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REVIEW ARTICLE
Ahead of print publication  

Pregnancy counseling in rheumatic diseases: Where science meets the steps


 Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission06-Apr-2020
Date of Acceptance24-Jun-2020

Correspondence Address:
Latika Gupta,
Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injr.injr_79_20

  Abstract 


Most rheumatic diseases (RDs) have a predilection for women in the reproductive age group. Common drugs used in rheumatology practice have identified risks to the fetus; thus, adequate pregnancy counseling is of utmost importance. Contraception and adequate preparation for the same can enhance the experience of motherhood and decrease intra as well as peripartum complications. The knowledge, as well as practices of contraception in autoimmune diseases, are low and varied in various populations. The challenges faced in different RDs are unique and keen understanding can be fruitful toward better patient care. A multi-disciplinary team effort between the patient, obstetricians, and the rheumatologist is the key to better maternal and fetal outcomes.

Keywords: Congenital heart block, lupus, myositis, pregnancy, rheumatology, scleroderma, vasculitis



How to cite this URL:
Balakrishnan A, Mehta P, Gupta L. Pregnancy counseling in rheumatic diseases: Where science meets the steps. Indian J Rheumatol [Epub ahead of print] [cited 2020 Oct 27]. Available from: https://www.indianjrheumatol.com/preprintarticle.asp?id=298052




  Introduction Top


Most rheumatic diseases (RDs) have a predilection for women with reproductive potential. The advent of better therapeutics and better disease control with treat-to-target strategies have led substantial proportions of women with RDs to consider conception.

The challenges in various RDs differand a keen understanding can be lead to improved care. Apart from the effects of disease on the pregnancy and vice versa, teratogenicity intra-partum and safety during lactation merit consideration. A multi-disciplinary team effort between the patient, obstetricians and the rheumatologist is vital to meticulous obstetric care and better maternal as well as fetal outcomes.

Thus, we reviewed recent literature on pregnancy counseling in RDs by following the search strategy proposed by Gasparyan et al.[1] Articles available on MEDLINE, published anytime, were reviewed using search words ((”pregnancy” [MeSH Terms] OR “pregnancy” [All Fields]) AND (”rheumatology” [MeSH Terms] OR “rheumatology” [All Fields]). Of the 2041 articles obtained, 1690 were human studies, and 1055 were published in the past 10 years. Seven hundred and twenty-two articles were obtained using the (NOT “review”) filter, which were further screened for relevant data. Additional information pertaining to specific diseases was obtained through an individualized search strategy.


  General Aspects Top


Contraception in rheumatic diseases

An open discussion about family planning with the patient is vital to good obstetric care. It is ideal to make an informed choice relevant to the drugs being prescribed. In young women planning to marry, it is vital to inform them that such discussions could be deferred until then. Such discussions can go a long way in gaining patient trust and ensuring compliance. In those married and planning conceptions at a later point in time, contraception ought to be discussed. Unfortunately, only one-third (32.1%) of women with RD use contraception despite being on at least one fetotoxic medication.[2] A vast majority of Indian women with RD are not advised contraception in the clinic.[3] The various means of contraception are delineated in [Table 1].
Table 1: Contraception in rheumatic diseases

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Drugs

Drugs and their effects on fertility merit special mention here as most patients express concerns regarding their safety [Table 2].
Table 2: Effect of drugs on fertility, pregnancy and recommended drug free period before conception

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While some drugs (such as methotrexate) are teratogenic and rated as category X, recent evidence suggests certain drugs (such as leflunomide) might be safer than previously believed to be.[5] The advent of pegylated forms of biologics has lent another class of drugs which can be deemed safe due to their original molecular size and crossover properties across the placental membrane.[6],[7]

Fertility

Another concern is the misbelief of reduced fertility in RDs. It is essential to explain to the patients that not all RDs affect fertility adversely, making contraceptive usage of utmost importance.[25] Several factors can affect fertility in both males and females, as detailed in [Figure 1]a.[26] A Norwegian cohort from the birth registry with RDs showed a lower incidence of live births with longer interpregnancy intervals and reduced fertility rate.[27] However, diseases such as lupus do not have an effect on fertility[28]de novo unless cytotoxic regimens such as cyclophosphamide have been used. The low conception rates could be arising out of the interplay of various social, cultural, and pathophysiologic factors. Wang et al., in a single-center retrospective review, found that age is the most critical determinant for gonadal toxicity, and CYC usage did not result in amenorrhea in patients aged 14–20. However, for patients with >36 g of total exposure, the relative risk of sustained amenorrhea was 2.1 (1.46–4.02), regardless of age.[29] Thus, the timing of conception might be a more relevant issue to discuss with the patients instead.
Figure 1: (a) Factors affecting fertility. (b) Physiological changes in pregnancy in the light of rheumatic diseases

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Heritability of rheumatic diseases

Most of the RDs have genetic as well as environmental risk factors. Genetic risk factors can be either MHC related or nonrelated genes. The risk of familial transmission of each disease includes heritability of the disease along with shared environmental risk factors.[30] Autoimmune diseases have a chance of familial transmission, and inherited disease can be the same or some other. Studies on the heritability of RDs are few and are limited by the distribution of diseases in different regions as well as confounding environmental factors.[31] Studies which are available are consolidated in [Table 3].
Table 3: Heritability of rheumatic diseases

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Relative risks to the offspring

The patients often express a concern of transmission to the child at the time of pregnancy counseling, and this should be addressed with due diligence.


  Preparing Patients for Pregnancy (Preconception Checklist) Top


Duration of remission

The EULAR recommends 6 months of disease quiescence before planning conception in patients with lupus.[41] The risk of flare is higher with active disease in the 6 months before conception. Tedeschi et al. found that in 147 pregnancies among 113 patients of lupus, the odds for organ-specific flare were much higher in women with the same type of organ involvement in the preceding 6 months.[42] Thus, it seems imperative to pay more attention to the organs previously involved in a particular patient while screening, as the nature of flares over time could be similar in each patient.

Organ damage and high risk

It is of utmost importance to assess patients for organ-specific damage and avoid pregnancy when deemed appropriate. The highest risk for adverse obstetric outcomes is seen in patients with pulmonary hypertension (spa >50 mm Hg), renal insufficiency (creatinine level >2.8 mg/dL), severe restrictive lung disease (forced vital capacity [FVC] <1 L), and active heart failure.[43] Blood pressure control should be optimal as the odds for maternal and fetal adverse pregnancy outcomes (APOs) increase with uncontrolled hypertension.[44] Patients with previous lupus nephritis are also deemed to be at higher risk than those without a history of it. In all such cases, alternative solutions to complete a family, such as surrogacy and adoption, should be offered.[45]

Screening anti-phospholipid and anti-Ro/La antibodies

Antibodies against phospholipids and SSA and SSB antigens confer additional and specific risks for recurrent abortions and fetal congenital heart block as well as neonatal lupus syndromes. Thus, the antibody screen for APLA and secondary Sjogren's should be done in patients with known rheumatological diseases as well as those with bad obstetric history.[46] It is important to note that anti-Ro antibodies can be present in up to 1% of the general population and even higher in RDs, thus making it crucial to check these in women with any known rheumatic illnesses.

Optimization of drugs

Once the drug list is checked [Table 2] and safety ensured, it is prudent to assure them of the safety and benefits of continuing HCQ, use of the same reduces disease flares in the intra and peripartum period[47] and is highly advisable in cases with systemic lupus erythematosus (SLE). However, the he dose of glucocorticoids is best kept to the minimum required (preferably <10 mg).[41]

e) Finally, all women should be screened for thyroid disorders and the routine antenatal screen as recommended by the obstetrician. A detailed flow-chart for prepregnancy screening is provided in [Figure 2].
Figure 2: Prepregnancy checklist in lupus

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  Special Situations in Pregnancy Top


Interpretation of clinical signs and laboratory tests

Interpretation of specific findings during pregnancy merits caution due to confounding by the physiologic changes during pregnancy. The intravascular volume increases by 30%–50%, thus proteinuria up to 300 mg/24 h is considered to be normal. Further, chloasma gravidarum can be confused with the malar rash of lupus. Complement levels show a physiologic rise during pregnancy, hence in patients of lupus, failure to rise or fall from the baseline (although within normal limits) should be viewed with caution.[48]

Symptoms of GERD increase during pregnancy due to a decrease in the tone of the lower esophageal sphincter and needs careful interpretation in patients with scleroderma (SSc). Pregnancy itself is a hypercoagulable state and may lead to thromboembolic complications akin to anti-phospholipid antibody syndrome. Finally, there is an increase in ligament laxity, and hence, joint pain in patients with RA may worsen. Furthermore, ESR rises physiologically and needs to be interpreted carefully in patients with inflammatory arthritis. Several SpA symptoms such as lumbar night pain, morning stiffness, and fatigue may also be overestimated in pregnancy[49] [Figure 1]b.

Obstetric antiphospholipid syndrome

Antiphospholipid Syndrome (APS) is one of the most important acquired causes of pregnancy loss.[50] Although APS has a theoretical risk of decreased fertility, there is limited data on it, and as of today, testing and treating is not required for those undergoingin vitro fertilization.[51,52] In the EUROAPS registry data, the rate of fetal loss, and obstetric complications were 22.2 and 52.2% respectively. Thrombosis was seen in 6.5% of patients mainly in the postpartum period and 7% of patients evolved to lupus later.[53] The live birth rate increased from 49.6% in untreated patients to 85 % in the patients who were treated as per the recommended regimen patients with no treatment showed a poor birth rate.[54] The risk is worse in those with previous APO, thrombosis in the previous 6–12 months, co-existent SLE, and triple antibody positivity.[41] The classification, risk score as well as management of obstetric APS is mentioned in [Table 4].
Table 4: Antiphospholipid syndrome in pregnancy

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Congenital heart block

The most prominent concern with the presence of anti-SSA/SSB antibodies is the risk of autoimmune congenital heart block[57] [Figure 3]. Mothers can be asymptomatic carriers as well. The presence of these antibodies has a 2% risk of congenital heart block, which increases to 17% in women with a previous history of a similarly affected fetus.[58] Hydroxychloroquine (HCQ) significantly decreases the risk to 7.5% in these women.[53] The Preventive Approach to Congenital Heart Block with HCQ study (NCT01379573) is currently recruiting patients to prospectively assess the effects of HCQ on the other cardiac outcomes.[59]
Figure 3: Anti Ro and Anti La antibodies causing congenital heart block

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Other rare complications of anti-Ro antibodies can be heart failure, endomyocardial fibroelastosis, and valvular disease. For women with a history of fetal congenital heart block, screening with fetal 2D echocardiography is generally recommended weekly from 16 weeks onward through 26 weeks. Anti-SSA or anti-SSB/La-positive mothers with no previous history of congenital heart block, most cardiologists recommend an initial cardiac ultrasound scan at 16–20 weeks with a repeat at 28 weeks when normal. The frequency of cardiac screening in the foetus has been studied in the PR Interval, and Dexamethasone Evaluation study, where out of the 98 pregnancies analysed, 1st degree heart block was uncommon and did not always precede a complete heart block. Further, advanced heart block and cardiomyopathy can, at times, occur within a week of a normal fetal cardiac scan.[60] Thus, frequent cardiac screening may not always detect a CHB in a timely fashion.[60] On the other hand, frequent cardiac screening can pose a significant financial burden, cause maternal anxiety and increase the load on health services. However, detecting a heart block when it is afirst degree in nature may be more amenable to treatment with fluorinated glucocorticoids, although this is not firmly established.[62]

Other features of neonatal lupus syndrome include a transient subacute cutaneous lupus rash exacerbated by exposure to ultraviolet radiation after birth, hematological manifestations (such as cytopenia) and hepatobiliary disease.[63] This is a lesser concern usually, as most of these manifestations resolve in thefirst 6–9 months of life as maternal anti-SSA/Ro antibodies are cleared from the infant's circulation.

Preeclampsia versus lupus nephritis

Preeclampsia is ten times more common in patients with lupus; with an incidence varying from 2% to 35% as compared to 2%–8% in the general population,[64],[65] although the prospective PROMISSE cohort estimated a higher risk (15%). The difficulty in differentiating a lupus flare from preeclampsia in the presence of hypertension, proteinuria, oedema and thrombocytopenia could account for varied reports of incidence.[44] [Supplementary Table 1] delineates the approach to differentiating between the two conditions.



The various factors predictive of preeclampsia include preexisting hypertension, diabetes, nulliparity, history of preeclampsia, and lupus-specific factors such as active disease, previous proliferative lupus nephritis, the presence of anti-phospholipid antibodies, thrombocytopenia, and low complements. At times, a renal biopsy may be required to differentiate the two. Although biopsy is contraindicated in thefirst and third trimesters, it could be done in the 2nd trimester of pregnancy, when deemed indispensable.[66]

Patients with preeclampsia require intensive monitoring of blood pressure and frequent investigations such as uric acid and urine protein levels for early detection of APOs.[67] Newer biomarkers such as the placental growth factor, serum endoglin, FMS like tyrosine kinase, alternative complement products have been studied to predict APOs.[68] Simple calculators have been devised by Wu et al. to predict APOs with a Area Under the Curve of 0.88. The authors identified three variables that independently predicted fetal loss: unplanned pregnancies (odds ratio [OR] 2.8, 1.1–7.2), low C3 (5.5, 2.3–13.0), and 24-h urinary protein (2.1, 2.3–15.1).[70]


  Salient Features of Rheumatic Diseases Top


Systemic lupus erythematosus

A recent metanalysis substantiated 25% higher risk of mild flares and 5% for severe flares in lupus during pregnancy.[69] Active disease in the preceding 6 months is the single most important determinant of an intra-partum flare. HCQ has consistently shown a remarkable effect in lowering the risk for flares both intra-partum and peri-partum (RR − 1.83–1.26).[66]

Sjogren's syndrome

Patients with pSS report dyspareunia from dryness, and an increased risk of neonatal deaths (OR 1.8, 1.3–1.5) compared to other RDs,[71] apart from fetal heart block, as previously described.

Inflammatory arthritis

Unexplained subfertility in RA is well-described, and speculations are rife about the role of NSAID and/or prednisolone usage and high disease activity.[71] The PARA study further affirmed a longer time to pregnancy in RA (in 42%), especially in the older and nulliparous, apart from the afore-mentioned groups. Thus, maximum control of disease and reduced drug usage should be ensured preconception.[74]

Uncontrolled disease incurs a higher risk of hypertension, prematurity, IUGR, and lower segment cesarean section in patients,[73] although most (48%–60%) decreased disease activity postpartum.

Spondyloarthritis[75]

The limited data on APO in spondyloarthritis, suggests flare rates ranging from 25% to 80%,[76],[77] being the highest in active disease, high C reactive protein and TNFi discontinuation in early pregnancy.[78] Further, a higher rate of preterm deliveries, IUGR, and cesarean section is observed in patients with Ankylosing spondylitis.[79]

On the other hand, pregnancy outcomes are reportedly excellent in psoriatic arthritis,[78] with a visible decline in cutaneous and musculoskeletal disease, although flares are described postpartum.[80]

Systemic vasculitis

As in all other diseases, hormonal changes in pregnancy, lead to Th1 suppression and Th2 polarization. Thus, many types of vasculitis (Takayasu's arteritis [TA] and Bechet's disease [BD]) have reportedly lower flare rates in pregnancy, whereas ANCA associated vasculitis (AAV) flares often, while data on other forms of vasculitis is limited.[81]

Most studies have focused on the pregnancy outcomes in TA and BD, as these affect women under 40 years of age. TA has a significant negative impact on maternal (hypertension) as well as fetal complications (IUGR and prematurity).[82] Studies from India also showed that fertility in TA is not different from the general population.[83] The scoring system by Wong et al. predicted low fetal weight with accuracy by a weighted score (0–2) of four parameters: involvement of the abdominal aorta, highest MAP in the third trimester, treatment started from which trimester of the pregnancy and co-existing preeclampsia[84] in Indian women with TA, whereas the standard outcome measures could not.[85]

On the other hand, pregnancy does not seem to have a significant impact on disease activity, with flare rates described as 5%.[82] With reasonable control of hypertension, the outcome can be improved in patients with stable disease, although cesarean section rates were higher than the general population.[86]

Patients with BD have good obstetric outcomes, with flares in 30%–36% patients, mostly manifest as oral or genital ulcers, arthritis, uveitis, erythema nodosum, and less frequently, thrombosis, although lower with colchicine. Notably, a history of thrombosis poses a high risk of APOs.[87],[88]

AAV affects older individuals, reducing potential co-occurrences with conception, although a systemic review recently described successful pregnancy in 86.5%.[89]

Scleroderma and mixed connective tissue disease

Erectile dysfunction[90] and decreased sexual activity[91] account for lower fertility rates in both men and women with SSc. The various physiological changes associated with pregnancy, such as an increase in the blood volume, cardiac output, decrease in the vascular resistance, and decreased tone of the lower esophageal sphincter, are more marked during the pregnancy in SSc.[92] Raynaud's phenomenon improves during pregnancy, whereas GERD symptoms are aggravated.[93]

Among those who conceive, a lower FVC (<50%), moderate-to-severe pulmonary artery hypertension, renal failure, or cardiomyopathy (Ejection fraction < 30%) leads to a higher risk of intrapartum complications such as preterm delivery, IUGR, and SGA than those without end-organ complications.[94]

Patients with rapidly progressive skin disease, anti-topoisomerase or anti RNAPIII antibodies and those receiving high dose glucocorticoids have a heightened risk of developing the SSc renal crisis;[95] necessitating stringent control of blood pressures at earliest possible. Despite the risk of oligohydramnios in pregnancy, ACEIs are the drug of choice. Notably, previous SRC does not increase the risk for a recurrence when controlled for several years before conception.[96] In patients with sine SSc SRC, it is difficult to distinguish from other thrombotic microangiopathies that can occur during antepartum or postpartum. However, the presence of antibodies may help in some situations.[97]


  Idiopathic Inflammatory Myositis Top


Most IIM tolerate pregnancy well in quiescent disease,[98] with good maternal outcomes though preterm delivery and SGA are reported. A high spontaneous abortion rate was recently observed in the absence of clinical or serologic APS in a cohort of women with IIM from India, suggesting a possible impact of health-care policy in the developing world in chronic diseases.[99]

The heterogeneity of IIM calls for collaborative efforts to identify the risk factors in stratified population sets, and gather more evidence on the impact of models of healthcare delivery in the different countries, and sociocultural factors on outcomes.[100]


  Postnatal Period and Lactation Top


The higher risk of flares of RDs in the postnatal period requires adequate vigilance in the postpartum period.[101] Drug safety in lactation is another important consideration.[102] The unique benefits of breastfeeding to the child and the mother; calls for a close consideration of the disease status and safety review of ongoing medicines while making an informed choice with the patient [Table 5]. Lipid soluble, non-ionized, non-protein bound small molecules are more likely to get transferred in breast milk,[103] an important guiding factor while prescribing drugs in that period.
Table 5: Safety of drugs in lactation

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  Social and Ethical Issues in India Top


Apart from medical and obstetric issues, it is important to be mindful of the sociocultural concerns which come to the fore in such times.[104] Chronic RDs run the risk of social stigmatization, worse when compounded by illiteracy and poverty. Contraception usage can be dismal in some societies, influenced by sociocultural and religious choices.[105]

Patient confidentiality is a right that ought to be respected at all times. Oftent, imes the patients are unable to return for follow-up for long periods due to social or personal constraints, this being the prime deciding factor for drug choices. It is important to discuss all treatment options and their benefits and risks with the patient (and their kin) for an informed choice. Spouse's rights when a woman chooses confidentiality are a grey area and oft-encountered but potentially challenging to manage. A counselor on the team could be an important resource to delve into the psychosocial intricacies. The engagement of voluntary women's support groups could be another potential solution.

Further, contraception failures are not unknown, and being diagnosed with an unplanned pregnancy could signify the risk of teratogenicity from ongoing drugs, alongside the huge decision to continue with the pregnancy versus not, keeping in mind the risk to both the fetus and the mother.[106] Recently, a landmark amendment of the MTP act in India suggested abortion irrespective of gestational age for medical reasons when substantial fetal anomalies were detected after the certification from a medical board appointed by the state.[104] This is not legalized as an act till now. In times when the patient's decision is to continue the pregnancy (which could be for various reasons) despite all risks, the patient's right has to be respected after appropriate documentation.

Finally, understanding sociocultural issues at interplay is an active area of research that merits consideration to prepare physicians toward better management of this oft encountered situation.


  Conclusion Top


Pregnancy in patients with RDs should be regarded as a high-risk situation that mandates vigilant monitoring by a multidisciplinary team comprising a rheumatologist, obstetrician, and social worker, where feasible. The limited treatment options and various challenging situations make it important to weigh maternal benefits against the perceived fetal risk. With appropriate preconceptional counseling and a coordinated multidisciplinary approach, optimum outcomes can be achieved.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gasparyan AY, Ayvazyan L, Blackmore H, Kitas GD. Writing a narrative biomedical review: considerations for authors, peer reviewers, and editors. Rheumatol Int 2011;31:1409-17.   Back to cited text no. 1
    
2.
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 2019;71:1132-40.   Back to cited text no. 2
    
3.
Galappatthy P, Jayasinghe JDD, Paththinige SC, Sheriff RMH, Wijayaratne LS. Pregnancy outcomes and contraceptive use in patients with systemic lupus Erythematosus, rheumatoid arthritis and women without a chronic illness: a comparative study. Int J Rheum Dis 2017;20:746-54.   Back to cited text no. 3
    
4.
Cromer BA, Scholes D, Berenson A, Cundy T, Clark MK, Kaunitz AM. Depot medroxyprogesterone acetate and bone mineral density in adolescents–The Black Box warning: a position paper of the Society for Adolescent Medicine. J Adolesc Health. 2006;39:296-301.   Back to cited text no. 4
    
5.
Bérard A, Zhao J-P, Shui I, Colilla S. Leflunomide use during pregnancy and the risk of adverse pregnancy outcomes. Ann Rheum Dis 2018;77:500–9.   Back to cited text no. 5
    
6.
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: [Table 1]. Rheumatology 2016;55:1698-702.   Back to cited text no. 6
    
7.
BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-”Part I: standard and biologic disease modifying anti-rheumatic drugs and corticosteroids | Rheumatology | Oxford Academic [Internet]. Available from: https://academic.oup.com/rheumatology/article/55/9/1693/1744535. [Last accessed on 2020 Feb 23].  Back to cited text no. 7
    
8.
Lloyd ME, Carr M, Mcelhatton P, Hall GM, Hughes RA. The effects of methotrexate on pregnancy, fertility and lactation. QJM Int J Med 1999;92:551-63.   Back to cited text no. 8
    
9.
Grosen A, Kelsen J, Hvas CL, Bellaguarda E, Hanauer SB. The Influence of Methotrexate Treatment on Male Fertility and Pregnancy Outcome After Paternal Exposure. Inflamm Bowel Dis 2017;23:561-9.   Back to cited text no. 9
    
10.
Weber-Schoendorfer C, Chambers C, Wacker E, Beghin D, Bernard N, Shechtman S, et al. Pregnancy Outcome After Methotrexate Treatment for Rheumatic Disease Prior to or During Early Pregnancy: A Prospective Multicenter Cohort Study. Arthritis Rheumatol 2014;66:1101-10.   Back to cited text no. 10
    
11.
Visser K, Katchamart W, Loza E, Martinez-Lopez JA, Salliot C, Trudeau J, et al. Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with a focus on rheumatoid arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative. Ann Rheum Dis 2009;68:1086-93.   Back to cited text no. 11
    
12.
Cosentino MJ, Chey WY, Takihara H, Cockett ATK. The Effects of Sulfasalazine on Human Male Fertility Potential and Seminal Prostaglandins. J Urol 1984;132:682-6.   Back to cited text no. 12
    
13.
Whirledge S, Cidlowski JA. Glucocorticoids, Stress, and Fertility. Minerva Endocrinol 2010;35:109-25.   Back to cited text no. 13
    
14.
Semet M, Paci M, Saïas-Magnan J, Metzler-Guillemain C, Boissier R, Lejeune H, et al. The impact of drugs on male fertility: a review. Andrology 2017;5:640-63.   Back to cited text no. 14
    
15.
Bandoli G, Palmsten K, Forbess Smith CJ, Chambers CD. A review of systemic corticosteroid use in pregnancy and the risk of select pregnancy and birth outcomes. Rheum Dis Clin North Am 2017;43:489–502.   Back to cited text no. 15
    
16.
Huong DL thi, Amoura Z, Duhaut P, Sbai A, Costedoat N, Wechsler B, et al. Risk of ovarian failure and fertility after intravenous cyclophosphamide. A study in 84 patients. J Rheumatol 2002;29:2571-6.   Back to cited text no. 16
    
17.
Gajjar R, Miller SD, Meyers KE, Ginsberg JP. Fertility preservation in patients receiving cyclophosphamide therapy for renal disease. Pediatr Nephrol 2015;30:1099-106.   Back to cited text no. 17
    
18.
El Sebaaly Z, Charpentier B, Snanoudj R. Fetal malformations associated with mycophenolate mofetil for lupus nephritis. Nephrol Dial Transplant 2007;22:2722-2722.   Back to cited text no. 18
    
19.
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;62:1494-503.   Back to cited text no. 19
    
20.
Kim H, Jeong JC, Yang J, Yang WS, Ahn C, Han DJ, et al. The optimal therapy of calcineurin inhibitors for pregnancy in kidney transplantation. Clin Transplant 2015;29:142-8.   Back to cited text no. 20
    
21.
Johansen CB, Jimenez-Solem E, Haerskjold A, Sand FL, Thomsen SF. The Use and Safety of TNF Inhibitors during Pregnancy in Women with Psoriasis: A Review. Int J Mol Sci 2018;19:1349. doi:10.3390/ijms19051349   Back to cited text no. 21
    
22.
Chakravarty EF, Murray ER, Kelman A, Farmer P. Pregnancy outcomes after maternal exposure to rituximab. Blood 2011 ;117:1499-506.   Back to cited text no. 22
    
23.
Nakajima K, Watanabe O, Mochizuki M, Nakasone A, Ishizuka N, Murashima A. Pregnancy outcomes after exposure to tocilizumab: A retrospective analysis of 61 patients in Japan. Mod Rheumatol 2016;26:667-71.   Back to cited text no. 23
    
24.
Youngstein T, Hoffmann P, Gül A, Lane T, Williams R, Rowczenio DM, et al. International multi-centre study of pregnancy outcomes with interleukin-1 inhibitors. Rheumatol Oxf Engl 2017;56:2102-8.   Back to cited text no. 24
    
25.
Østensen M. Sexual and reproductive health in rheumatic disease. Nat Rev Rheumatol 2017;13:485-93.   Back to cited text no. 25
    
26.
Østensen M, Andreoli L, Brucato A, Cetin I, Chambers C, Clowse MEB, et al. State of the art: Reproduction and pregnancy in rheumatic diseases. Autoimmun Rev 2015;14:376-86.   Back to cited text no. 26
    
27.
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;28:2310-4.   Back to cited text no. 27
    
28.
Götestam Skorpen C, Lydersen S, Gilboe I-M, Skomsvoll JF, Salvesen KŠ, Palm Ø, et al. Women with systemic lupus erythematosus get pregnant more easily than women with rheumatoid arthritis. Rheumatol Oxf Engl. 2018;57:1072-9.   Back to cited text no. 28
    
29.
Wang CL, Wang F, Bosco JJ. Ovarian failure in oral cyclophosphamide treatment for systemic lupus erythematosus. Lupus 1995;4:11-4.   Back to cited text no. 29
    
30.
Selmi C, Lu Q, Humble MC. Heritability versus the role of the environment in autoimmunity. J Autoimmun 2012;39:249-52.   Back to cited text no. 30
    
31.
Seldin MF. The Genetics of Human Autoimmune Disease: A Perspective on Progress in the Field and Future Directions. J Autoimmun 2015;64:1-12.   Back to cited text no. 31
    
32.
Kuo C-F, Grainge MJ, Valdes AM, See L-C, Luo S-F, Yu K-H, et al. Familial Aggregation of Systemic Lupus Erythematosus and Coaggregation of Autoimmune Diseases in Affected Families. JAMA Intern Med 2015;175:1518–26.   Back to cited text no. 32
    
33.
Wang J, Yang S, Chen JJ, Zhou SM, He SM, Liang YH, et al. Systemic lupus erythematosus: a genetic epidemiology study of 695 patients from China. Arch Dermatol Res 2007;298:485-91.   Back to cited text no. 33
    
34.
Lawrence JS, Martins CL, Drake GL. A family survey of lupus erythematosus. 1. Heritability. The Journal of Rheumatology 1987;14:913-921.  Back to cited text no. 34
    
35.
Karami J, Aslani S, Jamshidi A, Garshasbi M, Mahmoudi M. Genetic implications in the pathogenesis of rheumatoid arthritis; an updated review. Gene 2019;702:8–16.   Back to cited text no. 35
    
36.
Terao C, Ikari K, Nakayamada S, Takahashi Y, Yamada R, Ohmura K, et al. A twin study of rheumatoid arthritis in the Japanese population. Mod Rheumatol 2016;26:685-9.   Back to cited text no. 36
    
37.
Kuo C-F, Grainge MJ, Valdes AM, See L-C, Yu K-H, Shaw SWS, et al. Familial aggregation of rheumatoid arthritis and co-aggregation of autoimmune diseases in affected families: a nationwide population-based study. Rheumatology 2017 ;56:928-33.   Back to cited text no. 37
    
38.
Brophy S, Hickey S, Menon A, Taylor G, Bradbury L, Hamersma J, et al. Concordance of disease severity among family members with ankylosing spondylitis? J Rheumatol 2004;31:1775-8.   Back to cited text no. 38
    
39.
Chandran V. The Genetics of Psoriasis and Psoriatic Arthritis. Clin Rev Allergy Immunol 2013;44:149-56.   Back to cited text no. 39
    
40.
Akkoç N. Update on the epidemiology, risk factors and disease outcomes of Behçet's disease. Best Pract Res Clin Rheumatol 2018;32:261-70.   Back to cited text no. 40
    
41.
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;76:476-85.   Back to cited text no. 41
    
42.
Specific systemic lupus erythematosus disease manifestations in the six months prior to conception are associated with similar disease manifestations during pregnancy - S K Tedeschi, E Massarotti, H Guan, A Fine, B L Bermas, K H Costenbader, [Internet]. 2015. Available from: https://journals.sagepub.com/doi/abs/10.1177/0961203315586455. [Last accessed on 2020 Mar 20]  Back to cited text no. 42
    
43.
Kwok L-W, Tam L-S, Zhu T, Leung Y-Y, Li E. Predictors of maternal and fetal outcomes in pregnancies of patients with systemic lupus erythematosus. Lupus 2011;20:829-36.   Back to cited text no. 43
    
44.
Yan Yuen S, Krizova A, Ouimet JM, Pope JE. Pregnancy Outcome in Systemic Lupus Erythematosus (SLE) is Improving: Results from a Case Control Study and Literature Review. Open Rheumatol J 2008;2:89-98.  Back to cited text no. 44
    
45.
Borella E, Lojacono A, Gatto M, Andreoli L, Taglietti M, Iaccarino L, et al. Predictors of maternal and fetal complications in SLE patients: a prospective study. Immunol Res 2014;60:170-6.   Back to cited text no. 45
    
46.
Kim MY, Guerra MM, Kaplowitz E, Laskin CA, Petri M, Branch DW, et al. Complement activation predicts adverse pregnancy outcome in patients with systemic lupus erythematosus and/or antiphospholipid antibodies. Ann Rheum Dis 2018;77:549-55.   Back to cited text no. 46
    
47.
Clowse MEB, Magder L, Witter F, Petri M. Hydroxychloroquine in lupus pregnancy. Arthritis Rheum 2006;54:3640-7.   Back to cited text no. 47
    
48.
Jain V, Gordon C. Managing pregnancy in inflammatory rheumatological diseases. Arthritis Res Ther 2011;13:206.   Back to cited text no. 48
    
49.
Kristiansson P, Svärdsudd K, von Schoultz B. Serum relaxin, symphyseal pain, and back pain during pregnancy. Am J Obstet Gynecol 1996;175:1342-7.   Back to cited text no. 49
    
50.
Kim MY, Buyon JP, Guerra MM, Rana S, Zhang D, Laskin CA, et al. Angiogenic factor imbalance early in pregnancy predicts adverse outcomes in patients with lupus and antiphospholipid antibodies: results of the PROMISSE study. Am J Obstet Gynecol 2016;214:108.e1-108.e14.   Back to cited text no. 50
    
51.
Practice Committee of American Society for Reproductive Medicine. Anti-phospholipid antibodies do not affect IVF success. Fertil Steril 2008;90(5 Suppl):S172-173.   Back to cited text no. 51
    
52.
Sauer R, Roussev R, Jeyendran RS, Coulam CB. Prevalence of antiphospholipid antibodies among women experiencing unexplained infertility and recurrent implantation failure. Fertil Steril 2010;93:2441-3.   Back to cited text no. 52
    
53.
Alijotas-Reig J, Esteve-Valverde E, Ferrer-Oliveras R, Sáez-Comet L, Lefkou E, Mekinian A, et al. The European Registry on Obstetric Antiphospholipid Syndrome (EUROAPS): A survey of 1000 consecutive cases. Autoimmun Rev 2019;18:406-14.   Back to cited text no. 53
    
54.
Giles I, Yee C-S, Gordon C. Stratifying management of rheumatic disease for pregnancy and breastfeeding. Nature Reviews Rheumatology, 2019;15:391–402. doi:10.1038/s41584-019-0240-8.  Back to cited text no. 54
    
55.
Tektonidou MG, Andreoli L, Limper M, Amoura Z, Cervera R, Costedoat-Chalumeau N, et al. EULAR recommendations for the management of antiphospholipid syndrome in adults. Ann Rheum Dis 2019;78:1296-304.   Back to cited text no. 55
    
56.
Sciascia S, Sanna G, Murru V, Roccatello D, Khamashta MA, Bertolaccini ML. GAPSS: the Global Anti-Phospholipid Syndrome Score. Rheumatology 2013;52:1397-403.   Back to cited text no. 56
    
57.
Brito-Zerón P, Izmirly PM, Ramos-Casals M, Buyon JP, Khamashta MA. The clinical spectrum of autoimmune congenital heart block. Nat Rev Rheumatol 2015;11:301-12.   Back to cited text no. 57
    
58.
Costedoat-Chalumeau N, Amoura Z, Lupoglazoff J-M, Huong DLT, Denjoy I, Vauthier D, et al. Outcome of pregnancies in patients with anti-SSA/Ro antibodies: A study of 165 pregnancies, with special focus on electrocardiographic variations in the children and comparison with a control group. Arthritis Rheum 2004;50:3187-94.   Back to cited text no. 58
    
59.
Izmirly PM, Costedoat-Chalumeau N, Pisoni CN, Khamashta MA, Kim MY, Saxena A, et al. Maternal use of hydroxychloroquine is associated with a reduced risk of recurrent anti-SSA/Ro-antibody-associated cardiac manifestations of neonatal lupus. Circulation 2012;126:76-82.   Back to cited text no. 59
    
60.
Friedman DM, Kim MY, Copel JA, Davis C, Phoon CKL, Glickstein JS, et al. Utility of cardiac monitoring in fetuses at risk for congenital heart block: the PR Interval and Dexamethasone Evaluation (PRIDE) prospective study. Circulation. 2008 Jan 29;117:485–93.   Back to cited text no. 60
    
61.
Gupta S, Gupta N. Sjögren Syndrome and Pregnancy: A Literature Review. Perm J [Internet]. 2016;21. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5267941/. [Last accessed on 2020 Mar 28].  Back to cited text no. 61
    
62.
Brucato A, Cimaz R, Caporali R, Ramoni V, Buyon J. Pregnancy Outcomes in Patients with Autoimmune Diseases and Anti-Ro/SSA Antibodies. Clin Rev Allergy Immunol 2011;40:27–41.   Back to cited text no. 62
    
63.
Sammaritano LR, Bermas BL, editors. Contraception and Pregnancy in Patients with Rheumatic Disease [Internet]. New York: Springer-Verlag; 2014. Available from: https://www.springer.com/gp/book/9781493906727. [Last accessed on 2020 Mar 28].  Back to cited text no. 63
    
64.
Bundhun PK, Soogund MZS, Huang F. Impact of systemic lupus erythematosus on maternal and fetal outcomes following pregnancy: A meta-analysis of studies published between years 2001-2016. J Autoimmun 2017;79:17-27.   Back to cited text no. 64
    
65.
Buyon JP, Kim MY, Guerra MM, Laskin CA, Petri M, Lockshin MD, et al. Predictors of Pregnancy Outcomes in Patients With Lupus: A Cohort Study. Ann Intern Med 2015;163:153-63.   Back to cited text no. 65
    
66.
Eudy AM, Siega-Riz AM, Engel SM, Franceschini N, Howard AG, Clowse MEB, et al. Effect of pregnancy on disease flares in patients with systemic lupus erythematosus. Ann Rheum Dis 2018;77:855–60.   Back to cited text no. 66
    
67.
de Jesus GR, Mendoza-Pinto C, de Jesus NR, Dos Santos FC, Klumb EM, Carrasco MG, et al. Understanding and Managing Pregnancy in Patients with Lupus. Autoimmune Dis. 2015;2015:943490.   Back to cited text no. 67
    
68.
Anderson UD, Gram M, Škerström B, Hansson SR. First Trimester Prediction of Preeclampsia. Curr Hypertens Rep 2015;17:74.   Back to cited text no. 68
    
69.
Wu J, Zhang W-H, Ma J, Bao C, Liu J, Di W. Prediction of fetal loss in Chinese pregnant patients with systemic lupus erythematosus: a retrospective cohort study. BMJ Open. 2019 11;9:e023849.   Back to cited text no. 69
    
70.
Teng YKO, Bredewold EOW, Rabelink TJ, Huizinga TWJ, Eikenboom HCJ, Limper M, et al. An evidence-based approach to pre-pregnancy counselling for patients with systemic lupus erythematosus. Rheumatol Oxf Engl 2018 01;57:1707-20.   Back to cited text no. 70
    
71.
Upala S, Yong WC, Sanguankeo A. Association between primary Sjögren's syndrome and pregnancy complications: a systematic review and meta-analysis. Clin Rheumatol 2016;35:1949-55.   Back to cited text no. 71
    
72.
Provost M, Eaton JL, Clowse MEB. Fertility and infertility in rheumatoid arthritis. Curr Opin Rheumatol 2014;26:308-314.   Back to cited text no. 72
    
73.
Brouwer J, Hazes JMW, Laven JSE, Dolhain RJEM. Fertility in women with rheumatoid arthritis: influence of disease activity and medication. Ann Rheum Dis 2015;74:1836-41.   Back to cited text no. 73
    
74.
Lin H-C, Chen S-F, Lin H-C, Chen Y-H. Increased risk of adverse pregnancy outcomes in women with rheumatoid arthritis: a nationwide population-based study. Ann Rheum Dis 2010;69:715–7.   Back to cited text no. 74
    
75.
Nordgren B, Fridén C, Demmelmaier I, Bergström G, Opava CH. Long-term health-enhancing physical activity in rheumatoid arthritis--the PARA 2010 study. BMC Public Health. 2012;12:397. Published 2012 Jun 1. doi:10.1186/1471-2458-12-397.  Back to cited text no. 75
    
76.
Østensen 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;63:1212-7.   Back to cited text no. 76
    
77.
van den Brandt S, Zbinden A, Baeten D, Villiger PM, Østensen M, Förger F. Risk factors for flare and treatment of disease flares during pregnancy in rheumatoid arthritis and axial spondyloarthritis patients. Arthritis Res Ther 2017;19:64.   Back to cited text no. 77
    
78.
Mouyis MA, Thornton CC, Williams D, Giles IP. Pregnancy Outcomes in Patients with Psoriatic Arthritis. J Rheumatol 2017 ;44:128-9.   Back to cited text no. 78
    
79.
Jakobsson GL, Stephansson O, Askling J, Jacobsson LTH. Pregnancy outcomes in patients with ankylosing spondylitis: a nationwide register study. Ann Rheum Dis 2016;75:1838-42.   Back to cited text no. 79
    
80.
Polachek A, Li S, Polachek IS, Chandran V, Gladman D. Psoriatic arthritis disease activity during pregnancy and thefirst-year postpartum. Semin Arthritis Rheum 2017;46:740-5.   Back to cited text no. 80
    
81.
Machen L, Clowse MEB. Vasculitis and Pregnancy. Rheum Dis Clin 2017;43:239-47.   Back to cited text no. 81
    
82.
Comarmond C, Mirault T, Biard L, Nizard J, Lambert M, Wechsler B,et al. Takayasu Arteritis and Pregnancy. Arthritis Rheumatol Hoboken NJ 2015;67:3262-9.   Back to cited text no. 82
    
83.
Mandal D, Mandal S, Dattaray C, Banerjee D, Ghosh P, Ghosh A, et al. Takayasu arteritis in pregnancy: an analysis from eastern India. Arch Gynecol Obstet 2012;285:567-71.   Back to cited text no. 83
    
84.
Wong VC, Wang RY, Tse TF. Pregnancy and Takayasu's arteritis. Am J Med 1983;75:597-601.   Back to cited text no. 84
    
85.
Gupta L, Misra DP, Ahmed S, Jain A, Zanwar A, Lawrence A, et al. Poor obstetric outcomes in Indian women with Takayasu arteritis. Adv Rheumatol 2020;60:17.   Back to cited text no. 85
    
86.
Suri V, Aggarwal N, Keepanasseril A, Chopra S, Vijayvergiya R, Jain S. Pregnancy and Takayasu arteritis: A single centre experience from North India. J Obstet Gynaecol Res 2010;36:519-24.   Back to cited text no. 86
    
87.
Noel N, Wechsler B, Nizard J, Costedoat-Chalumeau N, Boutin DLTH, Dommergues M, et al. Behçet's disease and pregnancy. Arthritis Rheum 2013;65:2450-6.   Back to cited text no. 87
    
88.
Fredi M, Lazzaroni MG, Tani C, Ramoni V, Gerosa M, Inverardi F, et al. Systemic vasculitis and pregnancy: a multicenter study on maternal and neonatal outcome of 65 prospectively followed pregnancies. Autoimmun Rev 2015;14:686-91.   Back to cited text no. 88
    
89.
Singh P, Dhooria A, Rathi M, Agarwal R, Sharma K, Dhir V, et al. Successful treatment outcomes in pregnant patients with ANCA-associated vasculitides: A systematic review of literature. Int J Rheum Dis 2018;21:1734-40.   Back to cited text no. 89
    
90.
Hong P, Pope JE, Ouimet JM, Rullan E, Seibold JR. Erectile dysfunction associated with scleroderma: a case-control study of men with scleroderma and rheumatoid arthritis. J Rheumatol 2004;31:508–13.   Back to cited text no. 90
    
91.
Impens A, Rothman J, Schiopu E, Cole J, Dang J, Gendrano N, et al. Sexual activity and functioning in female scleroderma patients. Clin Exp Rheumatol 2009;27:38-43.   Back to cited text no. 91
    
92.
Chakravarty EF. Vascular Complications of Systemic Sclerosis during Pregnancy. Int J Rheumatol 2010;2010.   Back to cited text no. 92
    
93.
Steen VD. Pregnancy in Scleroderma. Rheum Dis Clin N Am 2007;33:345-58.   Back to cited text no. 93
    
94.
Taraborelli M, Ramoni V, Brucato A, Airò P, Bajocchi G, Bellisai F, et al. Brief report: successful pregnancies but a higher risk of preterm births in patients with systemic sclerosis: an Italian multicenter study. Arthritis Rheum 2012;64:1970-7.   Back to cited text no. 94
    
95.
Chung L, Flyckt RL, Colón I, Shah AA, Druzin M, Chakravarty EF. Outcome of pregnancies complicated by systemic sclerosis and mixed connective tissue disease. Lupus 2006;15:595-9.   Back to cited text no. 95
    
96.
Miniati I, Guiducci S, Mecacci F, Mello G, Matucci-Cerinic M. Pregnancy in systemic sclerosis. Rheumatology. 2008 Jun 1;47(suppl_3):iii16-8.   Back to cited text no. 96
    
97.
Abudiab M, Krause ML, Fidler ME, Nath KA, Norby SM. Differentiating scleroderma renal crisis from other causes of thrombotic microangiopathy in a postpartum patient. Clin Nephrol 2013;80:293-7.   Back to cited text no. 97
    
98.
Silva CA, Sultan SM, Isenberg DA. Pregnancy outcome in adult-onset idiopathic inflammatory myopathy. Rheumatology 2003;42:1168-72.   Back to cited text no. 98
    
99.
Gupta L, Zanwar A, Ahmed S, Aggarwal A. Outcomes of Pregnancy in Women With Inflammatory Myositis: A Retrospective Cohort From India [published online ahead of print, 2019 Feb 01]. J Clin Rheumatol. 2019;10.1097/RHU.0000000000000996. doi:10.1097/RHU.0000000000000996   Back to cited text no. 99
    
100.
Georgiou PE, Politi EN, Katsimbri P, Sakka V, Drosos AA. Outcome of lupus pregnancy: a controlled study. Rheumatology 2000 1;39:1014-9.  Back to cited text no. 100
    
101.
Doria A, Iaccarino L, Arienti S, Ghirardello A, Zampieri S, Rampudda ME, et al. Th2 immune deviation induced by pregnancy: The two faces of autoimmune rheumatic diseases. Reprod Toxicol 2006;22:234-41.   Back to cited text no. 101
    
102.
Krause ML, Amin S, Makol A. Use of DMARDs and biologics during pregnancy and lactation in rheumatoid arthritis: what the rheumatologist needs to know. Ther Adv Musculoskelet Dis 2014;6:169-84.   Back to cited text no. 102
    
103.
Bermas BL. Lactation and Management of Postpartum Disease. Rheum Dis Clin North Am 2017;43:249-62.   Back to cited text no. 103
    
104.
Muttreja P, Singh S. Family planning in India: The way forward. Indian J Med Res 2018;148:1.   Back to cited text no. 104
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105.
Singla S, Garg S, Attri B, Elhence A, Saluja P, Jain S. Contraceptive Practices and Awareness among Patients Attending a Rheumatology Clinic at a Tertiary Hospital in North India: a Cross-Sectional Survey. J Indian Acad Clin Med 2019;20:125.   Back to cited text no. 105
    
106.
Subramaniam C. India's new abortion law is progressive and has a human face [Internet]. ORF.. Available from: https://www.orfonline.org/expert-speak/india-new-abortion-law-progressive-human-face-62023/. [Last accessed on 2020 Apr 04].  Back to cited text no. 106
    


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