1
|
Guo P, Cao W. Case report: A pregnant woman with Crohn disease who used ustekinumab to the 3rd trimester developed severe infection. Medicine (Baltimore) 2023; 102:e36253. [PMID: 38050250 PMCID: PMC10695489 DOI: 10.1097/md.0000000000036253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/01/2023] [Indexed: 12/06/2023] Open
Abstract
RATIONALE Crohn disease (CD) and pregnancy often impact each other, which poses challenges for women with CD to successfully give birth to a healthy baby. The latest guideline recommends that patients with active inflammatory bowel disease delay pregnancy to induce remission and optimize disease control. Research data has showed that the incidence of infection and severe infection in patients treated with ustekinumab (UST) did not increase compared to those treated with a placebo. PATIENT CONCERNS This report describes the entire process of a pregnant woman with CD who has undergone ileostomy and long-term enteral nutrition and requires biological agents to control the disease, from conception to delivery. This case was pregnant during CD period and regularly treated with UST to the third trimester, with the onset of sepsis and septic shock at 38 weeks gestation. DIAGNOSES The patient was pathologically diagnosed with CD 16 years ago and admitted to our department at 38 weeks gestation. INTERVENTIONS After admission to our department, fetal heart monitoring indicated fetal distress, so we immediately terminated the pregnancy by cesarean section. After the diagnosis of septic shock, the patient was transferred to intensive care unit for active anti-infection and symptomatic supportive treatment. OUTCOMES The mother only experienced an infection in the third trimester, and cured by active treatment. The newborn was delivered at full term and confirmed to be low birth weight. LESSONS Her experience suggests that although pregnant during Crohn active period, a good outcome can be achieved through positively controlling with medication and closely monitoring it. The use of UST during pregnancy appears to be safe for both the mother and fetus but may be associated with severe infections.
Collapse
Affiliation(s)
- Peng Guo
- Department of Obstetrics and Gynecology, Zhongshan City People’s Hospital, Zhongshan, China
| | - Wulan Cao
- Department of Obstetrics and Gynecology, Zhongshan City People’s Hospital, Zhongshan, China
| |
Collapse
|
2
|
Izquierdo VP, Ovalle CP, Costa V, Leguízamo AM, Ordoñez JSF, Hani A. Pregnancy and Inflammatory Bowel Disease: A Special Combination. Middle East J Dig Dis 2023; 15:222-230. [PMID: 38523891 PMCID: PMC10955988 DOI: 10.34172/mejdd.2023.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 08/11/2023] [Indexed: 03/26/2024] Open
Abstract
Inflammatory bowel disease (IBD) comprises a spectrum of chronic immune-mediated diseases that affect the gastrointestinal tract. Onset typically occurs in early adulthood. The incidence of this disease has increased worldwide. Its prevalence has increased in Colombia and occurs predominantly in women. Considering that this disease is not curable, the main objective of management is to achieve remission. Many women are affected by IBD during different stages of their lives, including their reproductive life, pregnancy, and menopause. Because of this, the way the disease is managed in women of reproductive age can affect the course of IBD. Treatment and health maintenance strategies are very relevant; for patients with a desire to conceive, remission of the disease is very important at the time of conception and throughout the pregnancy to ensure adequate outcomes for both mother and fetus. Also, remission is necessary at least 3 months prior to conception. It is well known that active disease during conception and pregnancy is associated with adverse outcomes. In addition, active perianal disease is an indication of cesarean delivery, resulting in an increased risk of intestinal surgery and post-operative complications.
Collapse
Affiliation(s)
- Viviana Parra Izquierdo
- Gastroenterology and Rheumatology, Fundación Cardiovascular-Hospital Internacional de Colombia, Bucaramanga, Colombia
| | | | - Valeria Costa
- Gastroenterology, Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Ana María Leguízamo
- Gastroenterology, Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
| | | | - Albis Hani
- Gastroenterology, Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
| |
Collapse
|
3
|
Patel NB, Vinsard DG, Kattah AG, Kane SV. Decreased Risk of Preeclampsia in Women with Inflammatory Bowel Disease on Anti-Tumor Necrosis Factor Therapy. Dig Dis Sci 2023; 68:3557-3561. [PMID: 37402980 DOI: 10.1007/s10620-023-08016-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 06/18/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Evidence suggests that upregulation of tumor necrosis factor-alpha (TNF-α) plays a role in immune dysregulation in both preeclampsia and inflammatory bowel disease (IBD). AIMS We aimed to investigate whether anti-TNF therapy during pregnancy decreases the risk of preeclampsia in women with IBD. METHODS The study population included women with IBD and pregnancies who were followed at a tertiary care center from 2007 to 2021. Cases of preeclampsia were compared with controls with a normotensive pregnancy. Data on patient demographics, disease type and activity, pregnancy complications, and additional risk factors for preeclampsia were collected. The association between anti-TNF therapy and preeclampsia was analyzed using univariate analysis and multivariate logistic regression. RESULTS Women with preeclampsia were more likely to have a preterm delivery (44% vs. 12%, p < 0.001). More women without preeclampsia were exposed to anti-TNF therapy during pregnancy than women with preeclampsia (55% vs. 30%, p = 0.029). The majority of women (32/44) on anti-TNF therapy, either adalimumab or infliximab, continued to have some degree of exposure during the third trimester. Though not significant, multivariate analysis showed a trend towards a protective effect of anti-TNF therapy against developing preeclampsia if exposed during the third trimester (OR 0.39; 95% CI 0.14-1.12, p = 0.08). CONCLUSIONS In this study, anti-TNF therapy exposure was higher in IBD patients who did not develop preeclampsia than in those who did. While not significant, there was a trend towards a protective effect of anti-TNF therapy against preeclampsia if exposed during the third trimester.
Collapse
Affiliation(s)
- Nisha B Patel
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
| | | | - Andrea G Kattah
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
4
|
Jølving LR, Nielsen J, Andersen ML, Friedman S, Nørgård BM. Adverse birth outcomes and early-life infections after in utero exposure to corticosteroids for inflammatory bowel disease: a Danish nationwide cohort study. BMC Med 2023; 21:140. [PMID: 37046314 PMCID: PMC10091841 DOI: 10.1186/s12916-023-02817-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 03/06/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Systemic corticosteroids are often used to treat inflammatory bowel disease (IBD) flares during pregnancy as maintenance of disease remission is crucial to optimize pregnancy outcomes. However, there is little data regarding the effect of in utero exposure to corticosteroids on the risk of adverse birth outcomes and early-life infections in the offspring. METHODS We used the Danish national registries to establish a nationwide cohort of all singleton live births in women with IBD from 1995 to 2015. Outcomes in children exposed in utero to corticosteroids were compared to those who were not exposed. In logistic and Cox proportional hazard regression models, we adjusted the outcomes (major congenital malformation, preterm birth, small for gestational age, low 5-min Apgar score, and infections) for confounders such as body mass index, smoking, comorbidity, and additional medical IBD treatment. RESULTS After in utero exposure to corticosteroids at any time between 30 days prior to conception through the first trimester (n = 707), the adjusted hazard ratio of major congenital malformation was 1.28 (95% CI: 0.82-2.00) compared to children born to women with IBD, but not exposed to corticosteroids in utero (n = 9371). After in utero exposure to corticosteroids at any time during pregnancy (n = 1336), the adjusted odds ratios for preterm birth, small for gestational age, and low 5-min Apgar score were 2.45 (95% CI: 1.91-3.13), 1.21 (95% CI: 0.76-1.90), and 0.91 (95% CI: 0.33-2.52), respectively. Finally, the adjusted hazard ratio of overall infections in the first year of life was 1.14 (95% CI: 0.94-1.39). CONCLUSIONS This nationwide cohort study suggests that children of women with IBD exposed to corticosteroids in utero had an almost 2.5-fold increased risk of preterm birth. Use of corticosteroids is closely related to disease activity and we cannot adjust for the independent role of disease activity. It is however reassuring that the other examined birth and early-life outcomes were not statistically significantly increased.
Collapse
Affiliation(s)
- Line Riis Jølving
- Center for Clinical Epidemiology, Odense University Hospital, Kløvervænget 30, Entrance 216, 5000, Odense C, Denmark.
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Jan Nielsen
- Center for Clinical Epidemiology, Odense University Hospital, Kløvervænget 30, Entrance 216, 5000, Odense C, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mette Louise Andersen
- Center for Clinical Epidemiology, Odense University Hospital, Kløvervænget 30, Entrance 216, 5000, Odense C, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sonia Friedman
- Center for Clinical Epidemiology, Odense University Hospital, Kløvervænget 30, Entrance 216, 5000, Odense C, Denmark
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, USA
| | - Bente Mertz Nørgård
- Center for Clinical Epidemiology, Odense University Hospital, Kløvervænget 30, Entrance 216, 5000, Odense C, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, USA
| |
Collapse
|
5
|
Brondfield MN, Mahadevan U. Inflammatory bowel disease in pregnancy and breastfeeding. Nat Rev Gastroenterol Hepatol 2023:10.1038/s41575-023-00758-3. [PMID: 37002407 DOI: 10.1038/s41575-023-00758-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 06/19/2023]
Abstract
Inflammatory bowel disease (IBD) has a peak age of diagnosis before the age of 35 years. Concerns about infertility, adverse pregnancy outcomes, and heritability of IBD have influenced decision-making for patients of childbearing age and their care providers. The interplay between the complex physiology in pregnancy and IBD can affect placental development, microbiome composition and responses to therapy. Current evidence has shown that effective disease management, including pre-conception counselling, multidisciplinary care and therapeutic agents to minimize disease activity, can improve pregnancy outcomes. This Review outlines the management of IBD in pregnancy and the safety of IBD therapies, including novel agents, with regard to both maternal and fetal health. The vast majority of IBD therapies can be used with low risk during pregnancy and lactation without substantial effects on neonatal outcomes.
Collapse
Affiliation(s)
- Max N Brondfield
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Uma Mahadevan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
| |
Collapse
|
6
|
Laube R, Selinger CP, Seow CH, Christensen B, Flanagan E, Kennedy D, Mountifield R, Seeho S, Shand A, Williams AJ, Leong RW. Australian inflammatory bowel disease consensus statements for preconception, pregnancy and breast feeding. Gut 2023; 72:1040-1053. [PMID: 36944479 DOI: 10.1136/gutjnl-2022-329304] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/21/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Because pregnancy outcomes tend to be worse in women with inflammatory bowel disease (IBD) than in those without, we aimed to update consensus statements that guide the clinical management of pregnancy in patients with IBD. DESIGN A multidisciplinary working group was established to formulate these consensus statements. A modified RAND/UCLA appropriateness method was used, consisting of a literature review, online voting, discussion meeting and a second round of voting. The overall agreement among the delegates and appropriateness of the statement are reported. RESULTS Agreement was reached for 38/39 statements which provide guidance on management of pregnancy in patients with IBD. Most medications can and should be continued throughout pregnancy, except for methotrexate, allopurinol and new small molecules, such as tofacitinib. Due to limited data, no conclusion was reached on the use of tioguanine during pregnancy. Achieving and maintaining IBD remission before conception and throughout pregnancy is crucial to optimise maternofetal outcomes. This requires a multidisciplinary approach to engage patients, allay anxieties and maximise adherence tomedication. Intestinal ultrasound can be used for disease monitoring during pregnancy, and flexible sigmoidoscopy or MRI where clinically necessary. CONCLUSION These consensus statements provide up-to-date, comprehensive recommendations for the management of pregnancy in patients with IBD. This will enable a high standard of care for patients with IBD across all clinical settings.
Collapse
Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, New South Wales, Australia
| | | | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Britt Christensen
- Gastroenterology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Emma Flanagan
- Department of Gastroenterology, University of Melbourne, Melbourne, Victoria, Australia
| | - Debra Kennedy
- MotherSafe, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Reme Mountifield
- Department of Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Sean Seeho
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Antonia Shand
- Department of Maternal Foetal Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Astrid-Jane Williams
- Department of Gastroenterology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Rupert W Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, New South Wales, Australia
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Concord, New South Wales, Australia
- The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| |
Collapse
|
7
|
Rosiou K, Selinger CP. Obstetric Considerations in Pregnant Women with Crohn's Disease. J Clin Med 2023; 12:jcm12020684. [PMID: 36675613 PMCID: PMC9867236 DOI: 10.3390/jcm12020684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/03/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023] Open
Abstract
Crohn's disease affects many women of childbearing age. Fecundity rates are often lower than in the general population due to reduced fertility during active inflammation, effects of pelvic surgery or voluntary childlessness. Many women have concerns regarding the effects of pregnancy on their Crohn's, any potential effect of medication on the fetus, and passing on Crohn's disease to the offspring. International guidelines on reproduction for women with Crohn's disease provide evidence-based advice to patients and health care professionals. There is an increasing literature on the safety of advanced medication for Crohn's disease during pregnancy. This review article therefore focuses on obstetric considerations beyond medication safety. We provide information on fertility, factors affecting pregnancy and fetal outcomes, obstetric complications, factors influencing mode of delivery, management of intestinal stomas during pregnancy and general considerations around breast feeding.
Collapse
Affiliation(s)
| | - Christian P. Selinger
- Leeds Teaching Hospital NHS Trust, Gastroenterology, Leeds LS9 7TF, UK
- Research Institute at St James Hospital, University of Leeds, Leeds LS9 7TF, UK
- Correspondence:
| |
Collapse
|
8
|
Costa RV, Simões C, Correia L, Pinto L. Inflammatory Bowel Disease and Pregnancy: Is It a Marker for Adverse Outcomes? REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:915-924. [PMID: 36446558 PMCID: PMC9708404 DOI: 10.1055/s-0042-1756149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To assess obstetric/puerperal/neonatal outcomes in an inflammatory bowel disease (IBD) population and to analyze disease characteristics that may be associated to adverse outcomes. METHODS Retrospective descriptive analysis including 47 pregnant women with IBD (28 with Crohn's disease - CD and 19 with ulcerative colitis - UC) who delivered between March 2012 and July 2018 in a tertiary hospital. We reviewed clinical records to extract demographic information, previous medical history, disease subtype, activity, severity, treatment, and obstetric, puerperal, and neonatal outcome measures. RESULTS Obstetric and neonatal complications (composite outcomes) occurred in 55.3% and 14.6% of the IBD population, respectively, and were more frequent in UC patients. Preterm birth (PTB), preeclampsia, anemia, low birth weight (LBW), and neonatal death were also more frequent in UC patients. The rate of postpartum hemorrhage (PPH) was 14.9%, and it was higher in CD patients. Women with active IBD had more obstetric/neonatal adverse outcomes (fetal growth restriction and LBW in particular) and cesarean sections. Patients with medicated IBD had less obstetric/neonatal complications (PTB and LBW in specific) and cesarean sections but more PPH. CONCLUSION Women with IBD may have an increased risk of obstetric/puerperal/neonatal adverse outcomes. Ulcerative colitis patients had more obstetric and neonatal complications, whereas PPH was more frequent if CD patients. Other disease characteristics were considered, which allowed a better understanding of their possible influence. Although more research is needed, this work reinforces the importance of adequate surveillance to allow prompt recognition and treatment of complications.
Collapse
Affiliation(s)
- Rita Vicente Costa
- Gynecology and Obstetris Service, Hospital Distrital de Santarém, Santarém, Portugal,Address for correspondence Rita Vicente Costa, MSc Av. Bernardo Santareno, Santarém 2005-177Portugal
| | - Carolina Simões
- Gastroenterology Service, Hospital de Santa Maria, Lisboa, Portugal
| | - Luís Correia
- Gastroenterology Service, Hospital de Santa Maria, Lisboa, Portugal
| | - Luísa Pinto
- Gynecology and Obstetrics Service, Hospital de Santa Maria, Lisboa, Portugal
| |
Collapse
|
9
|
Post-neonatal Outcomes of Infants Born to Women with Active Trimester One Inflammatory Bowel Disease: A Pilot Study. Dig Dis Sci 2022; 67:5177-5186. [PMID: 35201477 DOI: 10.1007/s10620-022-07430-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/30/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Ulcerative colitis (UC) and Crohn's disease (CD) are chronic inflammatory bowel diseases (IBD) that affect women in their childbearing years. Early pregnancy flare-up negatively impacts obstetrical and perinatal outcomes, but the impact on infants is unclear. AIM To determine whether active IBD disease activity is associated with adverse post-neonatal outcomes post-partum. METHODS This is a single-center cohort study of women with IBD who underwent serial monitoring of post-neonatal outcomes post-partum. Infant outcomes were collected via self-filled questionnaires, including perinatal outcomes, APGAR scores, infant weights, heights, feeding habits and comorbidities within the first year of life. RESULTS There was a total of 98 women with IBD and 78 live births throughout the study: 50 women were enrolled during trimester one alone and 49 were included into the current study. Among the 49 analyzed, 32 were in remission and 17 were in relapse during trimester one. Trimester one disease activity was associated with more adverse obstetrical outcomes including emergency C-sections and reduced 1-min APGAR scores. At follow-up, infants born to women with T1-flare had reduced weight-for-age Z scores and length-for-age Z scores up to 6 months of age. CONCLUSIONS Active IBD during trimester one is correlated with adverse post-neonatal outcomes, particularly decreased infant weight and height up to 6 months of age. This suggests disease control in first trimester is essential for optimizing infant growth and post-neonatal outcomes.
Collapse
|
10
|
Guerrero Vinsard D, Karagozian R, Wakefield DB, Kane SV. Maternal Outcomes and Pregnancy-Related Complications Among Hospitalized Women with Inflammatory Bowel Disease: Report from the National Inpatient Sample. Dig Dis Sci 2022; 67:4295-4302. [PMID: 34406586 DOI: 10.1007/s10620-021-07210-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/02/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Previous studies have been inconsistent in reporting the risk of pregnancy-related complications in women with IBD. We aimed to investigate the differences in frequencies of pregnancy-related complications requiring hospitalization in women with IBD compared to women without IBD. METHODS We performed a population-based, cross-sectional study using the 2014 USA National Inpatient Sample. Frequencies of ICD-9 codes for pregnancy-related complications in women aged 18-35 years with IBD were compared to women with no IBD controlling for confounders predisposing to pregnancy complications. Adjusted odds ratios were calculated for each outcome. RESULTS A total of 6705 women with IBD and a pregnancy complication were discharged from the hospital in 2014. In multivariate analyses, there was no statistically significant difference between women with and without IBD for: spontaneous abortion, post-abortion complications, ectopic pregnancy, hemorrhage, severe preeclampsia, eclampsia, early labor, polyhydramnios, hyperemesis, missed abortion, mental disorder during pregnancy, and forceps delivery. Women with IBD had significant lower odds for prolonged pregnancy, gestational diabetes, fetal distress, umbilical cord complications, obstetric trauma, mild preeclampsia, and hypertension. There was, however, higher odds for infectious and parasitic complications (OR 1.74, 95% CI 1.42-2.14, p < 0.0001), UTIs (OR 1.65, 95% CI 1.07-2.60, p = 0.02), and anemia (OR 5.26, 95% CI 4.01-6.90, p < 0.0001). CONCLUSIONS In this large population-based analysis, women with IBD had higher odds for certain infections such as UTIs and anemia during pregnancy when compared to women with no IBD. For other pregnancy-related complications, women with IBD had the same or lower odds than women with no IBD. These data are important to share with women with IBD considering pregnancy.
Collapse
Affiliation(s)
- Daniela Guerrero Vinsard
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 1ST St SW, Rochester, MN, 55905, USA.
| | - Raffi Karagozian
- Department of Gastroenterology and Hepatology, Tufts Medical Center, Boston, MA, USA
| | | | - Sunanda V Kane
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 1ST St SW, Rochester, MN, 55905, USA
| |
Collapse
|
11
|
Wiestler M, Seidler U. Mit Morbus Crohn und Colitis ulcerosa sicher durch die Schwangerschaft. Geburtshilfe Frauenheilkd 2022. [DOI: 10.1055/a-1430-4878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
12
|
Schmidt M, Kühnert M, Kuschel B, Kehl S, Schäfer-Graf UM. Care of Women with Chronic Inflammatory Bowel Disease (Chronic IBD) During Pregnancy: Recommendations of the Obstetrics and Prenatal Medicine Working Group of the DGGG. Geburtshilfe Frauenheilkd 2021; 81:1348-1353. [PMID: 34899047 PMCID: PMC8654510 DOI: 10.1055/a-1429-2742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 03/10/2021] [Indexed: 11/25/2022] Open
Abstract
The incidence of chronic inflammatory bowel disease (chronic IBD) in persons of reproductive age is high. Chronic IBD does not typically lead to impaired fertility. Nevertheless, the percentage of women suffering from chronic IBD who have children is lower than that of the general population, due to self-imposed childlessness. Providing women with open, unbiased information and, if necessary, helping them to overcome baseless fears should therefore be an essential part of preconception counseling. With the exception of methotrexate, most standard drugs can and should be continued during pregnancy. If the pregnancy occurs during an inactive phase of disease, the rate of complications in pregnancy should, in principle, not be higher than normal. Nevertheless, pregnant women with chronic IBD are classed as high-risk pregnancies. Organ screening in accordance with DEGUM II criteria should be carried out in every case, and women must be monitored for the potential development
of placental insufficiency. Any flare-ups which occur during pregnancy should be treated in full. Vaginal delivery can be considered if there is no perianal manifestation of disease; however, the individual risk must be carefully weighed up.
Collapse
Affiliation(s)
- Markus Schmidt
- Klinik für Frauenheilkunde und Geburtshilfe, Sanakliniken Duisburg, Duisburg, Germany
| | - Maritta Kühnert
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Marburg, Marburg, Germany
| | - Bettina Kuschel
- Klinik und Poliklinik für Frauenheilkunde, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Sven Kehl
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
| | | |
Collapse
|
13
|
Guerrero Vinsard D, Kane SV. Biologics and pregnancy: a clinician's guide to the management of IBD in pregnant women. Expert Rev Gastroenterol Hepatol 2021; 15:633-641. [PMID: 33440996 DOI: 10.1080/17474124.2021.1876562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Women with inflammatory bowel disease (IBD) endorse a tremendous amount of concern about medication exposure during pregnancy and their effects on the fetus. Medical providers caring for this patient population should be well informed and feel comfortable counseling their patients for the best pregnancy outcome possible.Areas covered: It is of particular importance to understand the implications of use of biologics in preconception, pregnancy, and postpartum timeframes. Herein, we aim to inform the clinician about the impact of uncontrolled inflammation during pregnancy, the mechanisms of biologic transport through the placenta, the effects of biologics in maternal and neonatal outcomes, and additional postpartum considerations such as breastfeeding and vaccination safety.Expert opinion: The groundwork already set by previous research in terms of safety of biologic therapy during pregnancy has been reassuring. With the advent of more mechanisms of action but similar protein structure, i.e. they are IgG1 antibodies; the authors anticipate the recommendation of continuation of therapy throughout pregnancy will be sustained.
Collapse
Affiliation(s)
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, MN, USA
| |
Collapse
|
14
|
Laube R, Paramsothy S, Leong RW. Review of pregnancy in Crohn's disease and ulcerative colitis. Therap Adv Gastroenterol 2021; 14:17562848211016242. [PMID: 34046084 PMCID: PMC8135214 DOI: 10.1177/17562848211016242] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/19/2021] [Indexed: 02/04/2023] Open
Abstract
Inflammatory bowel disease (IBD) frequently affects women of childbearing age and can have implications in pregnancy. Most women with IBD have comparable fertility with women in the general population. Fertility is reduced in women with active disease or previous ileal-pouch-anal anastomosis (IPAA) surgery and is temporarily reduced in men taking sulfasalazine. Women with IBD have an increased risk of preterm delivery, low birth weight, small-for-gestational-age infants and Cesarean section (CS) delivery, however, no increased risk of congenital abnormalities. These adverse outcomes are particularly prevalent for women with active IBD compared with those with quiescent disease. Conception should occur during disease remission to optimize maternal and fetal outcomes and reduce the risk of disease exacerbations during pregnancy. Pre-conception counseling is therefore pertinent to provide patient education, medication review for risk of teratogenicity and objective disease assessment. Most medications are safe during pregnancy and breastfeeding, with the exception of methotrexate, ciclosporin, allopurinol and tofacitinib. Delivery modality should be guided by obstetric factors in most cases; however, CS is recommended for women with active perianal disease and can be considered for women with inactive perianal disease or IPAA. In conclusion, most women with IBD have uncomplicated pregnancies. Active IBD is the predominant predictor of poor outcomes and disease exacerbations; therefore, maintenance of disease remission during and before pregnancy is crucial.
Collapse
Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
| | - Sudarshan Paramsothy
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | - Rupert W. Leong
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2137, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
| |
Collapse
|
15
|
Kim MA, Kim YH, Chun J, Lee HS, Park SJ, Cheon JH, Kim TI, Kim WH, Park JJ. The Influence of Disease Activity on Pregnancy Outcomes in Women With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis. J Crohns Colitis 2021; 15:719-732. [PMID: 33175122 DOI: 10.1093/ecco-jcc/jjaa225] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Robust evidence regarding the impact of disease activity on pregnancy outcomes in women with inflammatory bowel disease [IBD] is crucial for both clinicians and patients in preparing a birth plan. We sought to perform a systematic review and meta-analysis to assess the pooled influences of disease activity on pregnancy outcomes in women with IBD. METHODS We searched MEDLINE, EMBASE and the COCHRANE library to identify articles comparing pregnancy outcomes between active and inactive IBD at the time of conception or during pregnancy. A meta-analysis was performed using a random-effects model to pool estimates and report odds ratios [ORs]. RESULTS A total of 28 studies were identified as eligible for the meta-analysis. In women with active IBD, the pooled ORs for low birth weight [LBW], preterm birth, small for gestational age [SGA], spontaneous abortion and stillbirths were respectively 3.81 (95% confidence interval [CI] 1.81-8.02), 2.42 [95% CI 1.74-3.35], 1.48 [95% CI 1.19-1.85], 1.87 [95% CI 1.17-3.0] and 2.27 [95% CI 1.03-5.04] compared to women with inactive IBD. In the subgroup analysis based on disease type, women with active ulcerative colitis had an increased risk of LBW, preterm birth and spontaneous abortion. Women with active Crohn's disease had a higher risk of preterm birth, SGA and spontaneous abortion. CONCLUSIONS Active IBD during the periconception period and pregnancy is associated with an increased risk of adverse pregnancy outcomes. Our data suggest that pregnancy should be planned when the disease is quiescent, and continuous disease control is important even during pregnancy.
Collapse
Affiliation(s)
- Min-A Kim
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Han Kim
- Department of Obstetrics and Gynecology, Severance Hospital, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Jaeyoung Chun
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Biostatics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
16
|
Leung KK, Tandon P, Govardhanam V, Maxwell C, Huang V. The Risk of Adverse Neonatal Outcomes With Maternal Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. Inflamm Bowel Dis 2021; 27:550-562. [PMID: 32469057 DOI: 10.1093/ibd/izaa122] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) may be at increased risk of adverse neonatal outcomes. The aim of this study was to determine pooled incidences and risk factors for these outcomes. METHODS Medline, Embase, and Cochrane Library were searched through May 2019 for studies reporting adverse neonatal outcomes in IBD. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS The pooled incidence of preterm birth, low birth weight, congenital anomalies, and infants transferred to the neonatal intensive care unit was 8.6% (95% CI, 7.0%-10.1%), 8.9% (95% CI, 7.3%-10.5%), 2.1% (95% CI, 1.6%-2.6%), and 4.9% (95% CI, 2.9%-6.9), respectively. Compared with healthy controls, patients with IBD were more likely to deliver infants with low birth weight (<2500 grams; OR, 2.78; 95% CI, 1.16-6.66) and infants admitted to the intensive care unit (OR, 3.33; 95% CI, 1.83-6.05). Patients with Crohn's disease had an increased incidence of congenital anomalies (OR, 3.03; 95% CI, 1.43-6.42). Among IBD patients, active disease was associated with increased incidence of preterm birth (OR, 2.06; 95% CI, 1.21-3.51), low birth weight (OR, 2.96; 95% CI, 1.54-5.70), and small for gestational age (OR, 2.62; 95% CI, 1.18-5.83). Antitumor necrosis factor (anti-TNF) use during pregnancy was associated with an increased incidence of neonatal intensive care unit admission (OR, 2.42; 95% CI, 1.31-4.45) and low birth weight (OR, 1.54; 95% CI, 1.01-2.35). CONCLUSIONS Patients with IBD, particularly with active disease or requiring anti-TNF therapy, may be at increased risk of developing adverse neonatal outcomes.
Collapse
Affiliation(s)
- Kristel K Leung
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Parul Tandon
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vivek Govardhanam
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Vivian Huang
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
17
|
Cao RH, Grimm MC. Pregnancy and medications in inflammatory bowel disease. Obstet Med 2021; 14:4-11. [PMID: 33995565 PMCID: PMC8107959 DOI: 10.1177/1753495x20919214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/20/2020] [Accepted: 02/21/2020] [Indexed: 12/27/2022] Open
Abstract
Inflammatory bowel disease (IBD) affects patients at a significant time in their lives, often coinciding with family planning or pregnancy. While advances in IBD therapies have afforded women greater opportunities for successful conception and pregnancy outcomes, there still remains considerable maternal fear surrounding continuation of treatment in pregnancy. With the exception of methotrexate, most IBD drugs are safe and well tolerated during pregnancy and are not associated with significant risk of adverse fetal or pregnancy outcomes. Furthermore, the current evidence overwhelmingly suggests that good control of disease activity and clinical remission at time of conception are the greatest prognostic factors for an uncomplicated pregnancy and maintenance of quiescent disease. Management of pregnant women with IBD should involve discussions with the mother and family about fears or concerns surrounding the impact of IBD on pregnancy. Mothers should be supported and counselled carefully on the safety and importance of adherence to therapy in maintaining remission. Optimal management of these women requires an inter-disciplinary team effort, involving the general practitioner, in close consultation with both gastroenterologists and obstetricians.
Collapse
Affiliation(s)
- Rena H Cao
- St George and Sutherland Clinical School,
University of New South Wales, Sydney, Australia
| | - Michael C Grimm
- St George and Sutherland Clinical School,
University of New South Wales, Sydney, Australia
| |
Collapse
|
18
|
Laube R, Paramsothy S, Leong RW. Use of medications during pregnancy and breastfeeding for Crohn's disease and ulcerative colitis. Expert Opin Drug Saf 2021; 20:275-292. [PMID: 33412078 DOI: 10.1080/14740338.2021.1873948] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: The peak age of diagnosis of inflammatory bowel disease (IBD) occurs during childbearing years, therefore management of IBD during pregnancy is a frequent occurrence. Maintenance of disease remission is crucial to optimize pregnancy outcomes, and potential maternal or fetal toxicity from medications must be balanced against the risks of untreated IBD.Areas covered: This review summarizes the literature on safety and use of medications for IBD during pregnancy and lactation.Expert opinion: 5-aminosalicylates, corticosteroids and thiopurines are safe for use during pregnancy, while methotrexate and tofacitinib should only be used with extreme caution. Anti-TNF agents (except certolizumab), vedolizumab, ustekinumab and tofacitinib readily traverse the placenta via active transport, therefore theoretically may affect fetal development. Certolizumab only undergoes passive transfer across the placenta, thus has markedly lower cord blood levels making it likely the safest biologic agent for infants. There is reasonable evidence to support the safety of anti-TNF monotherapy and combination therapy during pregnancy and lactation. Vedolizumab and ustekinumab are also thought to be safe in pregnancy and lactation, while tofacitinib is generally avoided due to teratogenic effects in animal studies.
Collapse
Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia
| | - Sudarshan Paramsothy
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | - Rupert W Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| |
Collapse
|
19
|
Ali MF, He H, Friedel D. Inflammatory bowel disease and pregnancy: fertility, complications and treatment. Ann Gastroenterol 2020; 33:579-590. [PMID: 33162735 PMCID: PMC7599341 DOI: 10.20524/aog.2020.0536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/27/2020] [Indexed: 12/30/2022] Open
Abstract
Inflammatory bowel disease (IBD) is commonly diagnosed and treated in the young population. Therefore, it is common that women anticipating or undergoing pregnancy will have to cope with the additional burden of their IBD. Pregnancy in an IBD patient also presents challenges for the practitioner, in that the usual diagnostic and therapeutic armamentarium of potential tests and therapies is disrupted. This review covers the implications of IBD for fertility, pregnancy and offspring, and discusses the management of IBD in pregnancy.
Collapse
Affiliation(s)
- Mohammad Fahad Ali
- Department of Gastroenterology and Hepatology, Guthrie Cortland Medical Center (Mohammad Fahad Ali)
| | - Harry He
- Department of Medicine, NYU Winthrop University Hospital (Harry He)
| | - David Friedel
- Department of Gastroenterology, NYU Winthrop University Hospital (David Friedel), USA
| |
Collapse
|
20
|
De Lima-Karagiannis A, Juillerat P, Sebastian S, Pedersen N, Bar-Gil Shitrit A, van der Woude CJ. Management of Pregnant Inflammatory Bowel Disease Patients During the COVID-19 Pandemic. J Crohns Colitis 2020; 14:S807-S814. [PMID: 33085970 PMCID: PMC7665400 DOI: 10.1093/ecco-jcc/jjaa125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
UNLABELLED The rapid emergence of the novel coronavirus [SARS-CoV2] and the coronavirus disease 2019 [COVID-19] has caused significant global morbidity and mortality. This is particularly concerning for vulnerable groups such as pregnant women with inflammatory bowel disease [IBD]. Care for pregnant IBD patients in itself is a complex issue because of the delicate balance between controlling maternal IBD as well as promoting the health of the unborn child. This often requires continued immunosuppressive maintenance medication or the introduction of new IBD medication during pregnancy. The current global COVID-19 pandemic creates an additional challenge in the management of pregnant IBD patients. In this paper we aimed to answer relevant questions that can be encountered in daily clinical practice when caring for pregnant women with IBD during the current COVID-19 pandemic. PODCAST This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast.
Collapse
Affiliation(s)
- A De Lima-Karagiannis
- Erasmus University Medical Center, Department of Gastroenterology and Hepatology, the Netherlands
| | - P Juillerat
- Gastroenterology, Clinic for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - S Sebastian
- IBD Unit, Hull University Teaching Hospital NHS Trust, Hull, UK
| | - N Pedersen
- Slagelse Hospital, University of Copenhagen, Department of Gastroenterology, Denmark
| | - A Bar-Gil Shitrit
- IBD MOM unit, Digestive Diseases Institute, Shaare Zedek Medical Center affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - C J van der Woude
- Erasmus University Medical Center, Department of Gastroenterology and Hepatology, the Netherlands,Corresponding author: C. Janneke van der Woude, Erasmus University Medical Center, Department of Gastroenterology and Hepatology, The Netherlands. Tel: 003110703320;
| |
Collapse
|
21
|
Truta B, Leeds IL, Canner JK, Efron JE, Fang SH, Althumari A, Safar B. Early Discontinuation of Infliximab in Pregnant Women With Inflammatory Bowel Disease. Inflamm Bowel Dis 2020; 26:1110-1117. [PMID: 31670762 DOI: 10.1093/ibd/izz250] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Early discontinuation of infliximab (IFX) in pregnant women with inflammatory bowel disease (IBD) decreases the intrauterine fetal exposure to the drug but may increase the risk of disease flaring leading to poor pregnancy outcomes. In this study, we assessed the impact of early IFX discontinuation on mother's disease activity and on their at-risk babies. METHODS In a retrospective study of the Truven Health Analytics MarketScan database from 2011 to 2015, we compared IBD patients who discontinued IFX more than 90 days ("early IFX") with those who discontinue IFX 90 days or less ("late IFX) before delivery. We evaluated the risk of flaring, defined by new steroid prescriptions, visits to emergency room and/or hospital admissions, the pregnancy outcomes, and the at-risk babies. RESULTS After IFX discontinuation, the early IFX group (68 deliveries) required significantly more steroid prescriptions than the late IFX group (318 deliveries) to control disease activity (P < 001). There were more preterm babies in the early IFX group (P < 049), but no difference within the 2 groups was noticed in the rate of intrauterine growth retardation, small for gestation, and stillborn babies. Similarly, there was no increase in acute respiratory infections, development delays, and congenital malformations in babies of the mothers from the late IFX vs early IFX groups. CONCLUSIONS Steroid-free remission IBD mothers are at risk for disease flares and preterm babies when IFX is discontinued early in pregnancy. Continuation of IFX seems to be safe at least for the first year of life.
Collapse
Affiliation(s)
- Brindusa Truta
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ira L Leeds
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sandy H Fang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Azah Althumari
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
22
|
Lee HH, Bae JM, Lee BI, Lee KM, Wie JH, Kim JS, Cho YS, Jung SA, Kim SW, Choi H, Choi MG. Pregnancy outcomes in women with inflammatory bowel disease: a 10-year nationwide population-based cohort study. Aliment Pharmacol Ther 2020; 51:861-869. [PMID: 32266739 DOI: 10.1111/apt.15654] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 10/18/2019] [Accepted: 01/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Data relating to the association between inflammatory bowel disease (IBD) and pregnancy outcomes are lacking in Korea. AIMS To determine the incidence rates of pregnancy outcomes in women with IBD. METHODS A nationwide population study was performed using the Korean National Health Insurance claims database. A total of 2058 women with IBD consisting of ulcerative colitis (UC, n = 1469) and Crohn's disease (CD, n = 589) were pregnant between 2007 and 2016. We compared their incidence of pregnancy outcomes with 20 580 age-matched controls without IBD. We also stratified the patients into those with quiescent to mild and moderate to severe IBD and compared the outcomes between them. RESULTS The pregnancy rate of women with IBD was lower than that of women without (25.7% vs 32.3%, P < 0.001). Caesarean section (46.5% vs 38.8%, odds ratio [OR] 1.43, 95% confidence interval [CI]: 1.17-1.75), and intrauterine growth retardation (IUGR) (3.0% vs 1.0%, OR 2.89, 95% CI: 1.59-5.26) were increased in CD patients than the controls. In regards to disease severity, there were no significant differences in pregnancy outcomes between patients with quiescent to mild IBD and the controls. However, the live birth rate of patients with moderate to severe IBD was lower than that of the controls (65.0% vs 69.9%, OR 0.79, 95%CI: 0.66-0.94). In addition, moderate to severe IBD was significantly associated with spontaneous abortion (14.9% vs 11.9%, OR 1.33, 95% CI: 1.04-1.68), caesarean section (46.4% vs 38.8%, OR 1.41, 95% CI: 1.14-1.74) and IUGR (3.4% vs 1.0%, OR 3.20, 95% CI: 1.75-5.84). CONCLUSIONS With the exception of moderate to severe disease, the incidences of adverse pregnancy outcomes in women with IBD are similar to that of the general population.
Collapse
Affiliation(s)
- Han H Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Catholic Photomedicine Research Institute, Seoul, Korea
| | - Jung Min Bae
- Department of Dermatology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bo-In Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Catholic Photomedicine Research Institute, Seoul, Korea
| | - Kang-Moon Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeong H Wie
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin S Kim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Catholic Photomedicine Research Institute, Seoul, Korea
| | - Young-Seok Cho
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Catholic Photomedicine Research Institute, Seoul, Korea
| | - Sung-Ae Jung
- Division of Gastroenterology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Sang W Kim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hwang Choi
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung-Gyu Choi
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Catholic Photomedicine Research Institute, Seoul, Korea
| |
Collapse
|
23
|
Garshol BF, Aamodt G, Madsen C, Vatn MH, Bengtson MB. The effect of nitrogen dioxide on low birth weight in women with inflammatory bowel disease: a Norwegian pregnancy cohort study (MoBa). Scand J Gastroenterol 2020; 55:272-278. [PMID: 32064969 DOI: 10.1080/00365521.2020.1726446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: Adverse birth outcomes are more frequent among mothers with inflammatory bowel diseases (IBDs) than non-IBD mothers. In recent studies, air pollution, such as high concentrations of nitrogen dioxide (NO2), is reckoned as a risk factor for preterm birth in the general population. In this study, we investigated whether IBD mothers are at higher risk of preterm birth when exposed to NO2 compared to non-IBD mothers.Methods: We used information from the Norwegian Mother, Father and Child Cohort Study (MoBa). The pregnancy cohort was linked to the Norwegian Medical Birth Registry and air-pollution exposure data available from a subset of the study cohort. The relevant outcome in this study was preterm birth. A total of 16,170 non-IBD and 92 IBD mothers were included in the study.Results: The mean exposure of NO2 during the pregnancy was similar for IBD and non-IBD mothers, 13.7 (6.9) μg/m3 and 13.6 (4.2) μg/m3, respectively.IBD mothers with higher exposure of NO2 in the second and third trimester were at significant risk of preterm birth compared to non-IBD mothers [OR = 1.28 (CI 95%: 1.04-1.59) and OR = 1.23 (95% CI: 1.06-1.43), respectively]. The mean NO2 exposure was significantly higher in IBD mothers with preterm birth than in IBD mothers who delivered at term, at 19.58 (1.57) μg/m3 and 12.89 (6.37) μg/m3, respectively.Conclusions: NO2 exposure influenced the risk of preterm birth in IBD mothers. Higher risk of preterm birth in IBD was associated with higher exposure of NO2, suggesting vulnerability of preterm birth in IBD when exposed to NO2.
Collapse
Affiliation(s)
| | - Geir Aamodt
- Department of Public Health Science, LANDSAM, Norwegian University of Life Sciences, Ås, Norway
| | - Christian Madsen
- Department of Health & Inequality, Norwegian Institute of Public Health, Oslo, Norway
| | - Morten Harald Vatn
- EpiGen Institute, Akershus University Hospital, University of Oslo, Oslo, Norway
| | - May-Bente Bengtson
- EpiGen Institute, Akershus University Hospital, University of Oslo, Oslo, Norway.,Medical Department, Vestfold Hospital Trust, Tønsberg, Norway
| |
Collapse
|
24
|
Bengtson MB, Haugen M, Brantsæter AL, Aamodt G, Vatn MH. Intake of dairy protein during pregnancy in IBD and risk of SGA in a Norwegian population-based mother and child cohort. BMC Gastroenterol 2020; 20:28. [PMID: 32013916 PMCID: PMC6998088 DOI: 10.1186/s12876-020-1182-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 01/29/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) tend to avoid dairy products to minimize abdominal pain and diarrhea. The aim of this study was to estimate the proportion of protein from dairy sources (PPDS) in mothers with and without IBD, and to explore the impact of PPDS on inadequate gestational weight gain (GWG) or small for gestational age (SGA) in IBD compared to non-IBD in the population-based Norwegian Mother, Father and Child Cohort Study (MoBa). METHODS MoBa includes about 95,000 pregnant women recruited throughout Norway from 1999 to 2008. IBD phenotype and complications during pregnancy and delivery were ascertained. This study included 148 mothers with Crohn disease (CD) and 194 with ulcerative colitis and 68,858 non-IBD mothers. In mid-pregnancy participants answered a comprehensive semi-quantitative food frequency questionnaire assessing diet since the start of pregnancy. PPDS was ranked in quartiles. The two lowest quartiles were merged and considered to represent the lowest of three PPDS groups. We used logistic regression analyses to model multivariate associations, adjusting for potential confounders. RESULTS The risk of belonging to the lowest PPDS group was twice as high in IBD mothers compared to non-IBD mothers (aOR = 2.02, 95% CI: 1.53, 2.67). Low compared to high PPDS strongly predicted inadequate GWG in CD (aOR = 4.22, 95% CI: 1.28, 13.92). Surprisingly, and in opposition to the non-IBD mothers, PPDS was positively associated with the risk of SGA in IBD mothers. IBD mother with low PPDS was associated with significantly lower risk of SGA than non-IBD mothers and IBD mothers with high PPDS (aOR = 0.19, 95% CI: 0.07, 0.50). The interaction term IBD/PPDS was the factor that linked SGA to IBD compared to non-IBD, and increased the association between IBD and SGA with a factor of three. CONCLUSION This study shows that intake of dairy products is lower in IBD mothers than in non-IBD mothers, and further, that low intake of dairy products in IBD mothers is associated with reduced risk of SGA compared to non-IBD and IBD mothers with high PPDS.
Collapse
Affiliation(s)
- May-Bente Bengtson
- EpiGen-Institute, Faculty Division Akershus University Hospital, University of Oslo, Oslo, Norway.
- Medical Department, Vestfold Hospital Trust, P.O. Box 2168, 3103, Tønsberg, Norway.
| | - Margaretha Haugen
- Division of Infection Control and Environmental Health, Department of Environmental Exposure and Epidemiology, Norwegian Institute of Public Health, P.O. Box 222-Skøyen, 0213, Oslo, Norway
| | - Anne Lise Brantsæter
- Division of Infection Control and Environmental Health, Department of Environmental Exposure and Epidemiology, Norwegian Institute of Public Health, P.O. Box 222-Skøyen, 0213, Oslo, Norway
| | - Geir Aamodt
- Department of Public Health Science, LANDSAM, Norwegian University of Life Sciences, P.O. Box 5003, 1432, Ås, Norway
| | - Morten H Vatn
- EpiGen-Institute, Faculty Division Akershus University Hospital, University of Oslo, Oslo, Norway
| |
Collapse
|
25
|
Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H, Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68:s1-s106. [PMID: 31562236 PMCID: PMC6872448 DOI: 10.1136/gutjnl-2019-318484] [Citation(s) in RCA: 1184] [Impact Index Per Article: 236.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
Collapse
Affiliation(s)
- Christopher Andrew Lamb
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas A Kennedy
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- University of Exeter, Exeter, UK
| | - Tim Raine
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Philip Anthony Hendy
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Philip J Smith
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Bu'Hussain Hayee
- King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Miranda C E Lomer
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gareth C Parkes
- Barts Health NHS Trust, London, UK
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Christian Selinger
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | | | - R Justin Davies
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Cathy Bennett
- Systematic Research Ltd, Quorn, UK
- Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | | | - Malcolm G Dunlop
- University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Omar Faiz
- Imperial College London, London, UK
- St Mark's Hospital, Harrow, UK
| | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Miles Parkes
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Jeremy Sanderson
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Daniel R Gaya
- Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Tariq H Iqbal
- Queen Elizabeth Hospital Birmingham NHSFoundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Stuart A Taylor
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Melissa Smith
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Matthew Brookes
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
- University of Wolverhampton, Wolverhampton, UK
| | - Richard Hansen
- Royal Hospital for Children Glasgow, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | | |
Collapse
|
26
|
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
Collapse
|
27
|
Noninvasive Methods For Assessing Inflammatory Bowel Disease Activity in Pregnancy: A Systematic Review. J Clin Gastroenterol 2019; 53:574-581. [PMID: 31306343 DOI: 10.1097/mcg.0000000000001244] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Active inflammatory bowel disease (IBD) may increase the risk of adverse outcomes during pregnancy. Our aim was to systematically review the role of noninvasive fecal tests, such as fecal calprotectin (FCP) and lactoferrin (FL), and laboratory tests including C-reactive protein (CRP), hemoglobin, and albumin in the assessment of IBD during pregnancy. A systematic search of electronic databases was performed through October 2018 for studies assessing the utility of fecal and laboratory tests in predicting IBD activity in pregnant patients. Active disease was defined based on routinely used clinical criteria such as the Harvey-Bradshaw Index or Mayo score for ulcerative colitis. Noninvasive test levels were stratified by the presence of active disease and by gestational period (preconception, first trimester, second trimester, and third trimester). Thirteen studies were included. Both FCP and FL levels were significantly higher in pregnant patients with IBD compared with those without IBD. FCP levels were also significantly higher in patients with active disease compared with those with the inactive disease during all gestational periods. Furthermore, 3 studies demonstrated no consistent correlation with serum CRP and active IBD during pregnancy. Similarly, serum albumin and hemoglobin levels did not correlate with disease activity in pregnant patients with IBD. Given the lack of high-quality evidence, only FCP appears to correlate with IBD activity in all gestational periods of pregnancy. The utility of the other noninvasive tests such as serum CRP, hemoglobin, and albumin remains to be determined in this population.
Collapse
|
28
|
Connor KL, Chehoud C, Altrichter A, Chan L, DeSantis TZ, Lye SJ. Maternal metabolic, immune, and microbial systems in late pregnancy vary with malnutrition in mice. Biol Reprod 2019; 98:579-592. [PMID: 29324977 DOI: 10.1093/biolre/ioy002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 01/08/2018] [Indexed: 01/08/2023] Open
Abstract
Malnutrition is a global threat to pregnancy health and impacts offspring development. Establishing an optimal pregnancy environment requires the coordination of maternal metabolic and immune pathways, which converge at the gut. Diet, metabolic, and immune dysfunctions have been associated with gut dysbiosis in the nonpregnant individual. In pregnancy, these states are associated with poor pregnancy outcomes and offspring development. However, the impact of malnutrition on maternal gut microbes, and their relationships with maternal metabolic and immune status, has been largely underexplored. To determine the impact of undernutrition and overnutrition on maternal metabolic status, inflammation, and the microbiome, and whether relationships exist between these systems, pregnant mice were fed either a normal, calorically restricted (CR), or a high fat (HF) diet. In late pregnancy, maternal inflammatory and metabolic biomarkers were measured and the cecal microbiome was characterized. Microbial richness was reduced in HF mothers although they did not gain more weight than controls. First trimester weight gain was associated with differences in the microbiome. Microbial abundance was associated with altered plasma and gut inflammatory phenotypes and peripheral leptin levels. Taxa potentially protective against elevated maternal leptin, without the requirement of a CR diet, were identified. Suboptimal dietary conditions common during pregnancy adversely impact maternal metabolic and immune status and the microbiome. HF nutrition exerts the greatest pressures on maternal microbial dynamics and inflammation. Key gut bacteria may mediate local and peripheral inflammatory events in response to maternal nutrient and metabolic status, with implications for maternal and offspring health.
Collapse
Affiliation(s)
- Kristin L Connor
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.,Health Sciences, Carleton University, Ottawa, Ontario, Canada
| | | | | | - Luisa Chan
- Second Genome, San Francisco, California, USA
| | | | - Stephen J Lye
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| |
Collapse
|
29
|
Abstract
PURPOSE OF REVIEW Roughly half of the nearly 1.6 million people with inflammatory bowel disease (IBD) are women of reproductive age. Caring for women with IBD who are also pregnant can be challenging, particularly if with a disease flare or in remission, as there are special considerations needed. RECENT FINDINGS Despite older studies concluding potential risks associated with IBD medical therapies, more recent literature reports healthier maternal and birth outcomes associated with disease control and reduction in the inflammatory burden. Most IBD therapies should generally be continued throughout all three trimesters without interruption as this is associated with better outcomes. SUMMARY Active IBD increases risk of pregnancy complications and adverse pregnancy outcomes. Most medications have a favorable safety profile for use during pregnancy, regardless if in disease flare or remission. Short course corticosteroids for induction and management of flare is permitted. Thiopurines should not be started during pregnancy for a disease flare, but may be continued during pregnancy if previously on monotherapy. Biologics should be continued throughout pregnancy without interruption and timing of third trimester dosing made based on drug levels and estimated date of delivery. Risks/benefit assessment of therapies and disease control is important and should be individualized.
Collapse
|
30
|
Brunelli R, Perrone S, Perrone G, Galoppi P, De Stefano MG, Maragno AM, Cesarini M, De Carolis A, Masselli G, Vernia P. New-onset ulcerative colitis in pregnancy associated to toxic megacolon and sudden fetal decompensation: Case report and literature review. J Obstet Gynaecol Res 2019; 45:1215-1221. [PMID: 31064034 DOI: 10.1111/jog.13996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 04/14/2019] [Indexed: 12/15/2022]
Abstract
Ulcerative colitis (UC) is a chronic inflammatory disease rarely arising during gestation. Because the available information is based on case reports or small retrospective studies, diagnosis may be difficult and treatment is still controversial. A case of toxic megacolon developing in late pregnancy associated to a sudden fetal decompensation is described. Diagnostic and clinical topics of acute UC onset in pregnancy are debated.A primipara, 34 years old, 33/0 weeks of gestation, was admitted with a diagnosis of preterm labor, associated to acute bloody diarrhea (up to 10 daily motions) and cramping abdominal pain. A diagnosis of new-onset early-stage UC was made by sigmoidoscopy. An intensive care regimen including hydrocortisone, antibiotics and parenteral nutrition was immediately started. Magnetic resonance imaging of maternal abdomen, fostered by the worsening patient conditions, evidenced dilatation of the entire colon and a severely hampered of fetal muscular tone.Toxic megacolon complicated by superimposed Clostridium difficile infection was associated to a sudden fetal decompensation diagnosed by chance during maternal abdominal magnetic resonance imaging. An emergency cesarean section was mandatory. According to a senior surgeon's decision, total colectomy was not immediately performed following cesarean section with reference to the absence of colonic perforation. We obtained a good short-term maternal outcome and an uncomplicated neonatal course. Counseling of those patients must be focused on timely and multidisciplinary intervention in order to improve the course of maternal disease and to prevent fetal distress.
Collapse
Affiliation(s)
- Roberto Brunelli
- Department of Gynecological Obstetrical and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Seila Perrone
- Department of Gynecological Obstetrical and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Giuseppina Perrone
- Department of Gynecological Obstetrical and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Paola Galoppi
- Department of Gynecological Obstetrical and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Maria G De Stefano
- Department of Gynecological Obstetrical and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Anna M Maragno
- Department of Gynecological Obstetrical and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Monica Cesarini
- Division of Gastroenterology, Department of Internal Medicine and Medical Specialties, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Aurora De Carolis
- Division of Gastroenterology, Department of Internal Medicine and Medical Specialties, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Gabriele Masselli
- Radiology Dea Department, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Piero Vernia
- Division of Gastroenterology, Department of Internal Medicine and Medical Specialties, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| |
Collapse
|
31
|
Lee KE, Jung SA, Park SH, Moon CM, Shim SY, Kim ES, Cho SJ, Kim SE, Cho KB, Yang SK. Influence of anti-tumor necrosis factor-alpha therapy to pregnant inflammatory bowel disease women and their children's immunity. Intest Res 2019; 17:237-243. [PMID: 30727711 PMCID: PMC6505087 DOI: 10.5217/ir.2018.00071] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 11/17/2018] [Indexed: 12/11/2022] Open
Abstract
Background/Aims The onset of inflammatory bowel disease (IBD) usually occurs at young age, and therefore, women IBD patients experience pregnancy during their disease progression. Recently, the use of anti-tumor necrosis factor-α (anti-TNF-α) has been rapidly increasing. The aim of this study was to evaluate pregnancy related outcomes in women with IBD who were treated with anti-TNF-α during pregnancy and immunity of their children. Methods Korean women with IBD who had been treated with anti-TNF-α during pregnancy had been enrolled. Medical records were reviewed and a survey was performed for each patient. For the patients who agreed on additional examination for their children, children’s growth, medical history and antibody to hepatitis B surface antigen (anti-HBs) titer were checked. Results All 18 patients had been diagnosed with Crohn’s disease. There was not any case of preterm delivery, low birth-weight infant, congenital anomaly, nor stillbirth. All 12 children had followed the regular vaccination schedule for hepatitis B and 4 of them showed negative results for anti-HBs. After the 1 booster vaccination, all children demonstrated seroconversion. Regarding live vaccines, 4 children had bacillus Calmette-Guerin and 4 had rotavirus vaccine before 6 months, without any specific side effects. Conclusions This was the first study of immunity of the children born from IBD women who had been treated with anti-TNF-α medication during their pregnancy. IBD women had comparable pregnancy outcomes with the general women population, suggesting that the disease activity rather than the administered medication would be more important in healthy pregnancy. Considering the history of vaccination and anti-HBs titers, immunity seems to be intact in the children.
Collapse
Affiliation(s)
- Ko Eun Lee
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Sung-Ae Jung
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Mo Moon
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - So Yeon Shim
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
| | - Eun Soo Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea.,Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Su Jin Cho
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
| | - Seong-Eun Kim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kwang Bum Cho
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
32
|
Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
Collapse
Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | |
Collapse
|
33
|
Wieringa JW, Driessen GJ, Van Der Woude CJ. Pregnant women with inflammatory bowel disease: the effects of biologicals on pregnancy, outcome of infants, and the developing immune system. Expert Rev Gastroenterol Hepatol 2018; 12:811-818. [PMID: 29972674 DOI: 10.1080/17474124.2018.1496820] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Relapse of inflammatory bowel disease (IBD) during conception and pregnancy has been associated with a negative pregnancy outcome. Therefore, it is advised to maintain drugs in order to prevent relapse. The effect of drugs, which cross the placenta, on children who have been exposed during pregnancy will be discussed in this review. Areas covered: A literature search was performed using the following search terms: inflammatory bowel disease, pregnancy, infant, antitumor necrosis factor alpha, infliximab, adalimumab, golimumab, certolizumab, anti-integrins, vedolizumab, anti-interleukin (IL)-12/23 ustekinumab, placenta, vaccination. Other studies were identified by using references from articles identified through our original literature search. The occurrence of unfavorable pregnancy outcome and congenital malformations does not seem to be increased after exposure to anti-TNFα, but the effects on the developing immune system are largely unknown. For anti-integrins and anti IL-12/23, the numbers of exposed pregnancies are too small to draw any conclusions. Expert commentary: Follow-up of the developing immune system in children exposed to these drugs seems warranted, preferably in a prospective study design.
Collapse
Affiliation(s)
- Jantien W Wieringa
- a Department or Pediatrics , Haaglanden Medical Center , The Hague , The Netherlands.,b Department of Pediatric Infectious Diseases and Immunology , Erasmus Medical Centre-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Gertjan J Driessen
- c Department of Pediatrics , Haga Teaching Hospital, Juliana Children's Hospital , The Hague , The Netherlands
| | | |
Collapse
|
34
|
de Lima A, Kanis SL, Escher JC, van der Woude CJ. Hepatitis B Vaccination Effective in Children Exposed to Anti-Tumour Necrosis Factor Alpha in Utero. J Crohns Colitis 2018; 12:948-953. [PMID: 29726943 DOI: 10.1093/ecco-jcc/jjy053] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 05/01/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Neonates exposed to tumour necrosis factor [TNF] alpha inhibitors in utero are born with detectable drug levels which can still be detected throughout the first year of life. Since 2011, the hepatitis B virus [HBV] vaccine is routinely administered to all newborns in the Netherlands. Adults treated with anti-TNF have been reported to respond inadequately to the HBV vaccine. The aim of this study was to compare anti-HB levels in anti-TNF-exposed children with non-exposed children following routine Dutch HBV vaccination. METHODS We performed a cross-sectional, controlled cohort study from 2014 to 2017 in a single, tertiary referral centre. Pregnant women treated with anti-TNF for inflammatory bowel disease [IBD] and their subsequent children were recruited from the IBD preconception outpatient clinic. Pregnant women not treated with anti-TNF for IBD and their subsequent children were eligible as controls. Adherence to the Dutch National Vaccination Programme was mandatory for participation in this study. A venous blood sample was obtained 1 month after final HBV vaccination. Anti-HB levels were measured by enzyme-linked immunosorbent assay. RESULTS Anti-HB levels at 12 months did not differ between the anti-TNF-exposed [n = 15] and the control group [n = 12] [> 1000 IU/l vs > 1000 IU/l, p = 0.59]. All children were successfully immunized against HBV, defined as anti-HB > 10 IU/l. Median anti-TNF levels determined in cord blood at birth were 9.0 µg/ml [interquartile range: 3.0-15.0 µg/ml] for infliximab and 0.4. µg/ml [interquartile range: 0.3-0.6 µg/ml] for adalimumab. There were no differences in general birth and health outcomes. CONCLUSION Children born with detectable anti-TNF levels can be effectively vaccinated against HBV.
Collapse
Affiliation(s)
- Alison de Lima
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Shannon L Kanis
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Johanna C Escher
- Department of Pediatrics, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, the Netherlands
| |
Collapse
|
35
|
Koslowsky B, Grisaru-Granovsky S, Livovsky DM, Milgrom Y, Goldin E, Bar-Gil Shitrit A. Pregnancy-Onset Inflammatory Bowel Disease: A Subtle Diagnosis. Inflamm Bowel Dis 2018; 24:1826-1832. [PMID: 29788306 DOI: 10.1093/ibd/izy081] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Inflammatory bowel diseases (IBDs) are commonly diagnosed during the reproductive years. IBD first manifested during pregnancy (pregnancy-onset IBD [POIBD]) is still an undescribed entity. The aim of the study was to evaluate the characteristics and maternal and neonatal outcomes of patients with POIBD. METHODS Data of all pregnant women with IBD within a single multidisciplinary referral clinic, IBD-MOM, between 2011-2016, were analyzed. Maternal and neonatal characteristics and outcomes were compared between the POIBD group and those diagnosed before pregnancy (non-POIBD). RESULTS We identified 237 women, 31 (15%) from the POIBD group and 206 (85%) from the non-POIBD group. Eight (3.5%) patients experienced early spontaneous pregnancy loss, all in the non-POIBD group. The POIBD diagnosis occurred in 16 (52%) patients during the first trimester, 10 (32%) in second trimester, and 5 (16%) during third trimester. Diagnosis of ulcerative colitis (UC) was significantly more common in the POIBD group compared with the non-POIBD group (22/31, 71% vs 50/206, 24%, respectively, P < 0.001). More UC than Crohn's disease patients had active disease during pregnancy (69% vs 50%, P = 0.03, respectively). POIBD patients experienced vaginal delivery in 100% of births, compared with 164 (79.6%) in the non-POIBD group (P = 0.017). The mean gestational age at birth and the neonatal weight were similar among the study groups; 38.6 weeks and 3040 g for POIBD patients, compared with 38.7 weeks and 3055 g in the non-POIBD group. CONCLUSIONS POIBD is a unique clinical entity, and the diagnosis is mostly UC. However, the maternal and neonatal outcomes are similar.
Collapse
Affiliation(s)
| | | | | | | | - Eran Goldin
- Digestive Diseases Institute, Jerusalem, Israel
| | | |
Collapse
|
36
|
Shitrit ABG, Cohen Y, Hassin O, Ya'acov AB, Farkash R, Koslowsky B, Milgrom Y, Livovsky DM, Samueloff A, Goldin E, Grisaru-Granovsky S. Antenatal Management for Women with Inflammatory Bowel Disease: Experience from Our 'IBD MOM' Clinic. Dig Dis Sci 2018; 63:1774-1781. [PMID: 29626275 DOI: 10.1007/s10620-018-5048-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 03/26/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Inflammatory bowel disease affects women during their reproductive years and thus pregnancy outcomes. IBD MOM is a multidisciplinary, single-center clinic established to benefit women with IBD and their neonates. AIM The aim of this study was to evaluate the perinatal outcomes of the IBD MOM clinic patients compared to patients who attended antenatal and gastrointestinal disease community clinics (IBD CC). METHODS This single-center, prospective study was conducted from 2011 to 2015. The primary outcome was cesarean delivery; secondary was adverse perinatal outcomes. In parallel, a new pregnancy-oriented, disease severity score was evaluated for its association with perinatal risk (score low = 0 to severe = 5). RESULTS We identified 90 women in the IBD MOM clinic and 206 in the IBD CC. Maternal age, smoking habits, pregnancy complications, and type of IBD (CD/UC) were similar between groups. Rates of labor induction and birth weight were also similar between IBD MOM and IBD GI. The IBD MOM overall preterm delivery (PTD) rate (< 37 weeks) was significantly higher 18.9 versus 9.7% (P = 0.028). The IBD MOM group had a significantly higher IBD MOM disease severity score that correlated with a higher rate of PTD. The overall IBD MOM score and scores > 3 were significantly associated with PTD risk in both groups (P = 0.013 and P = 0.004, respectively). CONCLUSION Women with moderate and severe IBD who attended a multidisciplinary clinic may benefit from this unique center. Healthcare planning policies can assume that costly, multidisciplinary clinics for women with IBD should be reserved for those with moderate and severe disease.
Collapse
Affiliation(s)
- Ariella Bar-Gil Shitrit
- IBD MOM Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel.
| | - Yael Cohen
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
| | - Ori Hassin
- Medical School, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Ami Ben Ya'acov
- IBD MOM Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
| | - Rivkah Farkash
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
| | - Benjamin Koslowsky
- IBD MOM Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
| | - Yael Milgrom
- IBD MOM Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
| | - Dan Meir Livovsky
- IBD MOM Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
| | - Arnon Samueloff
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
| | - Eran Goldin
- IBD MOM Unit, Digestive Diseases Institute, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Medical School, Hebrew University, Jerusalem, Israel
| |
Collapse
|
37
|
Decision making and outcome of pregnancies in female patients with inflammatory bowel disease: findings from a community-based practice. Eur J Gastroenterol Hepatol 2018. [PMID: 29543610 DOI: 10.1097/meg.0000000000001117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The aim of this study was to evaluate information provided on pregnancy, personal decision making, disease course, and outcome of pregnancy from a patient's perspective in a population of patients with inflammatory bowel disease (IBD) attending two general hospitals. PATIENTS AND METHODS A questionnaire was sent to all female patients with IBD in two general hospitals in the Netherlands. The questionnaire comprised four sections: (i) demographic data and medication use (ii) details on previous pregnancies and reasons for not becoming pregnant, (iii) outcome of pregnancies before IBD diagnosis, and (iv) outcome of pregnancies after IBD diagnosis. If necessary, medical records were reviewed to verify responses or for further medical details. RESULTS In total, 385 women returned the questionnaire, 501 completed pregnancies were reported, and 113 women had never been pregnant. In 272 women with at least one pregnancy, 334 pregnancies occurred before IBD diagnosis, 157 after IBD diagnosis, and in 10 cases, IBD was diagnosed during pregnancy. Medication for IBD was used in 67% of pregnancies after IBD diagnosis, mainly 5-ASA preparations (54%). Women with ulcerative colitis experienced more IBD-related complaints during pregnancy compared with women with Crohn's disease (25 vs. 14%, P=0.016). Additional medication (n=21) or surgery (n=2) for IBD during pregnancy was indicated in 14% of cases. Most women reported an uneventful pregnancy course (79%). Preterm birth occurred in 13% of pregnancies. CONCLUSION Pregnancy in women with IBD seen in a general hospital can be managed with a good outcome. Step-up therapy is needed in a minority of cases, and severe complications are rare.
Collapse
|
38
|
Pregnancy outcome following in utero exposure to azathioprine: A French comparative observational study. Therapie 2018; 73:199-207. [DOI: 10.1016/j.therap.2017.06.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/15/2017] [Accepted: 06/30/2017] [Indexed: 01/05/2023]
|
39
|
Thomas C, Monteil-Ganiere C, Mirallié S, Hémont C, Dert C, Léger A, Joyau C, Caldari D, Audrain M. A Severe Neonatal Lymphopenia Associated With Administration of Azathioprine to the Mother in a Context of Crohn's Disease. J Crohns Colitis 2018; 12:258-261. [PMID: 28961694 DOI: 10.1093/ecco-jcc/jjx123] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 08/30/2017] [Indexed: 12/12/2022]
Abstract
Azathioprine is commonly used in Crohn's disease. It has been administered to many pregnant women over many years without significant side effects. However, pancytopenia and severe combined immune deficiency-like disease have been reported in infants whose mothers received azathioprine throughout pregnancy. Moreover, myelotoxicity has been described in patients being treated with azathioprine and having a low or absent thiopurine S-methyl transferase [TPMT] activity.Here, we describe the case of a newborn girl found to be highly lymphopenic [< 300 CD3+ T cells] after a positive newborn screening for severe combined immuno deficiency. The clinical examination was normal. The mother was treated with azathioprine throughout her pregnancy, without any reduction of the dose. It was shown that the mother was heterozygous for the 3A [TPMT] activity mutation and that the baby was homozygous for the same mutation; 6-thioguanine nucleotides were high (744 pmol/8.108 red blood cells [RBC]) in the mother and detectable in the infant [177 pmol/8.108 RBC].Although rare, this case illustrates the potential grave consequences of unsuspected TPMT homozygosity in a newborn of a mother receiving thiopurines during pregnancy. Because of the severity of the risk for the newborn, consideration should be given to performing maternal genetic testing and newborn routine blood count in cases of thiopurine treatment during pregnancy.
Collapse
Affiliation(s)
- Caroline Thomas
- Service d'hématologie et d'immunologie pédiatrique, Hôpital Mère-Enfants, CHU de Nantes, Nantes, France
| | | | | | | | - Cecile Dert
- Direction de la recherche, cellule Innovation, CHU de Nantes, Nantes, France
| | - Alexandra Léger
- Service d'hématologie et d'immunologie pédiatrique, Hôpital Mère-Enfants, CHU de Nantes, Nantes, France.,Service d'immunologie, CHU de Nantes, Nantes, France
| | - Caroline Joyau
- Service de pharmacologie Clinique, CHU de Nantes, Nantes, France
| | - Dominique Caldari
- Service de pédiatrie, Hôpital Mère-Enfants, CHU de NANTES, Nantes, France
| | - Marie Audrain
- Service d'immunologie, CHU de Nantes, Nantes, France
| |
Collapse
|
40
|
Myklebust-Hansen T, Aamodt G, Haugen M, Brantsæter AL, Vatn MH, Bengtson MB. Dietary Patterns in women with Inflammatory Bowel Disease and Risk of Adverse Pregnancy Outcomes: Results from The Norwegian Mother and Child Cohort Study (MoBa). Inflamm Bowel Dis 2018; 24:12-24. [PMID: 29272477 PMCID: PMC6176893 DOI: 10.1093/ibd/izx006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of the study was to examine dietary patterns and risk of adverse pregnancy outcomes among mothers with inflammatory bowel disease (IBD) in the Norwegian Mother and Child Cohort Study (MoBa). METHOD MoBa enrolled participants from all over Norway between 1999 and 2008, and the study comprised 83,988 mothers, of whom there were 183 mothers with Crohn's disease (CD) and 240 with ulcerative colitis (UC). An additional questionnaire was submitted to mothers with IBD in 2013. We extracted three exploratory dietary patterns: a "Prudent," a "Western," and a "Traditional" pattern. We explored the relationship between dietary patterns and IBD and dietary patterns and adverse pregnancy outcomes: small for gestational age (SGA) and preterm delivery (PTD). RESULTS IBD mothers had a significantly lower adherence to the Traditional dietary pattern [mean score -0.10 (95% CI: - 0.2 - - 0.01)] than non-IBD mothers. In IBD mothers, middle and high adherence to the Traditional dietary pattern was associated with lower risk of SGA [OR tertile 2 vs. tertile 1: 0.44 (95% CI: 0.20 - 0.97) and OR tertile 3 vs. tertile 1: 0.23 (95% CI: 0.08-0.61)] than in IBD and non-IBD mothers with low adherence. In the IBD-subset analyses, similar results were demonstrated for UC mothers [OR tertile 2 vs. tertile 1: 0.21 (95% CI: 0.05 - 0.80) and OR tertile 3 vs. tertile 1: 0.16 (95% CI: 0.04 - 0.60)]. CONCLUSION In IBD mothers, higher adherence to a Traditional dietary pattern, characterized by high consumption of lean fish, fish products, potatoes, rice porridge, cooked vegetables, and gravy, was associated with lower risk of SGA.
Collapse
Affiliation(s)
- Thea Myklebust-Hansen
- Department of Public Health Science, Faculty of Landscape and Society, Norwegian University of Life Sciences, Ås, Norway,Address correspondence to: Thea Myklebust, MSc, Department of Public Health Science, Faculty of Landscape and Society, Norwegian University of Life Sciences, 1433 Ås, Norway, e-mail:
| | - Geir Aamodt
- Department of Public Health Science, Faculty of Landscape and Society, Norwegian University of Life Sciences, Ås, Norway
| | - Margaretha Haugen
- Department of Environmental Exposure and Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
| | - Anne Lise Brantsæter
- Department of Environmental Exposure and Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
| | - Morten H Vatn
- Institute of Clinical Medicine, University of Oslo, Campus Ahus and Oslo University Hospital Rikshospitalet, Oslo, Norway
| | | |
Collapse
|
41
|
Gonzalez-Suarez B, Sengupta S, Moss AC. Impact of inflammatory bowel disease activity and thiopurine therapy on birth weight: A meta-analysis. World J Gastroenterol 2017; 23:8082-8089. [PMID: 29259384 PMCID: PMC5725303 DOI: 10.3748/wjg.v23.i45.8082] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 10/24/2017] [Accepted: 10/24/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the effect of disease activity or thiopurine use on low birth weight and small for gestational age in women with inflammatory bowel disease (IBD).
METHODS Selection criteria included all relevant articles on the effect of disease activity or thiopurine use on the risk of low birth weight (LBW) or small for gestational age (SGA) among pregnant women with IBD. Sixty-nine abstracts were identified, 35 papers were full text reviewed and, only 14 of them met inclusion criteria. Raw data were extracted to generate the relative risk of LBW or SGA. Quality was assessed using the Newcastle Ottawa Scale.
RESULTS This meta-analysis is reported according to PRISMA guidelines. Fourteen studies met inclusion criteria, and nine reported raw data suitable for meta-analysis. We found an increased risk ratio of both SGA and LBW in women with active IBD, when compared with women in remission: 1.3 for SGA (4 studies, 95%CI: 1.0-1.6, P = 0.04) and 2.0 for LBW (4 studies, 95%CI: 1.5-2.7, P < 0.0001). Women on thiopurines during pregnancy had a higher risk of LBW (RR 1.4, 95%CI: 1.1-1.9, P = 0.007) compared with non-treated women, but when adjusted for disease activity there was no significant effect on LBW (RR 1.2, 95%CI: 0.6-2.2, P = 0.6). No differences were observed regarding SGA (2 studies; RR 0.9, 95%CI: 0.7-1.2, P = 0.5).
CONCLUSION Women with active IBD during pregnancy have a higher risk of LBW and SGA in their neonates. This should be considered in treatment decisions during pregnancy.
Collapse
Affiliation(s)
- Begoña Gonzalez-Suarez
- Division of Gastroenterology, Inflammatory Bowel Disease Center, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
| | - Shreyashee Sengupta
- Division of Gastroenterology, Inflammatory Bowel Disease Center, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
| | - Alan C Moss
- Division of Gastroenterology, Inflammatory Bowel Disease Center, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
| |
Collapse
|
42
|
Anti-TNF-α Use During the Third Trimester of Pregnancy in Women with Moderate-severe Inflammatory Bowel Disease and the Risk of Preterm Birth and Low Birth Weight. Inflamm Bowel Dis 2017; 23:1916-1923. [PMID: 28858070 DOI: 10.1097/mib.0000000000001234] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Little knowledge exists about the association between anti-tumor necrosis factor-alpha (anti-TNF-α) therapy for inflammatory bowel disease during late pregnancy and adverse birth outcomes. We aimed to examine whether treatment with anti-TNF-α during the third trimester affected preterm birth and low birth weight (LBW), compared with women who discontinued anti-TNF-α therapy before the third trimester. METHODS We identified a nationwide cohort of 219 women treated with anti-TNF-α during the pregnancy period and reviewed the medical records to extract clinical details. The exposed cohort (n = 113, 51.6%) constituted pregnancies exposed to anti-TNF-α during the third trimester, and the unexposed cohort (n = 106, 48.4%) constituted pregnancies with no anti-TNF-α during the third trimester. The association between anti-TNF-α therapy in the third trimester and adverse birth outcomes was studied (1) in those women who had clinical disease activity during pregnancy and (2) in women who had no clinical disease activity during pregnancy. RESULTS In women with disease activity, treated with anti-TNF-α during the third trimester, we found an adjusted odds ratio of 2.23 (95% confidence interval [CI], 0.80-6.20) for preterm birth and 1.16 (95% CI, 0.26-5.23) for LBW. Among women without disease activity, treated with anti-TNF-α therapy during the third trimester, we found an adjusted odds ratio of 3.36 (95% CI, 0.31-36.46) for preterm birth and 0.86 (95% CI, 0.05-14.95) for LBW. CONCLUSIONS For anti-TNF-α therapy in the third trimester, we found no statistically significant increased risk of either LBW or preterm birth.
Collapse
|
43
|
Bengtson MB, Martin CF, Aamodt G, Vatn MH, Mahadevan U. Inadequate Gestational Weight Gain Predicts Adverse Pregnancy Outcomes in Mothers with Inflammatory Bowel Disease: Results from a Prospective US Pregnancy Cohort. Dig Dis Sci 2017; 62:2063-2069. [PMID: 28332106 DOI: 10.1007/s10620-017-4547-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 03/15/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Malnutrition and weight loss are common features of patients with inflammatory bowel disease (IBD). AIM To explore the impact of inadequate gestational weight gain (GWG) on adverse outcomes among IBD mothers in the prospective US pregnancy in Inflammatory Bowel Disease and Neonatal Outcomes (PIANO) cohort. METHODS The PIANO cohort comprises 559 and 363 pregnant mothers with Crohn's disease (CD) and ulcerative colitis (UC), respectively, enrolled between 2006 and 2014. The mothers were followed during and after pregnancy to ascertain medication, measurement of disease activity and complications during pregnancy and at delivery. Inadequate GWG was based on US Institute of Medicine recommendations. The associations between inadequate GWG and adverse pregnancy outcomes in maternal IBD were analyzed, adjusted for diabetes, hypertension, smoking, maternal age, education, and disease activity. RESULTS Maternal CD and UC with inadequate GWG had a 2.5-fold increased risk of preterm birth (OR 2.5, CI 1.3, 4.9 and OR 2.5, CI 1.2, 5.6). Furthermore, an increased risk of intrauterine growth restriction and a trend for small for gestational age were demonstrated in CD but not in UC (OR 3.3, CI 1.1, 10.0, OR 4.5, CI 0.8, 24.3, p = 0.08). Flares increased risk of inadequate GWG (OR 1.6, CI 1.2, 2.3, p = 0.002) but did not change the associations between inadequate GWG and adverse pregnancy outcomes in our models. CONCLUSION The US PIANO cohort demonstrated that inadequate GWG was a strong independent predictor of adverse pregnancy outcomes in IBD mothers.
Collapse
Affiliation(s)
- May-Bente Bengtson
- EpiGen-Institute, Faculty Division Akershus and University of Oslo, Lørenskog, Norway. .,Medical Department, Vestfold Hospital Trust, P.O. Box 2168, 3103, Tønsberg, Norway.
| | - Christopher F Martin
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Geir Aamodt
- Norwegian University of Life Sciences, P.O. Box 5003, 1432, Ås, Norway
| | - Morten H Vatn
- EpiGen-Institute, Faculty Division Akershus and University of Oslo, Lørenskog, Norway
| | - Uma Mahadevan
- Division of Gastroenterology, University of California, San Francisco, CA, USA
| |
Collapse
|
44
|
Long-Term Disease Course and Pregnancy Outcomes in Women with Inflammatory Bowel Disease: An Indian Cohort Study. Dig Dis Sci 2017; 62:2054-2062. [PMID: 27785711 DOI: 10.1007/s10620-016-4353-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 10/17/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND The literature on interaction between pregnancy and inflammatory bowel disease (IBD) is inconsistent, and there are no reports on this aspect from Asia. This study evaluated the impact both IBD and pregnancy have on each other in a large cohort of Indian patients. METHODS In total, 514 females with ulcerative colitis (UC) or Crohn's disease (CD) aged between 18 and 45 years attending IBD clinic, at our institute, from July 2004 to July 2013 were screened, and patients with data on pregnancy status were included (n = 406). Pregnancies were categorized as either before, after or coinciding with disease onset. Long-term disease course was ascertained from prospectively maintained records. Pregnancy and fetal outcomes were recorded from antenatal records or individual interviews. RESULTS Of 406 patients (UC: 336, CD: 70), 310 became pregnant (UC: 256, CD: 54), with a total of 597 pregnancies (UC: 524, CD: 73). More UC patients with pregnancies were in long-term remission than non-pregnant patients (56.7 vs. 43.4 %, p = 0.04). Long-term remission was less frequent in UC patients in whom pregnancy coincided with disease onset than patients with pregnancies before and after/pregnancy after the disease onset (41.4 vs. 62.5 %, p = 0.023). Pregnancies after the disease onset were associated with more cesarean sections and adverse fetal outcomes than pregnancies before disease onset in both UC and CD patients. CONCLUSIONS Long-term disease course in UC patients was better in pregnant as compared to non-pregnant patients. Among pregnant UC patients, disease course was worst when pregnancy coincided with disease onset. Pregnancy and fetal outcomes were worse in pregnancy after disease onset than pregnancy before disease onset.
Collapse
|
45
|
Inadequate Gestational Weight Gain, the Hidden Link Between Maternal IBD and Adverse Pregnancy Outcomes: Results from the Norwegian Mother and Child Cohort Study. Inflamm Bowel Dis 2017; 23:1225-1233. [PMID: 28452861 DOI: 10.1097/mib.0000000000001123] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) are in general prone to weight loss. We explored the risk of inadequate gestational weight gain (GWG), and the impact of GWG on adverse pregnancy outcomes, among mothers with IBD in the Norwegian Mother and Child Cohort Study (MoBa). METHODS The MoBa with 95,200 mothers enrolled from 1999 to 2008, comprised 217 mothers with ulcerative colitis and 166 with Crohn's disease. Demographics were ascertained through a basic questionnaire before the first ultrasound visit and an IBD history and disease activity during pregnancy through a questionnaire mailed out in 2013. Inadequate GWG was based on the US Institute of Medicine recommendations. The associations between IBD and inadequate GWG or adverse pregnancy outcomes were explored, adjusted for diabetes, hypertension, smoking, maternal age, education, and disease activity. RESULTS Mothers with Crohn's disease (34.3%) and ulcerative colitis (26.7%) were more frequently exposed to inadequate GWG compared with non-IBD mothers (19.4%) (adjusted odds ratio [aOR] = 2.02, 95% confidence interval [CI], 1.42-2.86 and aOR = 1.46, 95% CI, 1.04-2.05, respectively). Mothers with IBD with inadequate GWG (exposed) had a 2-fold risk of small for gestational age infants compared with exposed non-IBD mothers (aOR = 1.93, 95% CI, 1.13-3.29). Exposed mothers with Crohn's disease and ulcerative colitis had a several-fold increased risk of small for gestational age compared with nonexposed IBD mothers (aOR = 4.5, 95% CI, 1.3-16.2, aOR = 5.5, 95% CI, 1.6-18.5). Disease activity was associated with reduced GWG (<13 kg compared with >17.5 kg) (aOR = 3.34, 95% CI, 1.33-8.38). CONCLUSIONS Inadequate GWG should be considered as a risk factor for adverse pregnancy outcomes or as a marker of disease activity.
Collapse
|
46
|
Kammerlander H, Nielsen J, Kjeldsen J, Knudsen T, Friedman S, Nørgård B. The Effect of Disease Activity on Birth Outcomes in a Nationwide Cohort of Women with Moderate to Severe Inflammatory Bowel Disease. Inflamm Bowel Dis 2017; 23:1011-1018. [PMID: 28346274 DOI: 10.1097/mib.0000000000001102] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Active inflammatory bowel disease (IBD) during conception and pregnancy may increase the risk of adverse birth outcomes. Former studies have examined heterogeneous groups of women with varying degrees of IBD severity. We aimed to examine the effect of active IBD on birth outcomes in a more homogeneous group of women with a moderate to severe disease course. Since in Denmark, moderate to severe IBD is an indication for use of anti-tumor necrosis factor-α therapy, we examined all women who used anti-tumor necrosis factor therapy during pregnancy. METHODS We identified a nationwide cohort of 219 singleton pregnancies in women treated with anti-tumor necrosis factor-α therapy during pregnancy (2005-2014). Pregnancies with clinical disease activity (65.8%) constituted the exposed cohort and pregnancies without disease activity constituted the unexposed (34.2%). Disease activity scores were supported by levels of fecal calprotectin. Outcomes included low birth weight, preterm birth, and congenital anomalies. RESULTS In women with IBD, disease activity was associated with adjusted odds ratio of low birth weight and preterm birth; 2.05 (95% confidence interval, 0.37-11.35) and 2.64 (95% confidence interval, 0.85-8.17), respectively. In those with clinical moderate to severe disease activity, the odds ratio for preterm birth was 3.60 (95% confidence interval, 1.14-11.36). In women with ulcerative colitis and disease activity, 19.5% had a child with low birth weight and 29.3% gave birth preterm. CONCLUSION In women with moderate to severe IBD, 66% experienced disease activity during pregnancy. In those with the highest degree of disease activity, the risk of preterm birth was increased 3 to 4 folds. The proportion of adverse birth outcomes was high, particularly among women with ulcerative colitis and disease activity.
Collapse
Affiliation(s)
- Heidi Kammerlander
- *Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark; †Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark; ‡Department of Medical Gastroenterology, Hospital of Southwest Jutland, Esbjerg, Denmark; and §Crohn's and Colitis Center, Brigham and Women's Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | |
Collapse
|
47
|
Poturoglu S, Ormeci AC, Duman AE. Treatment of pregnant women with a diagnosis of inflammatory bowel disease. World J Gastrointest Pharmacol Ther 2016; 7:490-502. [PMID: 27867682 PMCID: PMC5095568 DOI: 10.4292/wjgpt.v7.i4.490] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/18/2016] [Accepted: 09/22/2016] [Indexed: 02/06/2023] Open
Abstract
The frequency of diagnosis of inflammatory bowel disease (IBD) has increased in younger populations. For this reason, pregnancy in patients with IBD is a topic of interest, warranting additional focus on disease management during this period. The main objective of this article is to summarize the latest findings and guidelines on the management of potential problems from pregnancy to the breastfeeding stage. Fertility is decreased in patients with active IBD. Disease remission prior to conception will likely decrease the rate of pregnancy-related complications. Most of the drugs used for IBD treatment are safe during both pregnancy and breastfeeding. Two exceptions are methotrexate and thalidomide, which are contraindicated in pregnancy. Anti-tumor necrosis factor agents are not advised during the third trimester as they exhibit increased transplacental transmission and potentially cause immunosuppression in the fetus. Radiological and endoscopic examinations and surgical interventions should be performed only when absolutely necessary. Surgery increases the fetal mortality rate. The delivery method should be determined with consideration of the disease site and presence of progression or flare up. Treatment planning should be a collaborative effort among the gastroenterologist, obstetrician, colorectal surgeon and patient.
Collapse
|
48
|
Freud A, Beharier O, Walfisch A, Sergienko R, Landau D, Sheiner E. Maternal Inflammatory Bowel Disease During Pregnancy is Not a Risk Factor for Long-term Morbidity of the Offspring. J Crohns Colitis 2016; 10:1267-1272. [PMID: 27085078 DOI: 10.1093/ecco-jcc/jjw083] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 04/11/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS To investigate whether offspring of women suffering from inflammatory bowel disease [IBD] during their pregnancy are at an increased risk for long-term paediatric morbidity. METHODS In this population-based cohort study, we investigated the incidence of long-term [up to the age of 18 years] hospitalizations due to cardiovascular, endocrine, neurological, haematological, respiratory, gastrointestinal, and urinary paediatric morbidities of offspring of mothers affected by IBD during their pregnancy. Deliveries occurred between the years 1991 and 2014 in a regional tertiary medical centre. Newborns with congenital malformations as well as multiple pregnancies were excluded from the study. RESULTS During the study period, 255 352 deliveries met the inclusion criteria; 278 offspring were born to mothers with IBD. During the follow-up period, children born to mothers with IBD did not have an increased risk for long-term [up to the age of 18 years] morbidity compared with the control group. CONCLUSION Maternal IBD during pregnancy is not a risk factor for long-term paediatric morbidity of the offspring.
Collapse
Affiliation(s)
- Amir Freud
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ofer Beharier
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Asnat Walfisch
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ruslan Sergienko
- Epidemiology and Health Services Evaluation, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Daniella Landau
- Department of Pediatrics, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| |
Collapse
|
49
|
Pinder M, Lummis K, Selinger CP. Managing inflammatory bowel disease in pregnancy: current perspectives. Clin Exp Gastroenterol 2016; 9:325-335. [PMID: 27789969 PMCID: PMC5072556 DOI: 10.2147/ceg.s96676] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Inflammatory bowel disease (IBD) affects many women of childbearing age. The course of IBD is closely related to pregnancy outcomes with poorly controlled IBD increasing the risk of prematurity, low weight for gestation, and fetal loss. As such, women with IBD face complex decision making weighing the risks of active disease versus those of medical treatments. This review summarizes the current evidence regarding the safety and efficacy of IBD treatments during pregnancy and lactation aiming to provide up-to-date guidance for clinicians. Over 50% of women have poor IBD- and pregnancy-related knowledge, which is associated with views contrary to medical evidence and voluntary childlessness. This review highlights the effects of poor patient knowledge and critically evaluates interventions for improving patient knowledge and outcomes.
Collapse
Affiliation(s)
- Matthew Pinder
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust
| | - Katie Lummis
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust
| | - Christian P Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust; University of Leeds, Leeds, UK
| |
Collapse
|
50
|
Selinger CP, Ghorayeb J, Madill A. What Factors Might Drive Voluntary Childlessness (VC) in Women with IBD? Does IBD-specific Pregnancy-related Knowledge Matter? J Crohns Colitis 2016; 10:1151-8. [PMID: 26989194 DOI: 10.1093/ecco-jcc/jjw078] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 03/12/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Inflammatory Bowel Disease (IBD) affects many women of childbearing age, and rates of voluntary childlessness (VC) exceed those of the general population by far. The factors surrounding VC remain incompletely understood. METHODS Female members of the patient organisation Crohn's and Colitis UK aged 18-45 years were invited to complete an online questionnaire collecting data on demographics, disease characteristics, Crohn's and Colitis pregnancy-specific disease-related knowledge (CCPKnow), and childlessness status. RESULTS A total of 1324 women (mean age 33 years) completed the survey: 776 (59%) were diagnosed with Crohn's disease (CD), 496 (38%) with ulcerative colitis (UC) and 4% with inflammatory bowel disease-unclassified (IBD-U); 40% had children (14% pre-diagnosis (I); 26% post-diagnosis (II)), 36% planned to have children at some stage (III), 7% reported fertility problems (IV), and 17% were classified as voluntarily childless (VC). VC was associated with poorer CCPKnow scores [5.98 vs. 7.47 in (III); p < 0.001], older age [35 years old vs. 28 years old in (II); p < 0.001], unemployment (9.7% VC; p < 0.001), being single (34.5% VC; p < 0.001) not seeking medical advice (p < 0.001), and diagnosis of CD (19.3% vs. 13.9% UC; p = 0.015). Women with VC had more hospital admissions [mean 2.85 vs. 2.17 (III); p = 0.03] and surgical interventions [mean 1.27 vs. 0.65 (III); p < 0.001] CONCLUSION The aetiology of VC in women with IBD is multifactorial. Women's choice regarding children appears related to disease burden. VC is also associated with poor knowledge (CCPKnow), and women may stay childless unnecessarily. Patient education programmes could help to reduce the rate of VC in women with IBD, through correcting misconceptions and alleviating patient concerns.
Collapse
Affiliation(s)
| | | | - Anna Madill
- School of Psychology, University of Leeds, Leeds, UK
| |
Collapse
|