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Zhang X, Wu X, Chen L, He L. Autoimmune diseases and risk of gestational diabetes mellitus: a Mendelian randomization study. Acta Diabetol 2024; 61:161-168. [PMID: 37804336 DOI: 10.1007/s00592-023-02190-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 09/14/2023] [Indexed: 10/09/2023]
Abstract
AIMS Observational studies have reported that autoimmune diseases are associated with gestational diabetes mellitus (GDM), but the causality is unknown. The study aimed to evaluate the potential causal effect of autoimmune diseases on GDM. METHODS A two-sample Mendelian randomization (MR) study was designed using the summary statistics of GDM (123,579 individuals) and three common autoimmune diseases, including inflammatory bowel disease (IBD, 59,957 individuals), rheumatoid arthritis (RA, 80,799 individuals) and systemic lupus erythematosus (SLE, 14,267 individuals), from the genome-wide association study (GWAS). The fixed-effects inverse variance weighted (IVW) was used to deduce the causal association between autoimmune diseases and GDM, and sensitivity analyses were further performed. RESULTS The inverse variance weighting (IVW) method showed that RA and SLE increased the risk of GDM (RA: OR = 1.076, 95%CI = 1.033-1.122, P = 4.649E-04; SLE: OR = 1.025, 95%CI = 1.001-1.049, P = 0.044). But there were no any associations of IBD with GDM (P > 0.05). No significant horizontal pleiotropy was found by MR Egger regression (IBD: P for intercept = 0.905; RA: P for intercept = 0.103; SLE = P for intercept = 0.608). CONCLUSION This two-sample MR study found that both SLE and RA are positively associated with the risk of GDM. Our findings provide help for the future prevention and treatment of GDM to reduce associated maternal and fetal complications. However, more research is needed to obviate the role of the GC and the HCQ to ensure this relationship is causal.
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Affiliation(s)
- Xia Zhang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Obstetrics and Gynecology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Xiuyan Wu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Obstetrics and Gynecology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Lihong Chen
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Obstetrics and Gynecology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Lidan He
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
- Department of Obstetrics and Gynecology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China.
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2
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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.
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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
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3
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Genest G, Banjar S, Almasri W, Beauchamp C, Benoit J, Buckett W, Dzineku F, Gold P, Dahan MH, Jamal W, Jacques Kadoch I, Kadour-Peero E, Lapensée L, Miron P, Shaulov T, Sylvestre C, Tulandi T, Mazer BD, Laskin CA, Mahutte N. Immunomodulation for unexplained recurrent implantation failure: where are we now? Reproduction 2023; 165:R39-R60. [PMID: 36322478 DOI: 10.1530/rep-22-0150] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 11/02/2022] [Indexed: 11/05/2022]
Abstract
In brief Immune dysfunction may contribute to or cause recurrent implantation failure. This article summarizes normal and pathologic immune responses at implantation and critically appraises currently used immunomodulatory therapies. Abstract Recurrent implantation failure (RIF) may be defined as the absence of pregnancy despite the transfer of ≥3 good-quality blastocysts and is unexplained in up to 50% of cases. There are currently no effective treatments for patients with unexplained RIF. Since the maternal immune system is intricately involved in mediating endometrial receptivity and embryo implantation, both insufficient and excessive endometrial inflammatory responses during the window of implantation are proposed to lead to implantation failure. Recent strategies to improve conception rates in RIF patients have focused on modulating maternal immune responses at implantation, through either promoting or suppressing inflammation. Unfortunately, there are no validated, readily available diagnostic tests to confirm immune-mediated RIF. As such, immune therapies are often started empirically without robust evidence as to their efficacy. Like other chronic diseases, patient selection for immunomodulatory therapy is crucial, and personalized medicine for RIF patients is emerging. As the literature on the subject is heterogenous and rapidly evolving, we aim to summarize the potential efficacy, mechanisms of actions and side effects of select therapies for the practicing clinician.
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Affiliation(s)
- Geneviève Genest
- Department of Allergy and Immunology, McGill University, Montreal Quebec, Canada
| | - Shorooq Banjar
- Department of Allergy and Immunology, McGill University, Montreal Quebec, Canada
| | - Walaa Almasri
- Department of Allergy and Immunology, McGill University, Montreal Quebec, Canada
| | - Coralie Beauchamp
- Department of Gynaecology, University of Montreal, Montreal, Quebec, Canada
| | - Joanne Benoit
- Department of Gynaecology, University of Montreal, Montreal, Quebec, Canada
| | - William Buckett
- McGill University Health Centre Reproductive Centre, Montreal, Quebec, Canada
| | | | - Phil Gold
- Department of Allergy and Immunology, McGill University, Montreal Quebec, Canada
| | - Michael H Dahan
- Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montreal, Quebec, Canada
| | - Wael Jamal
- Department of Gynaecology, University of Montreal, Montreal, Quebec, Canada
| | | | - Einav Kadour-Peero
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
| | - Louise Lapensée
- Department of Gynaecology, University of Montreal, Montreal, Quebec, Canada
| | - Pierre Miron
- Fertilys Reproductive Center, Laval, Quebec, Canada
| | - Talya Shaulov
- Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montreal, Quebec, Canada
| | - Camille Sylvestre
- Division of Reproductive Endocrinology and Infertility, University of Montreal, Montreal, Quebec, Canada
| | - Togas Tulandi
- Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montreal, Quebec, Canada
| | - Bruce D Mazer
- Department of Pediatrics, McGill University, Division of Allergy Immunology and Clinical Dermatology, Montreal Children's Hospital, McGill University, Montréal, Quebec, Canada
| | - Carl A Laskin
- Deptartments of Medicine and Obstetrics & Gynecology University of Toronto, Toronto, Ontario, Canada
| | - Neal Mahutte
- The Montreal Fertility Centre, Montreal, Quebec, Canada
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4
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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.
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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:
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5
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A national study of pregnancy-related maternal and fetal outcomes in women with inflammatory bowel disease. Int J Colorectal Dis 2022; 37:1535-1543. [PMID: 35612619 DOI: 10.1007/s00384-022-04185-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS The incidence of inflammatory bowel disease (IBD) among women is highest during their reproductive years and current estimates suggest that the rate of conception is low in female IBD patients. The aim of our study was to assess the burden of adverse maternal and perinatal outcomes among female IBD patients. METHODS Using the national inpatient sample database from 2016 to 2018, we recruited all female patients above the age of 15 years admitted with a primary diagnosis of pregnancy and a secondary diagnosis of IBD. We adjusted our results for hospital and patient level variables including age, race, socioeconomic status, hypertension, diabetes mellitus, obesity, smoking, hyperlipidemia, alcohol use, and malnutrition. Multivariable regression analysis was used for analysis. RESULTS Pregnant women with IBD had greater odds of gestational diabetes (adjusted odds ratio [AOR] 1.55, 95% confidence interval [CI] 1.04-2.3, p 0.02), hypertensive complications (AOR 1.35, 95% CI 1.06-1.72, p 0.01), and pre-term delivery (AOR, 1.41 95% CI 1.13-1.76, p 0.003). Pregnancies with co-existent IBD were associated with fetal growth restriction (AOR 1.27, 95% CI 1-1.63, p 0.04) and fetal death (AOR 3.21, 95% CI 1.72-6.00, p < 0.01). Odds of experiencing postpartum hemorrhage or large for gestational age infant were comparable to general population. Crohn's disease was independently associated with increased odds of worse maternal and fetal outcome. IBD patients had increased mean length of stay by 0.14 days and increased mean hospital charges of $2741. CONCLUSIONS Women with IBD had greater likelihood of poor maternal and fetal outcomes and increased hospital resource utilization.
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Chugh R, Gaidos JKJ. Fertility and Pregnancy in Crohn's Disease. Gastroenterol Clin North Am 2022; 51:381-399. [PMID: 35595421 DOI: 10.1016/j.gtc.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The prevalence of inflammatory bowel disease is continuing to increase worldwide and is more commonly diagnosed in women of reproductive age. Individuals with Crohn's disease may have inaccurate perceptions regarding the rate of infertility, heritability, and the safety of taking therapies for Crohn's disease during pregnancy, all of which greatly affect their decisions surrounding family planning. Given this area of need for both patients and providers, in this article, we have included the latest evidence on the impact of Crohn's disease on fertility, heritability, pregnancy outcomes, and the safety of medications for Crohn's disease during pregnancy and lactation.
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Affiliation(s)
- Rishika Chugh
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA; Gastroenterology, Department of Medicine, University of California San Francisco, 1701 Divisadero, San Francisco, CA 94115, USA
| | - Jill K J Gaidos
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA; Section of Digestive Diseases, Yale Inflammatory Bowel Disease Program, 40 Temple Street, Suite 1C, New Haven, CT 06510, USA.
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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.
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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
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8
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Tandon P, Lee EY, Maxwell C, Hitz L, Ambrosio L, Dieleman L, Halloran B, Kroeker K, Huang VM. Fecal Calprotectin May Predict Adverse Pregnancy-Related Outcomes in Patients with Inflammatory Bowel Disease. Dig Dis Sci 2021; 66:1639-1649. [PMID: 32533542 DOI: 10.1007/s10620-020-06381-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/30/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The role of fecal calprotectin in predicting pregnancy-related outcomes in inflammatory bowel disease (IBD) remains unknown. AIM To determine whether increased fecal calprotectin during pregnancy is associated with adverse pregnancy outcomes in IBD. METHODS This is a multicenter cohort study of women with IBD who underwent fecal calprotectin monitoring during pregnancy. Fecal calprotectin levels were stratified by trimester, and adverse pregnancy-related outcomes were recorded. The Mann-Whitney U test assessed differences between continuous variables, whereas categorical variables were compared using the Chi-squared test. RESULTS Eighty-five women with IBD were included. First trimester fecal calprotectin was higher in patients who underwent emergency Cesarean birth compared to those who had a vaginal delivery (503 ug/g, IQR 1554.3 ug/g vs. 130 ug/g, IQR 482 ug/g, p = .030, respectively) and in those who delivered infants with low birth weight compared to normal birth weight (1511 ug/g, IQR 579 ug/g vs. 168 ug/g, IQR 413 ug/g, p = .049, respectively). Third trimester fecal calprotectin was higher in those with non-elective induction of labor (334.5 ug/g, IQR 1411.0 ug/g) compared to those with spontaneous delivery (116.5 ug/g, IQR 227.1 ug/g) (p = .025). Those with a fecal calprotectin ≥ 250 ug/g in the second trimester had an increased incidence of infants with low birth weight (35.3% vs. 3.8%) (p = .049), whereas those with a fecal calprotectin ≥ 250 ug/g in the third trimester had an increased incidence of non-elective induction of labor (43.8% vs. 10.3%, p = .030). CONCLUSIONS Fecal calprotectin may be a useful noninvasive marker to predict adverse pregnancy-related outcomes in patients with IBD.
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Affiliation(s)
- Parul Tandon
- Division of Gastroenterology, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441-600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Department of Medicine, University of Toronto, 441-600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Eugenia Y Lee
- Department of Medicine, University of Toronto, 441-600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynaecology, University of Toronto, 901-700 University Avenue, Toronto, ON, M5G 1Z5, Canada
| | - Lara Hitz
- Division of Gastroenterology, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441-600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Lindsy Ambrosio
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Levinus Dieleman
- Division of Gastroenterology, University of Alberta, 2-24A Zeidler Building, Edmonton, AB, T6G 2X8, Canada
| | - Brendan Halloran
- Division of Gastroenterology, University of Alberta, 130 University Campus NW, Edmonton, AB, T6G 2X8, Canada
| | - Karen Kroeker
- Division of Gastroenterology, University of Alberta, 8540 112th Street NW, Edmonton, AB, T6G 2X8, Canada
| | - Vivian M Huang
- Division of Gastroenterology, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441-600 University Avenue, Toronto, ON, M5G 1X5, Canada. .,Department of Medicine, University of Toronto, 441-600 University Avenue, Toronto, ON, M5G 1X5, Canada.
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Palmsten K, Bredesen D, JaKa MM, Kumar PC, Ziegenfuss JY, Kharbanda EO. "I know my body better than you:" patient focus groups to inform a decision aid on oral corticosteroid use during pregnancy. Pharmacoepidemiol Drug Saf 2021; 30:451-461. [PMID: 33314542 PMCID: PMC8686489 DOI: 10.1002/pds.5183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 12/07/2020] [Indexed: 01/03/2023]
Abstract
PURPOSE There is unmet need for decision support regarding medication use during pregnancy. We aimed to inform the development of a decision aid on oral corticosteroid (OCS) use during pregnancy through focus groups. METHODS We invited patients from one health system who had a recent live birth and a condition for which OCSs may be prescribed (ie, asthma or other autoimmune disease) to participate in focus groups. We conducted conventional qualitative content analysis of verbatim transcripts of the focus groups using inductive coding. RESULTS There were 30 participants across five focus groups from May to June 2019. Women endorsed the need for patient-provider discussions about OCS use during pregnancy in which the provider shares risks and benefits and the patient makes her decision. Furthermore, women generally expressed support for patient-centered handouts about OCS use during pregnancy that the provider discusses with the patient. When considering whether to take OCSs in pregnancy, women had concerns about: the medication's impact on their baby (eg, miscarriage, birth defects, long-term effects), themselves (eg, effects on mood, sleep, weight gain), pregnancy complications (eg, preterm birth, increased blood pressure), and lactation. Women wanted information on OCSs (eg, indications, length of treatment, and cost), alternative treatments, and risks of not taking OCSs. CONCLUSIONS We established patient need for a decision aid on OCS use during pregnancy that providers can discuss with patients. To address patient concerns, the aid should at a minimum describe the medication's impact on baby, including long-term effects, maternal health, pregnancy complications, and lactation.
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10
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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.
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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
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11
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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: 24] [Impact Index Per Article: 8.0] [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.
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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
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12
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Clark-Snustad K, Butnariu M, Afzali A. Women's Health and Ulcerative Colitis. Gastroenterol Clin North Am 2020; 49:769-789. [PMID: 33121695 DOI: 10.1016/j.gtc.2020.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Although ulcerative colitis affects males and females at similar rates, certain sex-specific differences influence the disease-related risks and experiences of females with ulcerative colitis. This article reviews topics that affect females with ulcerative colitis, including the impact of disease on the menstrual cycle, fertility, child bearing, sexual health, and recommendations for health care maintenance.
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Affiliation(s)
- Kindra Clark-Snustad
- Inflammatory Bowel Disease Program, Division of Gastroenterology, University of Washington, 1959 Northeast Pacific Street, Box 356424, Seattle, WA 98195, USA
| | - Madalina Butnariu
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 410 W. 10(th) Ave. 2(nd) floor, Columbus, OH 43210, USA
| | - Anita Afzali
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 West 12(th) Avenue, Room 280, Columbus, OH 43210, USA.
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13
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Goodman WA, Erkkila IP, Pizarro TT. Sex matters: impact on pathogenesis, presentation and treatment of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol 2020; 17:740-754. [PMID: 32901108 PMCID: PMC7750031 DOI: 10.1038/s41575-020-0354-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2020] [Indexed: 02/08/2023]
Abstract
Inflammatory bowel disease (IBD), as do most chronic inflammatory disorders, displays unique features and confers different risk factors in male and female patients. Importantly, sex-based differences in IBD exist for epidemiological incidence and prevalence among different age groups, with men and women developing distinct clinical symptoms and disparity in severity of disease. In addition, the presentation of comorbidities in IBD displays strong sex differences. Notably, particular issues exclusive to women's health, including pregnancy and childbirth, require specific considerations in female patients with IBD of childbearing age that can have a substantial influence on clinical outcomes. This Review summarizes the latest findings regarding sex-based differences in the epidemiology, clinical course, comorbidities and response to current therapies in patients with IBD. Importantly, the latest basic science discoveries in this area of investigation are evaluated to provide insight into potential mechanisms underlying the influence of sex on disease pathogenesis, as well as to design more personalized and efficacious care, in patients with IBD.
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Affiliation(s)
- Wendy A Goodman
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Ian P Erkkila
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Theresa T Pizarro
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
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14
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Lavie I, Lavie M, Doyev R, Fouks Y, Azem F, Yogev Y. Pregnancy outcomes in women with inflammatory bowel disease who successfully conceived via assisted reproduction technique. Arch Gynecol Obstet 2020; 302:611-618. [PMID: 32529298 DOI: 10.1007/s00404-020-05644-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/08/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Women with inflammatory bowel disease (IBD) have an increased risk for adverse pregnancy outcome, so as women using assisted reproduction technology (ART). However, data are scarce regarding the risk imposed by the combination of both. Thus, we aimed to assess pregnancy outcome in these women. METHODS A retrospective case-control study, of women with IBD who conceived using ART due to female infertility. The study group (IBD-ART) was matched using propensity score and compared in a 1:1 ratio with three control groups, IBD patients who conceived spontaneously (IBD-SP), women using ART (H-ART) and women who conceived spontaneously (H-SP). RESULTS The study group comprised of 49 women with IBD conceived via ART that gave birth at our center during the study period. All studied groups did not differ in demographics and obstetric characteristics. IBD groups (both ART and spontaneous) were comparable in disease status prior and throughout pregnancy. Maternal outcome showed no difference regarding preterm birth and pregnancy complications among all studied groups. Women in the IBD-ART group had decreased rates of vaginal delivery (34.7% vs 57.1%, p = 0.032) and higher rates of elective CS (32.7% vs 14.3%, p = 0.048) in comparison to H-SP group, but comparable rates to both IBD-SP and H-ART groups. Neonatal outcomes were comparable among all studied groups. In a sub-analysis by disease type, a higher rate of gestational diabetes was found among ulcerative colitis patients using ART (29.4% Crohn's vs 6.1% UC, p = 0.025). CONCLUSION Patients with IBD undergoing ART have comparable pregnancy outcome to women using ART and to patients with IBD with spontaneous pregnancy.
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Affiliation(s)
- Inbar Lavie
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michael Lavie
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel. .,Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Weizman 6 St, Tel-Aviv, Israel.
| | - Reut Doyev
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Weizman 6 St, Tel-Aviv, Israel
| | - Yuval Fouks
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Weizman 6 St, Tel-Aviv, Israel
| | - Foad Azem
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Weizman 6 St, Tel-Aviv, Israel
| | - Yariv Yogev
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Weizman 6 St, Tel-Aviv, Israel
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15
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Singh S, Picardo S, Seow CH. Management of Inflammatory Bowel Diseases in Special Populations: Obese, Old, or Obstetric. Clin Gastroenterol Hepatol 2020; 18:1367-1380. [PMID: 31712084 PMCID: PMC7183892 DOI: 10.1016/j.cgh.2019.11.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/25/2019] [Accepted: 11/04/2019] [Indexed: 02/07/2023]
Abstract
The epidemiology of inflammatory bowel disease (IBD) is progressively evolving impacting the type of patients with IBD we will see in clinical practice. In this review, we discuss specific challenges and solutions in the management of (1) obese, (2) older and (3) obstetric (pregnant) patients with IBD. With the global obesity epidemic, almost 1 in 3 patients with IBD are obese. Obesity is associated with greater difficulty in achieving remission, higher risk of disease relapse and higher burden and costs of hospitalization in patients with IBD. Obese patients also have inferior response to biologic therapy related to altered pharmacokinetics and obesity-mediated chronic inflammation. Surgical management of obese patients with IBD is also challenging. Similar to obesity, the prevalence of IBD in older patients is rising and it is anticipated that almost one-third of patients with IBD will be older than 60 years within the next decade. Older patients present unique diagnostic and therapeutic dilemmas, and management of these individuals warrants careful consideration of the risks of disease-related versus treatment-related complications, non-IBD-related extra-intestinal complications (eg, cardiovascular disease, malignancy), in the context of individual values, preferences, functional status and comorbidities. With evolving therapeutics, medical management of IBD surrounding pregnancy continues to be challenging. Overall, the management of pregnant patients requires a pro-active, multidisciplinary approach, with an emphasis on optimal disease control not just during, but prior to pregnancy. This often involves continuation of highly effective therapies, of which the vast majority are safe during pregnancy and breastfeeding, resulting in a reduction of risk of adverse maternal fetal outcomes.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, University of California San Diego, La Jolla, California.
| | - Sherman Picardo
- Inflammatory Bowel Disease Centre, Department of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H. Seow
- Inflammatory Bowel Disease Centre, Department of Gastroenterology, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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16
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Tandon P, Govardhanam V, Leung K, Maxwell C, Huang V. Systematic review with meta-analysis: risk of adverse pregnancy-related outcomes in inflammatory bowel disease. Aliment Pharmacol Ther 2020; 51:320-333. [PMID: 31912546 DOI: 10.1111/apt.15587] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/19/2019] [Accepted: 10/28/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The effect of inflammatory bowel disease (IBD) on pregnancy-related outcomes remains unknown. AIM To determine the risk of adverse maternal, placental and obstetric outcomes in IBD METHODS: We searched Medline, Embase and Cochrane library through May 2019 for studies reporting adverse maternal, placental and obstetric outcomes in patients with IBD. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for these outcomes in patients with IBD compared to healthy controls. RESULTS Fifty-three studies were included (7917 IBD pregnancies and 3253 healthy control pregnancies). Caesarean delivery was more common in patients with IBD compared to healthy controls (OR 1.79, 95% CI, 1.16-2.77). This remained significant for UC (OR 1.80, 95% CI, 1.21-2.90) but not CD (OR 1.48, 95% CI, 0.94-2.34). Similarly, gestational diabetes occurred more commonly in IBD (OR 2.96, 95% CI, 1.47-5.98). The incidences of placental diseases were 2.0% (95% CI, 0.9%-3.1%) for pre-eclampsia, 3.3% (95% CI, 0%-7.2%) for placental abruption, 0.5% (95% CI, 0.2%-0.9%) for placenta previa and 0.3% (95% CI, 0%-0.5%) for chorioamnionitis. Patients with IBD were more likely to experience preterm prelabour rupture of membranes (OR 12.10, 95% CI, 2.15-67.98), but not early pregnancy loss (OR 1.63, 95% CI 0.49-5.43). Anti-tumour necrosis factor therapy was not associated with chorioamnionitis (OR 1.12, 95% CI, 0.16-7.67), early pregnancy loss (OR 1.49, 95% CI, 0.83-2.64) or placenta previa (OR 1.58, 95% CI, 0.30-8.47). CONCLUSIONS Gestational diabetes and preterm prelabour rupture of membranes occurs more commonly in patients with IBD, although the incidence of placental diseases remains low.
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Affiliation(s)
- Parul Tandon
- Division of Gastroenterology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Kristel Leung
- Division of Gastroenterology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Vivian Huang
- Division of Gastroenterology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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17
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Lenti MV, Armuzzi A, Castiglione F, Fantini MC, Fiorino G, Orlando A, Pugliese D, Rizzello F, Vecchi M, Di Sabatino A. Are we choosing wisely for inflammatory bowel disease care? The IG-IBD choosing wisely campaign. Dig Liver Dis 2020; 52:44-50. [PMID: 31648921 DOI: 10.1016/j.dld.2019.09.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 09/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The "Choosing Wisely" campaigns have the aim of promoting a better clinician-patient relationship. AIMS The Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) conducted a choosing wisely campaign for IBD. METHODS Ten IG-IBD panellists conducted the campaign through a modified Delphi process. All IG-IBD members were asked to submit five statements starting with "Do not…" addressing any IBD-related procedure or treatment the necessity of which should be questioned. All recommendations were evaluated by the panellists who prioritised each item. The top ten recommendations were prioritised again by IG-IBD members, and the top five recommendations were identified. RESULTS 110 members (mean age 42 ± 12; 62 males) participated in the campaign. The top five recommendations were as follow: 1. Do not use corticosteroids for maintenance therapy, or without a clear indication; 2. Do not forget venous thromboembolism prophylaxis in hospitalised patients with active disease; 3. Do not treat perianal Crohn's disease with biologics without prior surgical evaluation; 4. Do not discontinue IBD-related medications during pregnancy unless specifically indicated; 5. Do not delay surgery. CONCLUSION The IG-IBD promoted a campaign with a bottom-up approach, identifying five recommendations that could be useful for providing a better IBD care, especially among non-IBD experts.
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Affiliation(s)
- Marco Vincenzo Lenti
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy.
| | - Alessandro Armuzzi
- IBD Unit, Presidio Columbus, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fabiana Castiglione
- Gastroenterology, Department of Clinical Medicine and Surgery, University Federico II of Naples, Naples, Italy
| | | | - Gionata Fiorino
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, Humanitas University, Rozzano, Italy
| | | | - Daniela Pugliese
- IBD Unit, Presidio Columbus, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fernando Rizzello
- Department of Internal Medicine and Gastroenterology, University of Bologna, Bologna, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Antonio Di Sabatino
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
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18
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Shannahan SE, Erlich JM, Peppercorn MA. Insights into the treatment of inflammatory bowel disease in pregnancy. Therap Adv Gastroenterol 2019; 12:1756284819852231. [PMID: 31191713 PMCID: PMC6540496 DOI: 10.1177/1756284819852231] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/17/2019] [Indexed: 02/04/2023] Open
Abstract
Patients diagnosed with inflammatory bowel disease (IBD) are most commonly diagnosed in late adolescence or early adulthood, with half of patients being diagnosed before age 32, thus impacting peak years of reproduction and family planning. While controlled IBD has no negative effects on the ability to conceive, there is overall a trend towards voluntary childlessness due to patients' concerns for adverse fetal outcomes from underlying IBD and from adverse medication effects. Active disease at the time of conception is associated with worsening disease activity during pregnancy and carries a higher risk of poor fetal outcomes. It is therefore important to maintain remission during pregnancy, which is often achieved with pharmacologic therapy. The goal of this paper is to provide a comprehensive review of the current literature and safety data for pharmacologic treatment of IBD in pregnancy, in breastfeeding women, and in men planning to have children.
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Affiliation(s)
- Sarah E. Shannahan
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jonathan M. Erlich
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mark A. Peppercorn
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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19
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Mahadevan U, Robinson C, Bernasko N, Boland B, Chambers C, Dubinsky M, Friedman S, Kane S, Manthey J, Sauberan J, Stone J, Jain R. Inflammatory Bowel Disease in Pregnancy Clinical Care Pathway: A Report From the American Gastroenterological Association IBD Parenthood Project Working Group. Gastroenterology 2019; 156:1508-1524. [PMID: 30658060 DOI: 10.1053/j.gastro.2018.12.022] [Citation(s) in RCA: 200] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Uma Mahadevan
- University of California, San Francisco, San Francisco, California
| | - Christopher Robinson
- Bon Secours St Francis and Summerville Medical Center, Charleston, South Carolina
| | - Nana Bernasko
- Penn State Health, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | | | - Marla Dubinsky
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Jacob Manthey
- American Gastroenterological Association, Bethesda, Maryland
| | - Jason Sauberan
- Sharp Neonatal Research Institute, San Diego, California
| | - Joanne Stone
- Icahn School of Medicine at Mount Sinai, New York, New York
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20
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Mahadevan U, Robinson C, Bernasko N, Boland B, Chambers C, Dubinsky M, Friedman S, Kane S, Manthey J, Sauberan J, Stone J, Jain R. Inflammatory Bowel Disease in Pregnancy Clinical Care Pathway: A Report From the American Gastroenterological Association IBD Parenthood Project Working Group. Am J Obstet Gynecol 2019; 220:308-323. [PMID: 30948039 DOI: 10.1016/j.ajog.2019.02.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Uma Mahadevan
- University of California, San Francisco, San Francisco, California
| | - Christopher Robinson
- Bon Secours St Francis and Summerville Medical Center, Charleston, South Carolina
| | - Nana Bernasko
- Penn State Health, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | | | - Marla Dubinsky
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Jacob Manthey
- American Gastroenterological Association, Bethesda, Maryland
| | - Jason Sauberan
- Sharp Neonatal Research Institute, San Diego, California
| | - Joanne Stone
- Icahn School of Medicine at Mount Sinai, New York, New York
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21
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Mahadevan U, Robinson C, Bernasko N, Boland B, Chambers C, Dubinsky M, Friedman S, Kane S, Manthey J, Sauberan J, Stone J, Jain R. Inflammatory Bowel Disease in Pregnancy Clinical Care Pathway: A Report From the American Gastroenterological Association IBD Parenthood Project Working Group. Inflamm Bowel Dis 2019; 25:627-641. [PMID: 30821832 DOI: 10.1093/ibd/izz037] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Uma Mahadevan
- University of California, San Francisco, San Francisco, California
| | - Christopher Robinson
- Bon Secours St Francis and Summerville Medical Center, Charleston, South Carolina
| | - Nana Bernasko
- Penn State Health, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | | | - Marla Dubinsky
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Jacob Manthey
- American Gastroenterological Association, Bethesda, Maryland
| | - Jason Sauberan
- Sharp Neonatal Research Institute, San Diego, California
| | - Joanne Stone
- Icahn School of Medicine at Mount Sinai, New York, New York
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22
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Bitencourt N, Bermas BL. Pharmacological Approach to Managing Childhood-Onset Systemic Lupus Erythematosus During Conception, Pregnancy and Breastfeeding. Paediatr Drugs 2018; 20:511-521. [PMID: 30175398 DOI: 10.1007/s40272-018-0312-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pediatric patients often have poor pregnancy outcomes. Systemic lupus erythematosus predominantly impacts women in their second to fourth decade of life, with childhood-onset disease being particularly aggressive. Reproductive issues are an important clinical consideration for pediatric patients with systemic lupus erythematosus (SLE), as maintaining good disease control and planning a pregnancy are important for maternal and fetal outcomes. In this clinical review, we will consider the safety of medications in managing childhood-onset SLE during conception, pregnancy, and breastfeeding. The developing fetus is at highest risk for teratogenicity from maternal medications during the period of critical organogenesis, which occurs between the first 3-8 weeks following conception. Medications known to be teratogenic, leading to a specific pattern of malformations, include mycophenolic acid, methotrexate, and cyclophosphamide. These should be discontinued prior to a planned pregnancy or as soon as pregnancy is suspected. Hydroxychloroquine is safe and should be continued throughout pregnancy and breastfeeding in those without contraindications to it. Azathioprine and calcineurin inhibitors are felt to be compatible with pregnancy in usual doses and may be used prior to and throughout pregnancy and lactation. Non-fluorinated corticosteroids including methylprednisolone and prednisone are inactivated by the placenta and can be used if needed for maternal indication during gestation. Addition of aspirin may be considered around the 12th week of gestation for prevention of pre-eclampsia. Illustrative cases are presented that demonstrate management of adolescents with childhood-onset SLE through conception, pregnancy, and breastfeeding.
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Affiliation(s)
- Nicole Bitencourt
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8884, USA
| | - Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8884, USA.
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23
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Palmsten K, Rolland M, Hebert MF, Clowse MEB, Schatz M, Xu R, Chambers CD. Patterns of prednisone use during pregnancy in women with rheumatoid arthritis: Daily and cumulative dose. Pharmacoepidemiol Drug Saf 2018; 27:430-438. [PMID: 29488292 DOI: 10.1002/pds.4410] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 12/08/2017] [Accepted: 01/28/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE To characterize prednisone use in pregnant women with rheumatoid arthritis using individual-level heat-maps and clustering individual trajectories of prednisone dose, and to evaluate the association between prednisone dose trajectory groups and gestational length. METHODS This study included pregnant women with rheumatoid arthritis who enrolled in the MotherToBaby Autoimmune Diseases in Pregnancy Study (2003-2014) before gestational week 20 and reported prednisone use without another oral glucocorticoid during pregnancy (n = 254). Information on medication use and pregnancy outcomes was collected by telephone interview plus by medical record review. Prednisone daily dose and cumulative dose were plotted by gestational day using a heat map for each individual. K-means clustering was used to cluster individual trajectories of prednisone dose into groups. The associations between trajectory group and demographics, disease severity measured by the Health Assessment Questionnaire at enrollment, and gestational length were evaluated. RESULTS Women used prednisone 3 to 292 days during pregnancy, with daily doses ranging from <1 to 60 mg. Total cumulative dose ranged from 8 to 6225 mg. Disease severity, non-biologic disease modifying anti-rheumatic drug use, and gestational length varied significantly by trajectory group. After adjusting for disease severity, non-biologic disease modifying anti-rheumatic drug use, and other covariates, the highest vs lowest daily dose trajectory group was associated with reduced gestational age at delivery (β: -2.3 weeks (95%: -3.4, -1.3)), as was the highest vs lowest cumulative dose trajectory group (β: -2.6 weeks (95%: -3.6, -1.5)). CONCLUSIONS In pregnant women with rheumatoid arthritis, patterns of higher prednisone dose were associated with shorter gestational length compared with lower dose.
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Affiliation(s)
- Kristin Palmsten
- HealthPartners Institute, Minneapolis, MN, USA.,Department of Pediatrics, University of California, San Diego, La Jolla, CA, USA
| | - Matthieu Rolland
- INSERM U1219-Centre Inserm Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
| | - Mary F Hebert
- Departments of Pharmacy and Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Megan E B Clowse
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Michael Schatz
- Department of Allergy, Kaiser Permanente Medical Center, San Diego, CA, USA
| | - Ronghui Xu
- Department of Mathematics, University of California, San Diego, La Jolla, CA, USA.,Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, USA
| | - Christina D Chambers
- Department of Pediatrics, University of California, San Diego, La Jolla, CA, USA.,Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, USA
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24
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Bandoli G, Palmsten K, Forbess Smith CJ, Chambers CD. A Review of Systemic Corticosteroid Use in Pregnancy and the Risk of Select Pregnancy and Birth Outcomes. Rheum Dis Clin North Am 2017; 43:489-502. [PMID: 28711148 PMCID: PMC5604866 DOI: 10.1016/j.rdc.2017.04.013] [Citation(s) in RCA: 157] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The evidence to date regarding corticosteroid exposure in pregnancy and select pregnancy and birth outcomes is limited and inconsistent. The authors provide a narrative review of published literature summarizing the findings for oral clefts, preterm birth, birth weight, preeclampsia, and gestational diabetes mellitus. Whenever possible, the results are limited to oral or systemic administration with a further focus on use in autoimmune disease. Although previous studies of corticosteroid exposure in pregnancy reported an increased risk of oral clefts in the offspring, more recent studies have not replicated these findings.
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Affiliation(s)
- Gretchen Bandoli
- Department of Pediatrics, University of California, San Diego, 9500 Gilman Drive, Mail Code 0828, La Jolla, CA 92093-0412, USA.
| | - Kristin Palmsten
- Department of Pediatrics, University of California, San Diego, 9500 Gilman Drive, Mail Code 0828, La Jolla, CA 92093-0412, USA
| | - Chelsey J Forbess Smith
- Department of Rheumatology, University of California, San Diego, 9500 Gilman Drive, Mail Code 0656, La Jolla, CA 92093-0412, USA
| | - Christina D Chambers
- Department of Pediatrics, University of California, San Diego, 9500 Gilman Drive, Mail Code 0828, La Jolla, CA 92093-0412, USA
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25
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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.
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Abstract
Research regarding fertility, medication safety, and pregnancy outcomes is increasing, but there are still many knowledge gaps in these areas. Women with ulcerative colitis and Crohn's disease may have decreased fertility because of voluntary childlessness and inflammatory bowel disease (IBD) surgery, and women with Crohn's disease may also have decreased ovarian reserve. Initial studies show that in vitro fertilization is a viable option, and laparoscopic ileoanal pouch anastomosis surgery improves fertility rates. Additional research is needed on the effect of disease activity on fertility and on the rates of pregnancy loss and ectopic pregnancies. We do not know how to reliably measure disease activity during pregnancy or the effect of pregnancy on the microbiome. Although immunomodulators and anti-tumor necrosis factor medications are relatively safe during pregnancy, the long-term effects of these medications on the child are unknown. The recommended mode of delivery is still debated, especially for women after ileoanal pouch anastomosis. There are multiple studies on the relative safety of immunomodulators and anti-tumor necrosis factor medications during pregnancy, and we know how to safely treat a pregnant patient with a disease flare. The best way to manage women with IBD who are pregnant or contemplating pregnancy is a multidisciplinary approach. Team members often include a gastroenterologist, a high-risk obstetrician, an infertility specialist, a colorectal surgeon, and a pediatrician with experience in caring for children of mothers with IBD. By integrating expertise from these disciplines, women with even very complex IBD should be able to have a healthy pregnancy and delivery.
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Damas OM, Deshpande AR, Avalos DJ, Abreu MT. Treating Inflammatory Bowel Disease in Pregnancy: The Issues We Face Today. J Crohns Colitis 2015; 9:928-36. [PMID: 26129693 DOI: 10.1093/ecco-jcc/jjv118] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 06/25/2015] [Indexed: 12/12/2022]
Abstract
Many women of childbearing age are living with inflammatory bowel disease [IBD], yet there are limited studies on the use of IBD medications in pregnancy. In this review, we provide a comprehensive update on the safety of these medications during pregnancy, particularly thiopurines and biologicals. Antibiotics, steroids, and aminosalicylates are relatively low risk for use in pregnancy, and growing evidence supports the safety of immunomodulators and anti-tumour necrosis factor agents as well. Available studies on infliximab, adalimumab, and certolizumab pegol show no increase in adverse events during pregnancy or perinatally. Similarly, studies on lactation demonstrate that concentrations of subcutaneous anti-tumour necrosis factor biologicals are undetectable, and levels of thiopurines and infliximab are negligible in breast milk. Less is known about anti-integrins in pregnancy [eg natalizumab and vedolizumab] but currently available data suggest they may be safe as well. Although more studies are needed to examine the long-term effects of these medications on offspring, the available data provide reassuring information for providers caring for women of childbearing age.
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Affiliation(s)
- Oriana M Damas
- University of Miami Miller School of Medicine, Department of Medicine, Division of Gastroenterology, Miami, FL
| | - Amar R Deshpande
- University of Miami Miller School of Medicine, Department of Medicine, Division of Gastroenterology, Miami, FL
| | - Danny J Avalos
- University of Miami Miller School of Medicine Palm Beach Regional Campus, Internal Medicine Division, Department of Medicine, West Palm Beach, FL
| | - Maria T Abreu
- University of Miami Miller School of Medicine, Department of Medicine, Division of Gastroenterology, Miami, FL
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FERTILIDAD Y EMBARAZO EN PACIENTES CON ENFERMEDADES INFLAMATORIAS INTESTINALES. REVISTA MÉDICA CLÍNICA LAS CONDES 2015. [DOI: 10.1016/j.rmclc.2015.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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