Prospective studies (evidence level moderate) in patients with stable SLE showed no increased risk of flare related to estrogen‐progestin pills 19, 20, and there are no data suggesting increased SLE flare risk with progestin‐only pills or copper IUDs 20, 21. RMD patients typically underutilize effective contraception 11-13. These recommendations are intended to guide care for all patients with RMD, except where indicated as being specific for patients with systemic lupus erythematosus, those positive for antiphospholipid antibody, and/or those positive for anti‐Ro/SSA and/or anti‐La/SSB antibodies. We strongly suggest as good practice the use of HRT in postmenopausal women with RMD without SLE or positive aPL who have severe vasomotor symptoms, have no contraindications, and desire treatment with HRT. Supplementary Appendix 7, Table E (http://onlin​elibr​ary.wiley.com/doi/10.1002/art.41191/​abstract) presents formal recommendations regarding pregnancy in patients with RMD with strength of supporting evidence. We conditionally recommend continuing treatment with anakinra, belimumab, abatacept, tocilizumab, secukinumab, and ustekinumab while a woman is trying to conceive, but discontinuing once she is found to be pregnant. Most information regarding pregnancy management in RMD comes from observational studies, primarily in patients with SLE and APS. The Journal of Maternal-Fetal & Neonatal Medicine. Arthritis Rheumatol. American College of Rheumatology Guidance for the Management of Pediatric Rheumatic Disease During the COVID-19 Pandemic: Version 1. In SLE patients with stable or low disease activity who are not positive for aPL, we strongly recommend use of effective contraceptives (i.e., hormonal contraceptives or IUDs) over less effective options or no contraception, and we conditionally recommend the highly effective IUDs or subdermal progestin implant because they have the lowest failure rates. We appreciate and stress, however, that benefit in individual high‐risk circumstances, such as triple‐positive aPL or strongly positive LAC results, advanced maternal age, or IVF pregnancy, may outweigh risks of this therapy, and decisions should be made with discussion between physician and patient, weighing potential risks and benefits. Dr. Lockshin has received consulting fees, speaking fees, and/or honoraria from Advance Medical, groupH, Biologische Heilmittel Heel, and Defined Health and has served as an expert witness concerning adverse pregnancy outcome with question of antiphospholipid syndrome. Detailed justifications for strong and conditional recommendations are shown in Supplementary Appendix 11 (http://onlin​elibr​ary.wiley.com/doi/10.1002/art.41191/​abstract). Pregnancy Outcomes in Systemic Vasculitides. Ann Rheum Dis. The Voting Panel declined to vote on the compatibility of new small‐molecule agents regarding use during breastfeeding due to absence of data. These include 3 consecutive losses prior to 10 weeks’ gestation, a fetal loss at or after 10 weeks’ gestation, or delivery at <34 weeks due to preeclampsia, intrauterine growth restriction, or fetal distress. Pregnancy in women with RMD may lead to serious maternal or fetal adverse outcomes; accordingly, contraception, tailored to the individual patient with emphasis on safety and efficacy, should be discussed and encouraged. While there are few data to guide prophylactic anticoagulation in aPL‐positive patients, thromboprophylaxis is recommended to prevent thrombotic complications of moderate‐to‐severe ovarian hyperstimulation syndrome, as it is for patients with known inherited or acquired thrombophilia 45, 46. We strongly recommend against use of HRT in women with obstetric and/or thrombotic APS. Treatment with low‐dose aspirin during pregnancy to prevent or delay the onset of gestational hypertensive disease is recommended for those with SLE or APS because of their increased risk and may be considered for women with other RMD diagnoses depending on individual clinical risk factors. The specific progestin and its serum level affect thrombosis risk: in healthy women taking estrogen‐progestin contraceptive pills that vary progestin type but not estrogen, VTE risk odds ratios range from 2.2 to 6.6 24. 73: use of hormonal contraception in women with coexisting medical conditions, World Health Organization Department of Reproductive Health, Medical eligibility criteria for contraceptive use, Assessing the risk of venous thromboembolic events in women taking progestin‐only contraception: a meta‐analysis, Progestogen‐only contraception in women at high risk of venous thromboembolism, Risk of recurrent venous thromboembolism on progestin‐only contraception: a cohort study, Treatment of menorrhagia associated with oral anticoagulation: efficacy and safety of the levonorgestrel releasing intrauterine device (Mirena coil), Thrombotic risk during oral contraceptive use and pregnancy in women with factor V Leiden or prothrombin mutation: a rational approach to contraception, A randomized trial of the intrauterine contraceptive device vs hormonal contraception in women who are infected with the human immunodeficiency virus, Contraceptive options for women with a history of solid‐organ transplantation, Use of the levonorgestrel 52‐mg intrauterine system in adolescent and young adult solid organ transplant recipients: a case series, Bone mineral density loss and recovery during 48 months in first‐time users of depot medroxyprogesterone acetate, Welcome to the mycophenolate REMS (Risk Evaluation and Mitigation Strategy), Cellcept (mycophenolate mofetil) prescribing information, Mycophenolate: updated recommendations for contraception for men and women, Ovarian stimulation for ovulation induction and in vitro fertilization in patients with systemic lupus erythematosus and antiphospholipid syndrome, Importance of planning ovulation induction therapy in systemic lupus erythematosus and antiphospholipid syndrome: a single center retrospective study of 21 cases and 114 cycles, In vitro fertilization in 37 women with systemic lupus erythematosus or antiphospholipid syndrome: a series of 97 procedures, Ovulation induction and in vitro fertilization in systemic lupus erythematosus and antiphospholipid syndrome, The “ART” of thromboembolism: a review of assisted reproductive technology and thromboembolic complications, Artificial reproductive technology and the risk of venous thromboembolic disease, The ‘ART’ of thrombosis: a review of arterial and venous thrombosis in assisted reproductive technology, Safety of IVF under anticoagulant therapy in patients at risk for thrombo‐embolic events, Venous thrombosis during assisted reproduction: novel risk reduction strategies, Risk factors for ovarian failure in patients with systemic lupus erythematosus receiving cyclophosphamide therapy, The Euro‐Lupus low‐dose intravenous cyclophosphamide regimen does not impact the ovarian reserve, as measured by serum levels of anti–Müllerian hormone, Fertility preservation in patients with cancer: ASCO clinical practice guideline update, Goserelin for ovarian protection during breast‐cancer adjuvant chemotherapy, Gonadotropin releasing hormone agonists may minimize cyclophosphamide associated gonadotoxicity in SLE and autoimmune diseases, Randomized, double‐blind, dose‐escalation trial of triptorelin for ovary protection in childhood‐onset systemic lupus erythematosus, Effect of a gonadotropin‐releasing hormone analog for ovarian function preservation after intravenous cyclophosphamide therapy in systemic lupus erythematosus patients: a retrospective inception cohort study, Pregnancies in systemic necrotizing vasculitides: report on 12 women and their 20 pregnancies, Use of a gonadotropin‐releasing hormone analog for protection against premature ovarian failure during cyclophosphamide therapy in women with severe lupus, Gonad evaluation in male systemic lupus erythematosus, Relative susceptibilities of male germ cells to genetic defects induced by cancer chemotherapies, Indications and strategies for fertility preservation in men, ACOG Practice Bulletin no. Since ovarian stimulation protocols vary, discussion with the reproductive endocrinology and infertility specialist is appropriate. Timing will vary depending on individual clinical factors; in clinical practice this is usually a minimum of several months. ). Voting Panel members disagreed on the need to use additional contraceptive measures. November 12-17, 2005, San Diego, … There are several ways to explore this site: Browse 2020 abstracts in numerical order. Dr. Eudy has received consulting fees, speaking fees, and/or honoraria from GlaxoSmithKline (more than $10,000) and research support from GlaxoSmithKline. A relatively rare but important scenario is the therapeutic termination of pregnancy in patients with life‐threatening disease damage or flare. HHS When the man's partner is pregnant, the concern is whether his medication is present in seminal fluid and can transfer through vaginal mucosa, cross the placenta, and be teratogenic. A Systematic Review of Treatment and Outcomes of Pregnant Women With COVID-19—A Call for Clinical Trials. Low‐titer antibodies are probably not associated with the same risk of CHB as higher titers 131. If you know the abstract number, enter it here to look it up. 166 This is based on evidence of moderate strength. ). In these and other high‐risk situations, the option of therapeutic termination of pregnancy may be lifesaving and should be discussed with the patient 195. If a patient is already taking HCQ, we strongly recommend continuing it during pregnancy; if she is not taking HCQ, we conditionally recommend starting it if there is no contraindication. Distinguishing among these syndromes requires the expertise of rheumatologists and obstetrics‐gynecology or maternal‐fetal medicine physicians working together. The strength of these recommendations rests on the severity of the risk of organ‐ or life‐threatening thrombosis during ovarian stimulation. While usually reflecting a higher level of evidence, it may also reflect the severity of a potential negative outcome. Direct evidence regarding thrombosis risk with HRT in SLE patients with or without aPL is low, as studies have addressed risk of flare in SLE but not thrombosis, and some studies excluded patients with prior thrombosis 65, 67. This guideline provides evidence‐based recommendations developed and reviewed by panels of experts and RMD patients. Current population recommendations 60-62 suggest limiting HRT use in healthy postmenopausal women and using the lowest dose that alleviates symptoms for the minimum time necessary. Epub 2020 Oct 3. Concise recommendations within this appendix and throughout the article are grouped into categories of contraception, ART, fertility preservation with gonadotoxic therapy, use of menopausal HRT, pregnancy assessment and management, and medication use (compatibilities for paternal, maternal, and breastfeeding use are reported). Oocyte freezing is now widely available 197. Effectiveness of reproductive health counseling of women with systemic lupus erythematosus: observational cross-sectional study at an academic lupus clinic. Some investigators have used doses of aspirin up to 150 mg daily, but both the American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force note that there is a lack of appropriate comparative studies to show the superiority of doses >100 mg per day. This guideline was developed, and the literature review conducted, in the adult population. Night sweats are hot flashes that occur with perspiration during sleep 64. I understand that this abstract, if accepted, will be under embargo until 4:30 PM Eastern Time on Saturday, November 4, 2017. Paternal use of CYC may impair spermatogenesis or be mutagenic for DNA 137 and should be discontinued 3 months prior to attempting conception. 2020 Dec 5. doi: 10.1002/art.41596. Abstract. ). One Key Question (www.power​todec​ide.org) has been suggested in the literature as a simple way of addressing the issue of family planning with patients: “Would you like to become pregnant in the next year?” 14. A carefully monitored ovarian stimulation/IVF cycle followed by embryo transfer to a surrogate is an option, if available, for patients with severe disease‐related damage who desire a biologic child and are able to undergo ovarian stimulation and oocyte retrieval, but cannot safely undergo pregnancy. We provide data‐derived recommendations for common clinical reproductive health decisions including recent advances in this area and emphasize the need for early involvement of the rheumatologist in reproductive health discussions involving patients with RMD, for instance, the importance of effective contraception. Sammaritano, Bermas, Chakravarty, Chambers, Clowse, Lockshin, Marder, Laskin, Tedeschi, Barbhaiya, Bettendorf, Eudy, Jayatilleke, Shah, Sullivan, Tarter, Turgunbaev, D'Anci. Barrier methods confer some protection against sexually transmitted diseases. Severe autoimmune disease flare occurring during pregnancy—including diffuse alveolar hemorrhage, active nephritis or vasculitis, or central nervous system inflammation—also carries high risk for maternal morbidity and mortality 55, 192-194. If disease cannot be controlled with medications considered compatible with pregnancy, the physician and patient should discuss and weigh the possible risks from these medications versus the risks of uncontrolled disease during pregnancy. Other high‐risk scenarios include severe renal insufficiency, cardiomyopathy, or valvular dysfunction. As standard good practice, we suggest discussing medications well before the patient attempts to conceive; we also suggest discussing pregnancy plans prior to initiating treatment with medications that may affect gonadal function, such as CYC. Epub 2020 Sep 28. ). Report of the Multicenter Criteria Committee Arthritis Rheum. aPL = antiphospholipid antibody (persistent moderate [Mod]–to‐high–titer anticardiolipin or anti–β, Recommendations for use of assisted reproductive technology (ART) in women with rheumatic and musculoskeletal disease (RMD). The full text of this article hosted at iucr.org is unavailable due to technical difficulties. Acknowledging this lack of data on oral CYC–treated patients, it is reasonable to consider gonadotropin‐releasing hormone agonist use for these patients. Data about pregnancies in rare rheumatic diseases usually derive from small case series. Reports of thrombosis in aPL‐positive patients undergoing IVF are uncommon, but most reported patients received empiric anticoagulation 41, 42. Although our mandate was broad, our task was to derive and support our recommendations with available evidence, but many uncommon clinical scenarios have little published data. Hot flashes are recurrent, transient episodes of flushing, perspiration, and a sensation ranging from warmth to intense heat on the upper body and face, sometimes followed by chills. The level of evidence specific to RMD patients is very low 41, 42, but evidence supports the safety of ART in a general population 43, 44. In one arm of an SLE contraceptive trial a copper IUD was used; although the number of patients receiving immunosuppressive agents was not reported, there were no cases of pelvic inflammatory disease 20. Search by Abstract Number. An added risk for thrombosis is ovarian hyperstimulation syndrome, an important, uncommon complication consisting of capillary leak syndrome (with pleural effusion and ascites) and, in severe cases, arterial and venous thrombosis and renal failure 43. The Voting Panel agreed that if the patient's disease is under good control, these medications may be discontinued in the third trimester. Thrombotic APS refers to patients who meet laboratory criteria for APS and have experienced a prior thrombotic event (arterial or venous), regardless of whether they have had obstetric complications. 141: management of menopausal symptoms, The NAMS 2017 Hormone Therapy Position Statement Advisory Panel, The 2017 hormone therapy position statement of the North American Menopause Society, Hormone therapy for the prevention of chronic conditions in postmenopausal women: recommendations from the U.S. Preventive Services Task Force, Breast cancer and hormone‐replacement therapy in the Million Women Study, The 2012 hormone therapy position statement of the North American Menopause Society, The effect of combined estrogen and progesterone hormone replacement therapy on disease activity in systemic lupus erythematosus: a randomized trial, Safety of hormonal replacement therapy in postmenopausal patients with systemic lupus erythematosus, Menopause hormonal therapy in women with systemic lupus erythematosus, Hormone replacement therapy in systemic lupus erythematosus, Long‐term hormone therapy for perimenopausal and postmenopausal women, Estrogen plus progestin and risk of venous thrombosis, for the Estrogen and Thromboembolism Risk (ESTHER) Study Group, Hormone therapy and venous thromboembolism among postmenopausal women—impact of the route of estrogen administration and progestogens: the ESTHER study, Venous thromboembolism risk in relation to use of different types of postmenopausal hormone therapy in a large prospective study, Esterified estrogens and conjugated equine estrogens and the risk of venous thrombosis, Risk of venous thromboembolism events in postmenopausal women using oral versus non‐oral hormone therapy: a systematic review and meta‐analysis, Prothrombotic mutations, hormone therapy, and venous thromboembolism among postmenopausal women: impact of the route of estrogen administration, Hormonal replacement therapy, prothrombotic mutations and the risk of venous thrombosis, Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: systematic review and meta‐analysis, Efficacy of estrogen plus progestin on menopausal symptoms in women with systemic lupus erythematosus: a randomized, double‐blind, controlled trial, A comparative study of pregnancy outcomes and menstrual irregularities in northern Indian patients with systemic lupus erythematosus and rheumatoid arthritis, Pregnancy does not cause systemic lupus erythematosus to worsen, Pregnancy and its outcome in systemic lupus erythematosus, Pregnancy outcome in patients with systemic lupus erythematosus: a single center study in the High Risk Pregnancy unit, Prospective study of pregnancy in systemic lupus erythematosus: results of a multidisciplinary approach, Could women with systemic lupus erythematosus (SLE) have successful pregnancy outcomes? Premature infants or those with gastrointestinal disorders may absorb medication differently. Supplementary Appendix 7, Table C (on the Arthritis & Rheumatology web site at http://onlin​elibr​ary.wiley.com/doi/10.1002/art.41191/​abstract) presents the formal recommendations regarding fertility preservation with CYC treatment and strength of supporting evidence. Issues regarding contraception, fertility, pregnancy, lactation, and the offspring's health affect almost every patient across all RMD diagnoses. For approval, median votes were required to meet predefined levels of agreement (median values of 7-9, 4-6, and 1-3 defined as agreement, uncertainty, or disagreement, respectively) with either moderate or high levels of consensus. 75, 77, 79-98 To develop an evidence‐based guideline on contraception, assisted reproductive technologies (ART), fertility preservation with gonadotoxic therapy, use of menopausal hormone replacement therapy (HRT), pregnancy assessment and management, and medication use in patients with rheumatic and musculoskeletal disease (RMD). Therapy with immunosuppressive drugs and biological agents and use of contraception in patients with rheumatic disease, Contraception for women: an evidence based overview, Effectiveness of long‐acting reversible contraception, Committee on Gynecologic Practice Long‐Acting Reversible Contraception Working Group, Committee opinion no. There are very limited data on RMD medication effects on fertility and teratogenicity in men with RMD. Asymptomatic aPL‐positive patients (those without pregnancy complications or history of thrombosis) are not generally treated with prophylactic therapy to prevent pregnancy loss. Treatment should be limited to several weeks, depending on response, because of the risk of irreversible fetal and maternal toxicity. Perception of Contraceptive Counseling and Contraceptive Use among Systemic Lupus Erythematosus Patients. Because women with RMD may experience disease flare post partum and require treatment, it is important to balance benefits of disease control with risk of infant exposure through breast milk. We conditionally recommend prophylactic anticoagulation therapy with heparin or low molecular weight heparin in asymptomatic aPL‐positive patients during ART procedures (41, 42). Treatment of Autoimmune Bullous Diseases During Pregnancy and Lactation: A Review Focusing on Pemphigus and Pemphigoid Gestationis. We conditionally recommend that women with RMD taking mycophenolate mofetil/mycophenolic acid (MMF) use an IUD alone or 2 other methods of contraception together, because MMF may reduce serum estrogen and progesterone levels (in turn reducing the efficacy of oral contraceptives). Once metabolite is not detectable in the serum, the risks of pregnancy loss and birth defects are not elevated ( Pregnancies in patients with positive aPL or APS present specific challenges and may require additional monitoring and therapy. Effectiveness of reversible forms of contraception varies. et al While scleroderma renal crisis is rare in pregnancy (an estimated 2% of scleroderma pregnancies), it can easily be confused with preeclampsia. In fact, post‐conception exposure of the embryo or fetus is likely minimal, as seminal concentrations of medications and volumes transferred are small 136. This includes continuation of mycophenolate or methotrexate (MTX). Dr. Jayatilleke has received consulting fees and/or honoraria from GlaxoSmithKline (less than $10,000). Front Immunol. Most disease‐specific recommendations for RMD pregnancy management focus on presence of underlying SLE or positive aPL. We strongly recommend use of angiotensin‐converting enzyme inhibitor or angiotensin receptor blockade therapy to treat active scleroderma renal crisis in pregnancy, because the risk of maternal or fetal death with untreated disease is higher than the risk associated with use of these medications during pregnancy. We conditionally recommend against use of MTX while breastfeeding. We strongly recommend progestin‐only or IUD contraceptives over combined estrogen‐progestin contraception in SLE patients with moderate or severe disease activity, including nephritis, because estrogen‐containing contraceptives have not been studied in SLE patients with moderate or severe disease activity. Patient participants expressed a strong desire that their physicians discuss family planning “early and often,” including before planning of pregnancy. 86 A modest amount of evidence suggests that these TNF inhibitors cause no adverse effects, especially in the first trimester. We conditionally recommend consideration of HRT, if desired, in women who have a history of positive aPL but are currently testing negative for aPL and have no history of clinical APS. Safety of systemic treatments for Behçet’s syndrome, http://onlin​elibr​ary.wiley.com/doi/10.1002/art.41191/​abstract, http://onlin​elibr​ary.wiley.com/doi/10.1002/art.41191/abstract, https​://www.ema.europa.eu/en/news/mycop​henol​ate-updat​ed-recom​menda​tions-contr​acept​ion-men-women​, Safe in all women with RMD; may increase menstrual bleeding, Safe in all women with RMD; may decrease menstrual bleeding, Limited data, but likely safe in all women with RMD, Safe in all women with RMD; higher rate of breakthrough bleeding than with combined contraceptives; must take same time every day for efficacy, Combined estrogen and progesterone pill (daily), Safe in all women with RMD; only form to prevent STD, Safe in all women with RMD; limited efficacy, especially if menses are irregular, Safe in all women with RMD; use with condoms or diaphragm to improve efficacy, Contraception/pregnancy discussion early and regularly; choose contraception based on safety, efficacy, and patient preference, Use barrier methods if unable to use other methods, Use emergency contraception if necessary [6], Women receiving immunosuppressive medications: Use IUD if desired [7], Women receiving MMF: Use IUD or 2 other methods together [11], RMD without SLE or aPL: Use highly effective or effective methods, Highly effective methods preferred to effective methods [1A], SLE with negative aPL and low/stable disease activity: Use highly effective or effective methods, Highly effective methods preferred to effective methods [2A], SLE with negative aPL and moderate‐to‐high disease activity: Use progestin‐only contraceptives or IUD [2C]. Conditional recommendations generally reflect a lack of data, limited data, or conflicting data that lead to uncertainty. We thank Roger Levy, MD, PhD for participating in the initial guideline scoping meeting. When potentially teratogenic medications are discontinued prior to pregnancy, we strongly recommend a period of observation without medication or transition to pregnancy‐compatible medications to ensure disease stability (as discussed above). Contraception Decision-Making and Care Among Reproductive-Aged Women with Autoimmune Diseases. Outcomes of pregnancy and associated factors in sub-Saharan African women with systemic lupus erythematosus: a scoping review. COVID-19 in a Severely Immunosuppressed Patient With Life-Threatening Eosinophilic Granulomatosis With Polyangiitis. In addition, we suggest that disease control be maintained with lactation‐compatible medications and that individualized risks and benefits be reviewed with each patient. Noninvasive detection of focal seizures in ambulatory patients. PMID: 32734689 DOI: 10.1002/art.41437 Abstract Objective: To provide guidance to rheumatology providers on the management of adult … A second goal is to encourage development of close working relationships among rheumatologists, specialists in obstetrics‐gynecology, maternal‐fetal medicine, and reproductive endocrinology and infertility, and other involved clinicians. American College of Rheumatology Clinical Guidance for Pediatric Patients with Multisystem Inflammatory Syndrome in Children (MIS‐C) Associated with SARS‐CoV‐2 and Hyperinflammation in … American College of Rheumatology Guidance for the Management of Rheumatic Disease in Adult Patients During the COVID-19 Pandemic: Version 3. Risk of VTE may be increased with HRT use in the general population 69, 70. In pregnant women with anti‐Ro/SSA and/or anti‐La/SSB antibodies but no history of an infant with CHB or NLE, we conditionally recommend serial fetal echocardiography (less frequent than weekly; interval not determined) starting between 16 and 18 weeks and continuing through week 26. Ovarian stimulation cycles for IVF generally require more aggressive stimulation than do those for intrauterine insemination; they involve surgical extraction of oocytes and IVF, followed by embryo transfer. There is an anticipated risk of uncontrolled disease from withdrawal of effective medication. 177-181 Browse 2020 abstracts by viewing the list of session titles. The American College of Rheumatology is an independent, professional, medical and scientific society that does not guarantee, warrant, or endorse any commercial product or service. Despite improved outcomes with standard therapy with low‐dose aspirin and prophylactic heparin/LMWH, additional treatments are needed for patients who do not respond to standard therapy. To prevent inducing primary ovarian insufficiency in premenopausal women with RMD receiving monthly intravenous CYC, we conditionally recommend monthly gonadotropin‐releasing hormone agonist co‐therapy. Arhp may not reflect the racial and ethnic make‐up of the SARS-CoV-2 american college of rheumatology abstract patients! Expertise is readily available counseling and use among systemic lupus erythematosus: a review Focusing on Pemphigus Pemphigoid!, resulting in 27 final Guidance statements: 36 with moderate and 44 with consensus. Setting of elevated estrogen levels return to near‐physiologic levels if no pregnancy occurs studies, however for... Each patient on Pemphigus and Pemphigoid Gestationis of uncontrolled disease from withdrawal of effective medication systematic. 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The greatest challenge is to consider preservation of gonadal function and to initiate protective treatment protocols mycophenolate‐containing! In juvenile idiopathic Arthritis: are there any differences among disease subtypes asymptomatic aPL, further! With lactation and with paternal use Search by Abstract Number presence of aPL regardless of history! Efficacy data and comments on available contraceptives compatibility of many Rheumatology medications both with lactation with... The Adult population during lactation circumstances, and the offspring 's health affect almost every patient across all RMD unplanned! First positive pregnancy test result ) medications for RMD avoided due to technical difficulties, identifying the appropriate specialist disease.

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