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IBD and pregnancy

Mother's health
by

rachel Shiner

on 5 February 2016

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Transcript of IBD and pregnancy

Drugs
Fertility
Sulphasalazine-
dose related reversible infertility
5ASA or aza- no effect on fertility
MTX-reversible oligospermia
Rectal surgery- erectile dysfunction, retrograde ejaculation
When disease is in remission- no effect on fertility
Active disease reduces fertility
Pelvic surgery particularly pouch surgery reduces fertility (decrease fecundicity by 80% post IAPP)
Infliximab/adalimumab

Men
Small study- decreased sperm quality,
Small study- increased sperm count post infusion
10 pregnancies from men recently exposed to
infliximab- one miscarriage and no fetal malformations
Pregnancy outcome
Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.
Cornish J et al. Gut 2007;56:830-837
 Test for heterogeneity: χ2 statistic with its degrees of freedom (df) and p value.
Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.
Cornish J et al. Gut 2007;56:830-837
 Test for heterogeneity: χ2 statistic with its degrees of freedom (df) and p value.
Breast Feeding
ECCO consensus statement:
No increase of congenital abnormality
No increase in spontaneous abortion
If surgery required -18-40% risk of stillbirth
Conception in remission advised
Influence of pregnancy on course of disease
If pregnancy occurs in remission- risk of relapse the same as non-pregnant state (20-35%) Miller 1986
If conception occurs during flare- 2/3 will have persistent activity- 2/3 of these disease activity will deteriorate (HLA disparity).
Clinical activity declines after pregnancy and parity Castiglione Italian Journal Gastro 1996- esp in patients with good nutritional status
Patients with a previous pregnancy require fewer resections and the interval between operations tends to be longer when compared with nulliparous women with CD. Nwokolo C 1994 Gut
No of flares decrease post partum UC 0.34 Vs 0.28 flares/yr and CD 0.76 Vs 0.12/yr p-0.004. Riis et al 2006
IBD patients have fewer births Vs control
(cc) image by nuonsolarteam on Flickr
Decreased libido-fatigue/anaemia/body image
Fear of passing disease to child
... small
dyspareunia-perineal disease
Decreased libido
(cc) photo by medhead on Flickr
Anaemia
Fatigue
Perineal disease
Fear of the disease
Will my child have IBD?
2–12 x higher risk Vs gen pop risk
If one parent CD- Child has 5% risk
If one parent Uc- 1.6% risk
If both- 35 % risk of IBD
Higher in Ashkenazi jews
Drugs
Disease activity
IBD and Pregnancy
Dr.Rachel Cooney
Introduction
Fertility- IBD patients have fewer children
Drugs- safety in pregnancy
How does IBD effect pregnancy outcome
Effect of pregnancy on IBD course
Pre pregnancy counselling
Breast feeding in IBD

Women
Azathioprine/6MP
Pre-pregnancy counselling
Greatest risk to mother and baby is active disease
Explain treatment in general same whether pregnant or not
Treat anaemia- fe /B12/Vit D
Close follow-up along with obstetrician
Higher Caesarian section rate
Stop MTX at least 8 weeks before pregnancy
Colon cancer surveillance
Smears and live vaccines up to date
Only 8.9% of patients received pre-pregnancy counselling
5ASA
Safe
Mesalazine up to a dose of 3g/day
Sulphasalazine- give 2mg folic acid/day
Topical therapy can be used throughout
Antibiotics
Use shortest course possible
Avoid metronidazole in first trimester
Fluroquinolones (cipro), considered safe in first trimester
Amoxicillin safe
Tetracyclines and sulphonamides should not be used
Steroids
Prednisolone- rapidly metabolised by the placental
inc risk of cleft palate 1st trim (OR 3)
Topical preps safe in 1st/2nd trimester
Complications for mother-Impair GT
Budesonide- only one report of 6 cases- no problems
high dose teratogenic in mice
Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.
Mahadevan U Gut 2006;55:1198-1206
 Fecundability ratio in patients with ulcerative colitis before and after diagnosis, and after ileal pouch anal anastomosis compared with healthy controls.
Breastfeeding
Mesalazine -safe- confirmed in prospective trials
Sulfasalzine- safe
Prednisolone - suggest to take dose 4 hours prior to feeding
Aza/6 mp- very low conc detected in breast milk, none detected in neonate
Infliximab not detected in breast milk
Conclusion
Greatest risk to mother and baby is active disease, not active medicating
Rate of congential malformations same as general pop
Increase rate of preterm delivery
Counsel patient
Liase with GP/obstetrician
Indications for bowel surgery- same as in non pregnant disease
Elective Surgery- if needed- do in second trimester
Avoid CT
MRI safe in 2nd/3rd trimester. Gandolidium toxic
C/S if active perianal disease (avoid episiotomy)
Stoma may prolapse during labour-usually reverts
Sigmoidoscopy safe (44 patients -Capelli 1996)
Limited literature on colonoscopy
In CD : Previous intestinal surgery was associated with a higher rate of caesarean sections.
No impact of disease activity on pregnancy outcome was observed.
Women on 5-ASA monotherapy were less likely to have caesarean sections (27% vs. 50%, P = 0.01), while those on combination therapy were at increased risk of this mode of delivery (57% vs. 34%, P = 0.02)
In UC : Older age and disease activity at any time during pregnancy were associated with a lower birth weight (mean 3146 g vs. 3343 g, P = 0.02 and 3110 g vs.3268 g P = 0.04, respectively).
Women on 5-ASA monotherapy were less likely to get preterm delivery (1% vs. 10%, P = 0.01) whereas patients on combination treatment were at increased risk of preterm delivery (13% vs. 1%, P = 0.03)
Regression analysis showed that age < 35 years, inactive disease course and nonsmokers carry the least risk of adverse pregnancy outcome
Safe, Cesame study- 215 pregnancies Gut 2010
Fetal liver in early preg lacks enzyme to convert
to active metabolites
Infliximab and adalimumab : IgG1 fragments-preferentially crosses placenta from 18/40
Efficency of transport increases exponentially in third trimester
Discontinue inflix at 30/40, ADA 34/40, Certolizumab cont
No live vaccines to baby (IgM def)
Case 1
27 year old woman
7 year history of Crohns Colitis
Mild Perianal disease
On mesalasine and 100mg azathioprine
In remission
Becomes pregnant
What are the chances her child will have IBD ?
Should she continue these meds?
Should she continue the pregnancy?
What are her options if her colitis becomes worse?
What are her options if her perianal disease becomes worse?
Should she have a C-section?
Question?
Case 2
20 year old woman with Pan Uc
Unplanned pregnancy
Diagnosed 6 months ago
On mesalazine orally and topically
In remission
Question
Should she continue her meds?
What are her options should her colitis get worse?
Can she have a sigmoidoscopy?
If her colitis becomes fulminant should she have cyclosporine or a colectomy?
122 women with IBD
44% breast fed-
Reason why not :
fear of med interaction
physician recommendation
choice
74% of women d/c meds when
breastfeeding-43% then flared
S.Kane 2006
Cyclosporine
Marion et al -5 cases 1996
4/5 live births
2/ underweight and preterm
no kidney problems
No congenital abnormalities
Inflammatory Bowel Diseases
Volume 17, Issue 9, pages 1846-1854, 6 JAN 2011 DOI: 10.1002/ibd.21583
http://onlinelibrary.wiley.com/doi/10.1002/ibd.21583/full#fig2
Outcome of pregnancy in women with inflammatory bowel disease treated with antitumor necrosis factor therapy
St Georges London ,Chakarbaty et al
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