 22.
    Corthay A. How do regulatory T cells work? Scand J Immunol. 2009;70(4):326–36.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Forger F, Marcoli N, Gadola S, Moller B, Villiger PM, Ostensen M. Pregnancy induces numerical and functional changes of CD4+CD25 high regulatory T cells in patients with rheumatoid arthritis. Ann Rheum Dis. 2008;67(7):984–90.PubMedCrossRefGoogle Scholar
  24. 24.
    Norgaard M, Larsson H, Pedersen L, Granath F, Askling J, Kieler H, et al. Rheumatoid arthritis and birth outcomes: a Danish and Swedish nationwide prevalence study. J Intern Med. 2010;268(4):329–37.PubMedCrossRefGoogle Scholar
  25. 25.
    Langen ES, Chakravarty EF, Liaquat M, El-Sayed YY, Druzin ML. High rate of preterm birth in pregnancies complicated by rheumatoid arthritis. Am J Perinatol. 2014;31(1):9–14.PubMedGoogle Scholar
  26. 26.
    Wallenius M, Skomsvoll JF, Irgens LM, Salvesen KA, Nordvag BY, Koldingsnes W, et al. Pregnancy and delivery in women with chronic inflammatory arthritides with a specific focus on first birth. Arthritis Rheum. 2011;63(6):1534–42.PubMedCrossRefGoogle Scholar
  27. 27.
    Smith CJF, Forger F, Bandoli G, Chambers CD. Factors associated with preterm delivery among women with rheumatoid arthritis and juvenile idiopathic arthritis. Arthritis Care Res. 2018.Google Scholar
  28. 28.
    Bharti B, Lee SJ, Lindsay SP, Wingard DL, Jones KL, Lemus H, et al. Disease severity and pregnancy outcomes in women with rheumatoid arthritis: results from the Organization of Teratology Information Specialists Autoimmune Diseases in pregnancy project. J Rheumatol. 2015;42(8):1376–82.PubMedCrossRefGoogle Scholar
  29. 29.
    Rom AL, Wu CS, Olsen J, Kjaergaard H, Jawaheer D, Hetland ML, et al. Fetal growth and preterm birth in children exposed to maternal or paternal rheumatoid arthritis: a nationwide cohort study. Arthritis Rheum. 2014;66(12):3265–73.CrossRefGoogle Scholar
  30. 30.
    de Man YA, Hazes JM, van der Heide H, Willemsen SP, de Groot CJ, Steegers EA, et al. Association of higher rheumatoid arthritis disease activity during pregnancy with lower birth weight: results of a national prospective study. Arthritis Rheum. 2009;60(11):3196–206.PubMedCrossRefGoogle Scholar
  31. 31.
    Birru Talabi M, Clowse MEB, Blalock SJ, Moreland L, Siripong N, Borrero S. Contraception use among reproductive-age women with rheumatic diseases. Arthritis Care Res. 2018.Google Scholar
  32. 32.
    Daniels KDJ, Jones J. Current contraceptive status among women aged 15–44: United States, 2011–2013. In: NCHS Data Brief. Hyattsville: National Center for Health Statistics; 2015. p. 1–8.Google Scholar
  33. 33.
    Toomey D, Waldron B. Family planning and inflammatory bowel disease: the patient and the practitioner. Fam Pract. 2013;30(1):64–8.PubMedCrossRefGoogle Scholar
  34. 34.
    U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement; Final Recommendations. Ann Intern Med. 151:716–26.Google Scholar
  35. 35.
    Qaseem A, Humphrey LL, Harris R, Starkey M, Denberg TD. Clinical Guidelines Committee of the American College of P: screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(1):67–72.PubMedCrossRefGoogle Scholar
  36. 36.
    Moyer VA. Force USPST: screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;156(12):880–91. W312.PubMedCrossRefGoogle Scholar
  37. 37.
    Tepper NK, Curtis KM, Nanda K, Jamieson DJ. Safety of intrauterine devices among women with HIV: a systematic review. Contraception. 2016;94(6):713–24.PubMedCrossRefGoogle Scholar
  38. 38.
    Heinemann K, Reed S, Moehner S, Minh TD. Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices in the European Active Surveillance Study on Intrauterine Devices. Contraception. 2015;91(4):274–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra-Infante F, Guzman-Rodriguez R. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med. 2001;345(8):561–7.PubMedCrossRefGoogle Scholar
  40. 40.
    Curtis KJT, Tepper NK, Zapata L, Horton L, Jamieson DJ, Whiteman MK. U.S. Medical Eligibility Criteria for contraceptive use. In: Centers for Disease Control and Prevention: Morbidity and Mortality Weekly Report; 2016.Google Scholar
  41. 41.
    •• Gotestam Skorpen C, Hoeltzenbein M, Tincani A, Fischer-Betz R, Elefant E, Chambers C, et al. The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Ann Rheum Dis. 2016;75(5):795–810. This is a very important set of guidelines to help providers weigh the risks and benefits of anti-rheumatic drug use in anticipation of or during pregnancy. Guidelines from the American College of Rheumatology are forthcoming in 2019. PubMedCrossRefGoogle Scholar
  42. 42.
    CDC. Effectiveness of family planning methods. 2018.Google Scholar
  43. 43.
    Flint J, Panchal S, Hurrell A, van de Venne M, Gayed M, Schreiber K, et al. BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-part I: standard and biologic disease modifying anti-rheumatic drugs and corticosteroids. Rheumatology. 2016;55(9):1693–7.PubMedCrossRefGoogle Scholar
  44. 44.
    •• Flint J, Panchal S, Hurrell A, van de Venne M, Gayed M, Schreiber K, et al. BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-Part II: analgesics and other drugs used in rheumatology practice. Rheumatology. 2016;55(9):1698–702. This is another important set of guidelines to help providers safely prescribe anti-rheumatic drugs before, during, or after pregnancy.PubMedCrossRefGoogle Scholar
  45. 45.
    Panchal S, Khare M, Moorthy A, Samanta A. Catch me if you can: a national survey of rheumatologists and obstetricians on the use of DMARDs during pregnancy. Rheumatol Int. 2013;33(2):347–53.PubMedCrossRefGoogle Scholar
  46. 46.
    Hays S. The cultural contradictions of motherhood. New Haven: Yale University Press; 1998.Google Scholar
  47. 47.
    Mother to Baby. https://mothertobaby.org.
  48. 48.
  49. 49.
    Duffy DM. Novel contraceptive targets to inhibit ovulation: the prostaglandin E2 pathway. Hum Reprod Update. 2015;21(5):652–70.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Nakhai-Pour HR, Broy P, Sheehy O, Berard A. Use of nonaspirin nonsteroidal anti-inflammatory drugs during pregnancy and the risk of spontaneous abortion. CMAJ. 2011;183(15):1713–20.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Dathe K, Fietz AK, Pritchard LW, Padberg S, Hultzsch S, Meixner K, et al. No evidence of adverse pregnancy outcome after exposure to ibuprofen in the first trimester - evaluation of the national Embryotox cohort. Reprod Toxicol. 2018;79:32–8.PubMedCrossRefGoogle Scholar
  52. 52.
    Koren G, Florescu A, Costei AM, Boskovic R, Moretti ME. Nonsteroidal antiinflammatory drugs during third trimester and the risk of premature closure of the ductus arteriosus: a meta-analysis. Ann Pharmacother. 2006;40(5):824–9.PubMedCrossRefGoogle Scholar
  53. 53.
    Viktil KK, Engeland A, Furu K. Outcomes after anti-rheumatic drug use before and during pregnancy: a cohort study among 150,000 pregnant women and expectant fathers. Scand J Rheumatol. 2012;41(3):196–201.PubMedCrossRefGoogle Scholar
  54. 54.
    Palmsten K, Hernandez-Diaz S, Kuriya B, Solomon DH, Setoguchi S. Use of disease-modifying antirheumatic drugs during pregnancy and risk of preeclampsia. Arthritis Care Res. 2012;64(11):1730–8.CrossRefGoogle Scholar
  55. 55.
    Ostensen ME, Skomsvoll JF. Anti-inflammatory pharmacotherapy during pregnancy. Expert Opin Pharmacother. 2004;5(3):571–80.PubMedCrossRefGoogle Scholar
  56. 56.
    Norgard B, Pedersen L, Christensen LA, Sorensen HT. Therapeutic drug use in women with Crohn’s disease and birth outcomes: a Danish nationwide cohort study. Am J Gastroenterol. 2007;102(7):1406–13.PubMedCrossRefGoogle Scholar
  57. 57.
    AAP. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001;108(3):776–89.CrossRefGoogle Scholar
  58. 58.
    Janssen NM, Genta MS. The effects of immunosuppressive and anti-inflammatory medications on fertility, pregnancy, and lactation. Arch Intern Med. 2000;160(5):610–9.PubMedCrossRefGoogle Scholar
  59. 59.
    Kemp MW, Newnham JP, Challis JG, Jobe AH, Stock SJ. The clinical use of corticosteroids in pregnancy. Hum Reprod Update. 2016;22(2):240–59.PubMedGoogle Scholar
  60. 60.
    American College of O, Gynecologists: ACOG Committee Opinion number 313, September 2005. The importance of preconception care in the continuum of women’s health care. Obstet Gynecol. 2005;106(3):665–6.CrossRefGoogle Scholar
  61. 61.
    Ostensen M. Piroxicam in human breast milk. Eur J Clin Pharmacol. 1983;25(6):829–30.PubMedCrossRefGoogle Scholar
  62. 62.
    Noviani M, Wasserman S, Clowse ME. Breastfeeding in mothers with systemic lupus erythematosus. Lupus. 2016;25(9):973–9.PubMedCrossRefGoogle Scholar
  63. 63.
    Mahadevan U, Wolf DC, Dubinsky M, Cortot A, Lee SD, Siegel CA, et al. Placental transfer of anti-tumor necrosis factor agents in pregnant patients with inflammatory bowel disease. Clin Gastroenterol Hepatol. 2013;11(3):286–92 quiz e224.PubMedCrossRefGoogle Scholar
  64. 64.
    Clowse ME. The use of anti-TNFalpha medications for rheumatologic disease in pregnancy. Int J Women's Health. 2010;2:199–209.CrossRefGoogle Scholar
  65. 65.
    Hoxha A, Calligaro A, Di Poi E, Peccatori S, Favaro M, Del Ross T, et al. Pregnancy and foetal outcomes following anti-tumor necrosis factor alpha therapy: a prospective multicentre study. Joint Bone Spine. 2017;84(2):169–73.PubMedCrossRefGoogle Scholar
  66. 66.
    Clowse MEB, Scheuerle AE, Chambers C, Afzali A, Kimball AB, Cush JJ, et al. Pregnancy outcomes after exposure to Certolizumab pegol: updated results from a pharmacovigilance safety database. Arthritis Rheum. 2018;70(9):1399–407.CrossRefGoogle Scholar
  67. 67.
    Diav-Citrin O, Otcheretianski-Volodarsky A, Shechtman S, Ornoy A. Pregnancy outcome following gestational exposure to TNF-alpha-inhibitors: a prospective, comparative, observational study. Reprod Toxicol. 2014;43:78–84.PubMedCrossRefGoogle Scholar
  68. 68.
    Weber-Schoendorfer C, Oppermann M, Wacker E, Bernard N, network of French pharmacovigilance c, Beghin D, et al. Pregnancy outcome after TNF-alpha inhibitor therapy during the first trimester: a prospective multicentre cohort study. Br J Clin Pharmacol. 2015;80(4):727–39.PubMedPubMedCentralCrossRefGoogle Scholar
  69. 69.
    • Vinet E, De Moura C, Pineau CA, Abrahamowicz M, Curtis JR, Bernatsky S. Serious Infections in rheumatoid arthritis offspring exposed to tumor necrosis factor inhibitors: a cohort study. Arthritis Rheumatol. 2018;70(10):1565–71. This study shows that infection risk is generally low among neonates exposed to TNF-alpha inhibitors in utero , although there may be an increased risk of infections from infliximab.PubMedCrossRefGoogle Scholar
  70. 70.
    Clowse ME, Forger F, Hwang C, Thorp J, Dolhain RJ, van Tubergen A, et al. Minimal to no transfer of certolizumab pegol into breast milk: results from CRADLE, a prospective, postmarketing, multicentre, pharmacokinetic study. Ann Rheum Dis. 2017;76(11):1890–6.PubMedPubMedCentralCrossRefGoogle Scholar
  71. 71.
    Andreoli L, Bertsias GK, Agmon-Levin N, Brown S, Cervera R, Costedoat-Chalumeau N, et al. EULAR recommendations for women's health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome. Ann Rheum Dis. 2017;76(3):476–85.PubMedPubMedCentralCrossRefGoogle Scholar
  72. 72.
    Chambers CD, Johnson DL, Robinson LK, Braddock SR, Xu R, Lopez-Jimenez J, et al. Birth outcomes in women who have taken leflunomide during pregnancy. Arthritis Rheum. 2010;62(5):1494–503.PubMedPubMedCentralCrossRefGoogle Scholar
  73. 73.
    •• Mouyis M, Flint JD, Giles IP. Safety of anti-rheumatic drugs in men trying to conceive: a systematic review and analysis of published evidence. Semin Arthritis Rheum. 2018. This is one of the first reviews available to help providers to counsel men with rheumatic diseases about medications in anticipation of pregnancy. Google Scholar
  74. 74.
    Larsen MD, Friedman S, Magnussen B, Norgard BM. Birth outcomes in children fathered by men treated with anti-TNF-alpha agents before conception. Am J Gastroenterol. 2016;111(11):1608–13.PubMedCrossRefGoogle Scholar
  75. 75.
    Wallenius M, Lie E, Daltveit AK, Salvesen KA, Skomsvoll JF, Kalstad S, et al. No excess risks in offspring with paternal preconception exposure to disease-modifying antirheumatic drugs. Arthritis Rheum. 2015;67(1):296–301.CrossRefGoogle Scholar
  76. 76.
    Clowse ME, Wolf DC, Forger F, Cush JJ, Golembesky A, Shaughnessy L, et al. Pregnancy outcomes in subjects exposed to Certolizumab pegol. J Rheumatol. 2015;42(12):2270–8.PubMedCrossRefGoogle Scholar
  77. 77.
    O'Morain C, Smethurst P, Dore CJ, Levi AJ. Reversible male infertility due to sulphasalazine: studies in man and rat. Gut. 1984;25(10):1078–84.PubMedPubMedCentralCrossRefGoogle Scholar
  78. 78.
    Riley SA, Lecarpentier J, Mani V, Goodman MJ, Mandal BK, Turnberg LA. Sulphasalazine induced seminal abnormalities in ulcerative colitis: results of mesalazine substitution. Gut. 1987;28(8):1008–12.PubMedPubMedCentralCrossRefGoogle Scholar
  79. 79.
    Weber-Schoendorfer C, Hoeltzenbein M, Wacker E, Meister R, Schaefer C. No evidence for an increased risk of adverse pregnancy outcome after paternal low-dose methotrexate: an observational cohort study. Rheumatology (Oxford). 2014;53(4):757–63.CrossRefGoogle Scholar
  80. 80.
    Eck LK, Jensen TB, Mastrogiannis D, Torp-Pedersen A, Askaa B, Nielsen TK, et al. Risk of adverse pregnancy outcome after paternal exposure to methotrexate within 90 days before pregnancy. Obstet Gynecol. 2017;129(4):707–14.PubMedCrossRefGoogle Scholar
  81. 81.
    Winter RW, Larsen MD, Magnussen B, Friedman S, Kammerlander H, Norgard BM. Birth outcomes after preconception paternal exposure to methotrexate: a nationwide cohort study. Reprod Toxicol. 2017;74:219–23.PubMedCrossRefGoogle Scholar
  82. 82.
    Birru Talabi M, Clowse MEB, Schwarz EB, Callegari LS, Moreland L, Borrero S. Family planning counseling for women with rheumatic diseases. Arthritis Care Res. 2018;70(2):169–74.CrossRefGoogle Scholar
  83. 83.
    Bellanca HK, Hunter MS. ONE KEY QUESTION(R): preventive reproductive health is part of high quality primary care. Contraception. 2013;88(1):3–6.PubMedCrossRefGoogle Scholar
  84. 84.
    Geist C, Aiken AR, Sanders JN, Everett BG, Myers K, Cason P, et al. Beyond intent: exploring the association of contraceptive choice with questions about pregnancy attitudes, timing and how important is pregnancy prevention (PATH) questions. Contraception. 2018.Google Scholar
  85. 85.
    Callegari LS, Aiken AR, Dehlendorf C, Cason P, Borrero S. Addressing potential pitfalls of reproductive life planning with patient-centered counseling. Am J Obstet Gynecol. 2017;216(2):129–34.PubMedCrossRefGoogle Scholar
  86. 86.
    Kavanaugh A, Cush JJ, Ahmed MS, Bermas BL, Chakravarty E, Chambers C, et al. Proceedings from the American College of Rheumatology Reproductive Health Summit: the management of fertility, pregnancy, and lactation in women with autoimmune and systemic inflammatory diseases. Arthritis Care Res. 2015;67(3):313–25.CrossRefGoogle Scholar
  87. 87.
    Clowse ME. Managing contraception and pregnancy in the rheumatologic diseases. Best Pract Res Clin Rheumatol. 2010;24(3):373–85.PubMedCrossRefGoogle Scholar
  88. 88.
    Borrero S, Nikolajski C, Steinberg JR, Freedman L, Akers AY, Ibrahim S. Schwarz EB: “It just happens”: a qualitative study exploring low-income women’s perspectives on pregnancy intention and planning. Contraception. 2015;91(2):150–6.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Rheumatology and Clinical Immunology, Department of MedicineUniversity of PittsburghPittsburghUSA

Personalised recommendations