Women with rheumatic diseases have unique reproductive health needs, and family planning counseling is a critical component to their overall healthcare. Pregnancy may accelerate disease progression in systemic lupus erythematosus (SLE), antiphospholipid antibody syndrome (APS), vasculitides and inflammatory myopathies. Counseling patients with rheumatic disease about family planning can be vital, because well-controlled disease at the time of conception has been associated with better outcomes. Additionally, family planning counseling can help prevent unintended pregnancy, aid in patients achieving their desired number of children, and identify and minimize pregnancy-related health risks.
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In a recent review, published in the February 2018 issue of Arthritis Care & Research, Mehret Birru Talabi, MD, PhD, and colleagues examined the latest research on providing family planning counseling to women with rheumatic disease and the role of rheumatologists. Reviewers offer practical suggestions for optimizing communication about reproductive health and addressing the effectiveness of contraception.
According to research, only 56% of rheumatologists routinely provide family planning counseling to women of reproductive age. Some rheumatologists may feel underqualified or uncomfortable discussing these issues. Additionally, research showed that primary care physicians and obstetrician-gynecologists may be unaware that contraceptives or pregnancy may augment rheumatic disease activity, and that some anti-rheumatic drugs may affect fetal development. “[Fifty-seven percent] deferred family planning to subspecialists,” write the authors. “Some providers may also believe that rheumatologists are responsible for family planning and teratogenic medication risk counseling of rheumatic disease patients.”
The authors note, “Rheumatologists are uniquely qualified to manage rheumatic disease activity during pregnancy. … Patients and providers may be reassured to learn that many pregnancies for women with rheumatic diseases are normal and uncomplicated.”
Communication: “[Although] women in several surveys desired family planning counseling, they generally preferred for their clinicians to initiate these conversations,” write the reviewers. At the time of diagnosis and before initiating or changing potentially teratogenic medications, clinicians should initiate a family planning conversation with every reproductive-age female patient, using a patient-centered approach.
“These conversations should ascertain a woman’s pregnancy desires or goals, explain how the rheumatic disease may be affected by pregnancy or vice versa [and] evaluate risks for unintended pregnancy and inadvertent fetal exposure to teratogenic medications,” write the authors. Clinicians should also assess a patient’s desire for contraception and determine appropriate treatment regimes if pregnancy is desired. Additionally, providers should avoid making assumptions about a patient’s childbearing capacity based on sociodemographic factors.
When working with patients with active rheumatic disease who wish to become pregnant, clinicians should review guidelines for anti-rheumatic drug management during pregnancy and lactation. Pregnant patients should be comanaged by a rheumatologist, obstetrician-gynecologist and/or maternal-fetal medicine specialist, if appropriate, to ensure the rheumatic disease is controlled and maternal and fetal health are optimized.
Contraception: “Research evaluating contraceptive safety has focused primarily on SLE, RA and APS, but most [contraceptive] methods appear to be safe for women with other rheumatic diseases,” write the authors.
The reviewers emphasize the importance of contraceptive counseling in family planning, outlining the common side effects for patients with rheumatic disease, efficacy and reversibility of multiple methods. Although method selection should be guided by a patient’s individual preferences, women with chronic diseases who have an increased risk of pregnancy complications may consider contraceptive efficacy particularly important.
According to research, progestin-only subdermal implants are the most effective contraceptives available (first-year failure rate 0.05%). But long-acting reversible contraceptives, such as intrauterine devices (IUDs), are also highly effective for preventing pregnancy.
“To benefit all rheumatic disease patients, providers may expand their competencies to provide patient-centered, respectful and comprehensive family planning counseling,” write the authors in their conclusion. “Education in family planning and patient-centered communication should be incorporated into specialty and subspecialty training. Through enhanced attention to family planning, we can empower individuals with rheumatic diseases to make important decisions to improve their health, and the well-being of their children and families.”
Birru Talabi M, Clowse MEB, Schwarz EB, et al. Family planning counseling for women with rheumatic diseases. Arthritis Care Res (Hoboken). 2018 Feb;70(2):169–174. doi: 10.1002/acr.23267.