1
|
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
|
2
|
Bell C, Tandon P, Lentz E, Marshall JK, Narula N. Systematic review and meta-analysis: Safety of vedolizumab during pregnancy in patients with inflammatory bowel disease. J Gastroenterol Hepatol 2021; 36:2640-2648. [PMID: 34110640 DOI: 10.1111/jgh.15574] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 05/17/2021] [Accepted: 06/06/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Vedolizumab is a novel monoclonal antibody used in patients with inflammatory bowel disease, often affecting women of child-bearing age. We aimed to compare maternal and fetal adverse outcomes in pregnancies of women with inflammatory bowel disease exposed to vedolizumab versus those on other treatment. METHODS We performed a systematic literature search through December 2020 looking for studies including outcomes from pregnancies of female inflammatory bowel disease patients treated with vedolizumab. Our primary outcome was a composite of adverse pregnancy-related events in pregnancies of female patients on vedolizumab compared with those of disease-matched controls on other medication regimens. Events of interest included preterm births, early loss of pregnancy, late fetal death, elective termination of pregnancy, and congenital anomalies. RESULTS Four studies were included in our review meeting criteria for our primary analysis. Compared with those with no vedolizumab exposure, pregnancies with vedolizumab exposure had an increase in overall adverse pregnancy-related outcomes (odds ratio [OR] 2.18, 95% confidence interval [CI], 1.52-3.13). The vedolizumab group also had increased preterm births (OR 2.16, 95% CI, 1.28-3.66), and early loss of pregnancies (OR 1.79, 95% CI, 1.06-3.01) but no difference in number of live births (OR 0.60, 95%CI, 0.36-1.00), or congenital malformations (OR 1.56, 95% CI, 0.56-4.37). CONCLUSIONS Our systematic review highlights possible concern with the general safety of vedolizumab in pregnancy, as an increase in overall total unfavorable outcomes was observed. Premature births and early loss of pregnancy were also more prevalent in pregnant female patients on vedolizumab. It is possible these findings are confounded by disease activity, and further prospective cohort studies of vedolizumab and pregnancy outcomes are warranted.
Collapse
Affiliation(s)
- Conor Bell
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Parul Tandon
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Eric Lentz
- Michael DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Neeraj Narula
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
3
|
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
|
4
|
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
|
5
|
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
|
6
|
Abstract
BACKGROUND Reasons for the increased incidence of cesarean delivery among women with inflammatory bowel disease remain unclear. We assessed cesarean delivery incidence and factors influencing mode of delivery in women with inflammatory bowel disease. METHODS We performed a 10-year retrospective cohort study of nulliparous women who delivered a singleton infant at our institution. We compared the risk of each mode of delivery in women with Crohn's disease and ulcerative colitis with women without inflammatory bowel disease. We assessed mode of delivery indications for patients with inflammatory bowel disease and whether cesarean deliveries were planned. RESULTS The overall incidence of cesarean delivery among women with Crohn's disease (24/59; 40.7%) was similar to that among women without inflammatory bowel disease (7868/21,805; 36.1%) (risk ratio 1.1 [95% confidence interval, 0.83, 1.5]; P = 0.46), but was increased in the subgroups with active and inactive perianal disease (risk ratio 2.3; P < 0.01). Women with ulcerative colitis had a 1.8-fold increased relative risk of cesarean delivery (41/65; 63.1%) (95% confidence interval, 1.5, 2.1; P < 0.01), with highest incidence in patients with ileal pouch-anal anastomosis. Forty-nine percent of ulcerative colitis and 66.7% of Crohn's disease cesarean deliveries were unplanned, with only 1 unplanned delivery performed for active inflammatory bowel disease. Most unplanned deliveries were for arrest of descent/dilation and nonreassuring fetal heart tracings. Seventy-five percent of planned cesarean deliveries were for inflammatory bowel disease-related indications. CONCLUSIONS Women with ulcerative colitis and perianal Crohn's disease have an increased incidence of cesarean delivery. At least half of cesarean deliveries are unplanned.
Collapse
|
7
|
Sridhar A, Cwiak CA, Kaunitz AM, Allen RH. Contraceptive Considerations for Women with Gastrointestinal Disorders. Dig Dis Sci 2017; 62:54-63. [PMID: 27885460 DOI: 10.1007/s10620-016-4383-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 11/15/2016] [Indexed: 12/19/2022]
Abstract
Gastroenterologists are in a unique position to assist women with chronic gastrointestinal disorders in order to optimize their health prior to pregnancy. Women, whether with chronic conditions or not, and their infants are more likely to be healthy when pregnancies are planned. Achieving a planned pregnancy at the ideal time or preventing pregnancy altogether requires the use of appropriate contraceptives. There is a broad range of contraceptives available to women in the USA, and the majority of women with digestive diseases will be candidates for all effective methods. Guidance from the Centers for Disease Control and Prevention aids clinicians in prescribing appropriate contraceptives to women with medical disorders. This review will focus on contraception for women with inflammatory bowel disease and chronic liver disease, including liver transplant.
Collapse
Affiliation(s)
- Aparna Sridhar
- The Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave CHS 22-229, Los Angeles, CA, 90095, USA
| | - Carrie A Cwiak
- The Department of Gynecology and Obstetrics, Emory University School of Medicine, 49 Jesse Hill Jr. Drive SE, Atlanta, GA, 30303, USA
| | - Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, 653-1 W. 8th Street, Jacksonville, FL, 32209, USA
| | - Rebecca H Allen
- The Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, 101 Dudley Street, Providence, RI, 02905, USA.
| |
Collapse
|
8
|
Bröms G, Granath F, Stephansson O, Kieler H. Preterm birth in women with inflammatory bowel disease - the association with disease activity and drug treatment. Scand J Gastroenterol 2016; 51:1462-1469. [PMID: 27739352 DOI: 10.1080/00365521.2016.1208269] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The inflammatory bowel diseases (IBD), Crohn's disease (CD) and ulcerative colitis (UC) have been associated with an increased risk of preterm birth. MATERIAL AND METHODS We identified all 246 singleton preterm births among women with IBD between July 2006 and December 2010 as cases and an equal number of controls with IBD from the Swedish national health registers, matched by maternal age, parity and IBD diagnosis (CD/UC). From register data and medical charts, we obtained information on reproductive history, comorbidity, disease activity and drug treatment (corticosteroids, 5-aminosalicylates, sulfasalazine, thiopurines and anti-TNF) as risk factors for preterm birth. Associations were estimated using conditional logistic regression and results were presented as odds ratios (OR) with 95% confidence intervals (CI). RESULTS Previous preterm birth was more common among cases, OR 6.13 (95%CI: 2.51-15.01). Significant activity at any time during pregnancy (OR: 2.20; 95%CI: 1.37-3.53), and in particular both in early and in late pregnancy, was more common for cases (OR: 4.78 95%; CI: 2.10-10.9). The OR for immunosuppressive treatment with thiopurines or anti-TNF was 1.88 (1.04-3.39) without significant activity and 12.78 (95%CI: 3.68-44.72) with. The risk for women who discontinued thiopurines was 6.56 (1.44-29.82). CONCLUSIONS Significant activity and immunosuppressive treatment was associated with preterm birth, particularly in women with both. The existing recommendations to aim at maintaining quiescent disease during pregnancy, even if it means continuing immunosuppressive treatment, are rational.
Collapse
Affiliation(s)
- Gabriella Bröms
- a Unit of Clinical Epidemiology , Centre for Pharmacoepidemiology, Karolinska Institutet , Stockholm , Sweden.,b Department of Internal Medicine , Danderyd University Hospital , Stockholm , Sweden
| | - Fredrik Granath
- a Unit of Clinical Epidemiology , Centre for Pharmacoepidemiology, Karolinska Institutet , Stockholm , Sweden
| | - Olof Stephansson
- a Unit of Clinical Epidemiology , Centre for Pharmacoepidemiology, Karolinska Institutet , Stockholm , Sweden.,c Department of Women's and Children's Health, Division of Obstetrics and Gynecology , Karolinska Institutet , Stockholm , Sweden
| | - Helle Kieler
- a Unit of Clinical Epidemiology , Centre for Pharmacoepidemiology, Karolinska Institutet , Stockholm , Sweden
| |
Collapse
|
9
|
Adverse Pregnancy Outcomes Among Women with Inflammatory Bowel Disease: A Population-Based Study from England. Inflamm Bowel Dis 2016; 22:1621-30. [PMID: 27306070 DOI: 10.1097/mib.0000000000000802] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND There is limited contemporary population-based evidence on adverse birth outcomes and pregnancy-related complications for women with inflammatory bowel disease (IBD). This study provides such estimates of these risks and assesses variation by IBD type and surgical interventions. METHODS We calculated the proportion of pregnancies in women with and without IBD between 1997 and 2012 throughout England using linked primary (Clinical Practice Research Datalink) and secondary care (Hospital Episode Statistics) data. Risk of pregnancy-related complications and adverse birth outcomes in women with Crohn's disease and ulcerative colitis were compared with risks in women without IBD using odds ratios (ORs). RESULTS Of 364,363 singleton pregnancies resulting in live or stillbirths, 1969 (0.5%) were in women with IBD. Women with Crohn's disease were more likely to have preterm births (OR = 1.42; 95% confidence interval, 1.12-1.79), babies with low birth weights (OR = 1.39; 95% confidence interval, 1.05-1.83), and postpartum hemorrhage (OR = 1.27; 95% confidence interval, 1.04-1.55), whereas women with ulcerative colitis were only at increased risk of preterm births with an absolute risk difference of <2.7%. These risks remained independent of caesarean section. Prior surgery for IBD did not increase the risk of adverse birth outcomes or pregnancy-related complications compared with cases without surgery, however, women with IBD were more likely to have an elective caesarean section. CONCLUSIONS Women with Crohn's disease have increased risks of some specific pregnancy-related complications and adverse birth outcomes which are independent of caesarean section, however, the absolute risk differences are small, indicating that most women with IBD will have an uncomplicated pregnancy.
Collapse
|
10
|
Pregnancy and the Patient with Inflammatory Bowel Disease: Fertility, Treatment, Delivery, and Complications. Gastroenterol Clin North Am 2016; 45:285-301. [PMID: 27261899 DOI: 10.1016/j.gtc.2016.02.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
For many women with inflammatory bowel disease (IBD), the illness coincides with their childbearing years. IBD increases the risk of pregnancy complications and adverse pregnancy outcomes. The multidisciplinary care team should emphasize the importance of medication adherence to achieve preconception disease control and maintain corticosteroid-free remission throughout pregnancy. Medication adjustments to reduce fetal exposure may be considered on an individualized basis in quiescent disease; however, any benefits of such adjustments remain theoretic and there is risk of worsening disease activity. Mode of delivery is determined by obstetric indications, except for women with active perianal disease who should consider cesarean delivery.
Collapse
|
11
|
Gawron LM, Sanders J, Steele KP, Flynn AD. Reproductive Planning and Contraception for Women with Inflammatory Bowel Diseases. Inflamm Bowel Dis 2016; 22:459-64. [PMID: 26484636 PMCID: PMC6861010 DOI: 10.1097/mib.0000000000000606] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Women with chronic medical conditions, such as inflammatory bowel diseases, are at increased risk for adverse pregnancy outcomes. Pregnancy outcomes for these conditions are best during stable disease remission. Unfortunately, women with inflammatory bowel disease are equally as likely as the general population to have unintended pregnancies. Patients look to their gastroenterologist for contraceptive counseling; however, the current standards for disease management do not prioritize this topic. Guidelines based on available evidence and expert opinion, such as the Centers for Disease Control U.S. Medical Eligibility Criteria for Contraceptive Use, exist to help practitioners provide safe and effective contraception to women with chronic medical conditions. If health care providers were to educate themselves and screen women with inflammatory bowel disease for risk of unintended pregnancy, there would be a reduction in the number of unintended pregnancies and subsequent adverse neonatal and maternal outcomes.
Collapse
Affiliation(s)
- Lori M. Gawron
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jessica Sanders
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah
| | | | - Ann D. Flynn
- Division of Gastroenterology and Nutrition, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| |
Collapse
|
12
|
Abstract
Immunomodulators and biologic medications, alone or in combination, form the core therapeutic strategy for managing moderate-to-severe inflammatory bowel disease (IBD). IBD incidence peaks during the prime reproductive years, raising concerns about the impact of disease and its treatment on fertility, maternal and fetal health during pregnancy, breastfeeding safety, and childhood development. Although IBD increases risk of pregnancy complications independent of disease activity, adverse pregnancy outcomes are more common when disease is active. To mitigate fetal risk, women should conceive while disease is quiescent. Aside from methotrexate, immunomodulators and biologics may be used during pregnancy to achieve and maintain disease control. Based on available safety data, there is no increased risk of congenital anomalies among infants exposed to these medications. Active thiopurine metabolites and most monoclonal antibodies cross the placenta and are detectable in neonates. They are detectable in breast milk in minute levels as well. The impact of this exposure on neonatal outcomes is discussed. Adjusted dosing schedules during gestation may reduce fetal drug exposure, though the maternal risks of such manipulation require careful consideration. Ongoing prospective studies will further inform risk assessment, including for newer medications such as the anti-integrin agents.
Collapse
|
13
|
Androulakis I, Zavos C, Christopoulos P, Mastorakos G, Gazouli M. Safety of anti-tumor necrosis factor therapy during pregnancy in patients with inflammatory bowel disease. World J Gastroenterol 2015; 21:13205-13211. [PMID: 26715803 PMCID: PMC4679752 DOI: 10.3748/wjg.v21.i47.13205] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 07/24/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Treatment of inflammatory bowel disease has significantly improved since the introduction of biological agents, such as infliximab, adalimumab, certolizumab pegol, and golimumab. The Food and Drug Administration has classified these factors in category B, which means that they do not demonstrate a fetal risk. However, during pregnancy fetuses are exposed to high anti-tumor necrosis factor (TNF) levels that are measurable in their plasma after birth. Since antibodies can transfer through the placenta at the end of the second and during the third trimesters, it is important to know the safety profile of these drugs, particularly for the fetus, and whether maintaining relapse of the disease compensates for the potential risks of fetal exposure. The limited data available for the anti-TNF drugs to date have not demonstrated any significant adverse outcomes in the pregnant women who continued their therapy from conception to the first trimester of gestation. However, data suggest that anti-TNFs should be discontinued during the third trimester, as they may affect the immunological system of the newborn baby. Each decision should be individualized, based on the distinct characteristics of the patient and her disease. Considering all the above, there is a need for more clinical studies regarding the effect of anti-TNF therapeutic agents on pregnancy outcomes.
Collapse
|
14
|
Inflammatory Bowel Disease Increases Risk of Adverse Pregnancy Outcomes: A Meta-Analysis. Dig Dis Sci 2015; 60:2750-61. [PMID: 26070523 DOI: 10.1007/s10620-015-3677-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 04/17/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Inflammatory bowel disease may place women at greater risk of adverse pregnancy outcomes. AIM To examine the association between inflammatory bowel disease and adverse pregnancy outcomes: preterm birth, small for gestational age (SGA) birth weight, congenital anomalies, and stillbirth. METHODS We searched PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov for studies published from January 1980 through February 2014 and reference lists of relevant studies. We reviewed 1748 citations and identified studies evaluating outcomes of pregnancies complicated by inflammatory bowel disease. Selected studies evaluated one or more of the outcomes of interest, were in English, and gave sufficient details to perform meta-analysis. Three investigators independently reviewed articles for inclusion; discordant decisions were resolved by team review and consensus. Twenty-three studies that included 15,007 women with inflammatory bowel disease (5449 Crohn's, 6559 ulcerative colitis) and 4,614,271 controls met selection criteria. Random-effects analytical methods were used to generate pooled odds ratios. RESULTS We found an increased odds of the outcomes studied among women with inflammatory bowel disease compared with non-diseased controls: 1.85 for preterm birth (22 studies; 95 % confidence interval [CI] 1.67-2.05), 1.36 for SGA birth weight (13 studies; 95 % CI 1.16-1.60), 1.57 for stillbirth (10 studies; 95 % CI 1.03-2.38), and 1.29 for congenital anomalies (11 studies; 95 % CI 1.05-1.58). The latter result, however, may be unreliable secondary to publication bias. CONCLUSION Inflammatory bowel disease may increase the odds of adverse pregnancy outcomes.
Collapse
|
15
|
Khan N, Asim H, Lichtenstein GR. Safety of anti-TNF therapy in inflammatory bowel disease during pregnancy. Expert Opin Drug Saf 2015; 13:1699-708. [PMID: 25406728 DOI: 10.1517/14740338.2014.973399] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The highest incidence of inflammatory bowel disease (IBD) is seen between the second and fourth decades of life, which is the most fertile age for women. Increased disease activity has been shown to effect female fertility and pregnancy outcomes, stressing the need for drugs that can safely induce and maintain clinical remission without harming either the mother or fetus. AREAS COVERED Anti-TNF-α agents have been shown to be effective in both inducing and maintaining remission among IBD patients. This review highlights the results of previous studies conducted on pregnant women who were exposed to anti-TNF-α agents during the course of their pregnancy. The drugs reviewed include infliximab (IFX), adalimumab (ADA), certolizumab pegol (CZP) and golimumab (GMB). Of > 200 articles reviewed, 105 were included in the manuscript based on relevance. The keywords used were anti-TNF, infliximab, adalimumab, certolizumab, golimumab, biologics, pregnancy and inflammatory bowel disease. EXPERT OPINION Anti-TNF agents have been studied extensively during pregnancy from the early case reports to the more recent prospective Pregnancy in IBD and Neonatal Outcomes study. A comprehensive review of the literature has shown that biologics can be safely used during pregnancy. In view of this safety data, it is recommended to maintain therapy during pregnancy.
Collapse
Affiliation(s)
- Nabeel Khan
- University of Pennsylvania Perelman School of Medicine, Department of Gastroenterology , Philadelphia, PA , USA
| | | | | |
Collapse
|
16
|
Furderer T, Mantion G, Heyd B. Emergency surgery for intestinal obstruction revealing ileal Crohn's disease (CD) during pregnancy. BMJ Case Rep 2015; 2015:bcr-2013-009468. [PMID: 25969480 DOI: 10.1136/bcr-2013-009468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Few data are available regarding emergency surgery for Crohn's disease (CD) during pregnancy. A 22-year -old woman, at 26 weeks of pregnancy, was admitted for premature labour, intestinal obstruction and systemic inflammation. Biology and ultrasonography were not helpful; imaging was completed with a CT scan, which confirmed the mechanical ileal obstruction. The intestinal obstruction worsened and led to emergency surgery. An inflammatory stenosis of the terminal ileum with two fistulas was found. An ileal resection and ileostomy were performed. The pathological analysis of the resected specimen confirmed CD. The postoperative course was uneventful. The delivery of a baby with normal weight and status occurred at term (40 weeks of amenorrhoea). There have been only 10 case reports of intestinal complications revealing CD during pregnancy. The delay in diagnosis and adequate treatment led to significant maternal and fetal morbidity and mortality. This case suggests that intestinal surgery for CD is feasible during pregnancy and may be associated with a favourable outcome for the baby as well as for the mother.
Collapse
Affiliation(s)
| | | | - Bruno Heyd
- University Hospital Besançon, Besançon, France
| |
Collapse
|
17
|
|
18
|
Bharadwaj S, Philpott JR, Barber MD, Graff LA, Shen B. Women's health issues after ileal pouch surgery. Inflamm Bowel Dis 2014; 20:2470-82. [PMID: 25185688 DOI: 10.1097/mib.0000000000000171] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for patients with ulcerative colitis and familial polyposis who require colectomy. This surgical intervention allows for resection of colon, while offering intestinal continuity with fecal continence, discontinuation of most medications related to ulcerative colitis and reduction in the risk of colitis-associated neoplasia. As a proportion of these patients are women of childbearing age, it is important to understand the impact on reproductive health and function. Although limited data exist, restorative proctocolectomy/IPAA does not seem to adversely affect menstrual function. In general, sexual function is reported to improve postsurgery with the ability to achieve orgasm unaltered. However, dyspareunia is commonly reported post restoratively. Of concern, there are data to suggest that fertility is decreased post-IPAA. The reasons stated are pelvic adhesions and obstruction of fallopian tubes. Laparoscopic approach may improve fertility outcomes by reducing postoperative adhesions as compared with the open approach. Once achieved, pregnancy in patients with IPAA is characterized by a transient increase in stool frequency that resolves postdelivery. Whether vaginal delivery or cesarean section is preferred route of delivery in these patients is still controversial. But commonly cesarean section is advocated for patients' post-IPAA to prevent anal sphincter injury and long-term effects on pouch function. All of these issues should be included in the discussion with women who are contemplating IPAA, so they are well aware of them before deciding on the best management plan.
Collapse
Affiliation(s)
- Shishira Bharadwaj
- Departments of *Gastroenterology & Hepatology, and †Obstetrics and Gynecology, Cleveland Clinic Foundation, Cleveland, Ohio; and ‡Department of Clinical Heath Psychology, University of Manitoba, Winnipeg, MB, Canada
| | | | | | | | | |
Collapse
|
19
|
Khan N, Asim H, Lichtenstein GR. Safety of anti-TNF therapy in inflammatory bowel disease during pregnancy. Expert Opin Drug Saf 2014. [DOI: 10.1517/14740338.2015.973399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
20
|
The impact of hormonal contraception on disease-related cyclical symptoms in women with inflammatory bowel diseases. Inflamm Bowel Dis 2014; 20:1729-33. [PMID: 25105949 PMCID: PMC8449542 DOI: 10.1097/mib.0000000000000134] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Women with inflammatory bowel diseases (IBD) commonly report an increase in their IBD symptoms related to their menstrual cycle. Hormonal contraceptives are safe for women with IBD and frequently used for reproductive planning, but data are lacking on their effect on IBD-related symptoms. METHODS We completed a cross-sectional phone survey of 129 women (31% response rate), aged 18 to 45 years, with IBD in an academic practice between March and November 2013. An electronic database query identified eligible women, and we sent an opt-out letter before contact. Questions included demographics, medical and reproductive history, and current/previous contraceptive use. Women were asked if/how their menses affected IBD-related symptoms and if/how their contraceptive affected symptoms. We calculated descriptive statistics and made comparisons by Crohn's disease versus ulcerative colitis on Stata V11. RESULTS Participants were predominately white (85%) and college educated (97%), with a mean age of 34.2 (SD 6.2, range 19-45) years. Sixty percent had Crohn's disease, and 30% had IBD-related surgery previously. Half of the participants were parous, and 57% desired future pregnancy. Of the participants, 88% reported current or past hormonal contraceptive use and 60% noted cyclical IBD symptoms. Symptomatic improvement in cyclical IBD symptoms was reported by 19% of estrogen-based contraceptive users and 47% of levonorgestrel intrauterine device users. Only 5% of all hormonal method users reported symptomatic worsening. CONCLUSIONS In a subset of women with IBD, 20% of hormonal contraception users reported improved cyclical menstrual-related IBD symptoms. Health care providers should consider potential noncontraceptive benefits of hormonal contraception in women with cyclical IBD symptoms.
Collapse
|
21
|
Abstract
Biologic therapies, including anti-tumor necrosis factor antibody therapy and anti-integrin antibodies, are currently approved for the treatment of and are increasingly being used in patients with moderate to severe inflammatory bowel disease, including Crohn disease and ulcerative colitis. Because patients who require these medications are often in their child-bearing years, knowledge of the safety of these medications before and after pregnancy is imperative. This article summarizes the available data regarding the use of biologic therapy during and after pregnancy, highlighting such issues as safety for mother and newborn, length of medication use during pregnancy, and breastfeeding after pregnancy while on biologic therapy.
Collapse
Affiliation(s)
- Sara Horst
- Vanderbilt University Medical Center, 1211 21st Avenue, South 220 Medical Arts Building, Nashville, TN 37232, USA
| | - Sunanda Kane
- Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| |
Collapse
|
22
|
Mountifield R, Andrews JM, Bampton P. It IS worth the effort: Patient knowledge of reproductive aspects of inflammatory bowel disease improves dramatically after a single group education session. J Crohns Colitis 2014; 8:796-801. [PMID: 24467964 DOI: 10.1016/j.crohns.2013.12.019] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 12/20/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Individuals with Inflammatory Bowel Disease (IBD) have poor knowledge regarding the implications of disease for fertility and pregnancy. Previous studies suggest that this poor knowledge adversely influences reproductive decision making. AIM To examine the effect of a single group education session on IBD-specific reproductive knowledge in subjects with IBD. METHOD People with IBD attending an educational event were invited to complete the CCPKnow questionnaire, testing reproductive knowledge in IBD, before and after an evidenced based presentation on this topic delivered by a Gastroenterologist. RESULTS Of 248 attendees, 155 participated; 69% female, mean age 40.3years. CCPKnow scores (maximum 17) were low at baseline and increased significantly post education (mean 5.4 pre vs. 14.5 post education; p<0.0001). A large majority (65.1%) of subjects had "poor" (score <8) knowledge at baseline, compared with only 1.9% after education (p<0.0001). Whilst all subareas of knowledge improved after education, the most important improvement was in attitudes toward medication use in pregnancy: 33.5% of subjects indicated at baseline that women should avoid all drugs in pregnancy compared with only 1.2% post education (p<0.0001). CONCLUSION A single group-delivered education event focussed on reproductive issues in IBD can dramatically improve patient knowledge. This has the potential to change reproductive behaviour and may reduce voluntary childlessness resulting from misperceptions amongst individuals with IBD.
Collapse
Affiliation(s)
- Réme Mountifield
- Dept Gastroenterology and Hepatology, Flinders Medical Centre, South Australia, Australia; Flinders University of South Australia, Australia.
| | - Jane M Andrews
- IBD Service, Dept Gastroenterology and Hepatology and School of Medicine, University of Adelaide at Royal Adelaide Hospital, South Australia, Australia.
| | - Peter Bampton
- Dept Gastroenterology and Hepatology, Flinders Medical Centre, South Australia, Australia; Flinders University of South Australia, Australia.
| |
Collapse
|
23
|
Birth outcomes in women with inflammatory bowel disease: effects of disease activity and drug exposure. Inflamm Bowel Dis 2014; 20:1091-8. [PMID: 24810137 DOI: 10.1097/mib.0000000000000060] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ulcerative colitis (UC) and Crohn's disease (CD) have been associated with increased risks of adverse birth outcomes. Disease activity and drug exposure may contribute to the association. METHODS A cohort from the Swedish health registers including 470,110 singleton births in Sweden from July 2006 to December 2010; 1833 to women with UC and 1220 to women with CD. Birth outcomes for women with UC and CD were compared with outcomes among those without disease. Diseased women were categorized by drug exposure, need of surgery, and hospital admissions as (1) no disease activity and (2) stable or (3) flaring disease. Logistic regression was used to calculate odds ratios with adjustments (aOR) for maternal age, parity, smoking status, body mass index, and comorbidity. RESULTS There were increased risks of preterm birth for both UC (aOR, 1.78; 95% confidence interval [CI], 1.49-2.13) and CD (aOR, 1.65; 95% CI, 1.33-2.06). Risks were more pronounced in women with flaring disease during pregnancy. Risks of small for gestational age, low Apgar score, and hypoglycemia were also increased. The risk of stillbirth was elevated in women with CD, particularly among those with flaring disease (aOR, 4.48; 95% CI, 1.67-11.90). Thiopurine exposure increased risks for preterm birth, both in women with stable (aOR, 2.41; 95% CI, 1.05-5.51) and with flaring disease (aOR, 4.90; 95% CI, 2.76-8.69). CONCLUSIONS Women with UC and CD are at increased risk of adverse birth outcomes, such as stillbirth, growth restriction, and preterm birth, particularly when they suffer from flares throughout pregnancy. Thiopurine exposure seems to further increase risks, independently of disease activity.
Collapse
|
24
|
Huang VW, Habal FM. From conception to delivery: managing the pregnant inflammatory bowel disease patient. World J Gastroenterol 2014; 20:3495-506. [PMID: 24707132 PMCID: PMC3974516 DOI: 10.3748/wjg.v20.i13.3495] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 01/12/2014] [Accepted: 02/26/2014] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) typically affects patients during their adolescent and young adult years. As these are the reproductive years, patients and physicians often have concerns regarding the interaction between IBD, medications and surgery used to treat IBD, and reproduction, pregnancy outcomes, and neonatal outcomes. Studies have shown a lack of knowledge among both patients and physicians regarding reproductive issues in IBD. As the literature is constantly expanding regarding these very issues, with this review, we provide a comprehensive, updated overview of the literature on the management of the IBD patient from conception to delivery, and provide action tips to help guide the clinician in the management of the IBD patient during pregnancy.
Collapse
|
25
|
Gawron LM, Gawron AJ, Kasper A, Hammond C, Keefer L. Contraceptive method selection by women with inflammatory bowel diseases: a cross-sectional survey. Contraception 2014; 89:419-25. [PMID: 24486008 DOI: 10.1016/j.contraception.2013.12.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 12/22/2013] [Accepted: 12/24/2013] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Women with inflammatory bowel diseases (IBDs) utilize contraception at a lower rate than the general population. We sought to identify factors associated with contraceptive use and selection of more effective methods in IBD patients at risk for unintended pregnancy. STUDY DESIGN An online survey was distributed to women with IBD in January 2013. Contraceptive methods were categorized by effectiveness and associations with use explored by demographics, disease characteristics and reproductive goals. RESULTS A total of 162 respondents were analyzed: 62% had Crohn's disease and 38% ulcerative colitis. Mean age was 31 (range 20-45), 97% identified as White, and 53% were nulliparas. Seventy-four percent were currently using IBD medications. A quarter of participants (23%) used no contraception, 17% used highly effective methods, 41% used short-term hormonal methods, and 19% chose barrier/behavioral methods. Prior IBD-related surgery, biologic therapy use and low education attainment were associated with no contraception use. Of contraceptive users, age, parity, insurance status, IBD surgery and prior immunomodulator use were associated with highly effective method selection. CONCLUSIONS A quarter of women with IBD at risk for pregnancy in this study population reported no contraceptive method use. Higher levels of IBD activity influence contraceptive use and method selection, which could guide future patient and provider educational interventions. IMPLICATIONS Pregnancy planning is important for women with inflammatory bowel diseases to avoid adverse outcomes in a disease-poor state. Use of contraception assists in avoidance of unintended pregnancy. IBD characteristics are targets for educational interventions to improve uptake of highly effective contraceptive methods.
Collapse
Affiliation(s)
- Lori M Gawron
- Department of Obstetrics and Gynecology, Section of Family Planning, Northwestern University, Chicago, IL, USA.
| | - Andrew J Gawron
- Division of Hepatology and Gastroenterology, Northwestern University, Chicago, IL, USA
| | | | - Cassing Hammond
- Department of Obstetrics and Gynecology, Section of Family Planning, Northwestern University, Chicago, IL, USA
| | - Laurie Keefer
- Division of Hepatology and Gastroenterology, Northwestern University, Chicago, IL, USA
| |
Collapse
|
26
|
Gawron LM, Hammond C, Keefer L. Documentation of reproductive health counseling and contraception in women with inflammatory bowel diseases. PATIENT EDUCATION AND COUNSELING 2014; 94:134-7. [PMID: 24126091 PMCID: PMC3985491 DOI: 10.1016/j.pec.2013.09.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 09/06/2013] [Accepted: 09/15/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Inflammatory bowel diseases (IBD) are commonly diagnosed during women's reproductive years. Counseling is important to avoid unintended pregnancy in a disease-poor state. We sought to determine reproductive counseling documentation by gastroenterologists in women with IBD. METHODS An electronic query identified women, age 18-45, with IBD in an academic gastroenterology practice from 2010 to 2012. A random sample (15%) chart review determined contraception documentation and content/frequency of reproductive counseling. RESULTS 100 patients were analyzed. Median age was 35 (range 19-45), 53% were married, and 69% had Crohn's disease. Median time since IBD diagnosis was 9 years (range 1-32) with a 5 visit median (range 1-45) over 31 months (range 1-105). A contraceptive method was identified in 24% of all patients. Nineteen patients (19%) had documentation of reproductive counseling. Only 1/100 patients had a specific reference to using contraception to avoid pregnancy. The remaining counseling included (1) medication effects on pregnancy, (2) disease control before pregnancy, or (3) mode of delivery planning. CONCLUSIONS Outside of listing contraception as a "current medication", documentation of reproductive counseling at gastroenterology visits for IBD is sparse. PRACTICE IMPLICATIONS In light of the importance of reproductive planning for women with IBD, future research on incentives and barriers to counseling is warranted.
Collapse
Affiliation(s)
- Lori M Gawron
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, USA.
| | - Cassing Hammond
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, USA
| | - Laurie Keefer
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, USA
| |
Collapse
|
27
|
Abstract
This article provides an overview of the obstetric and gynecological manifestations of Crohn’s disease (CD). High incidence of the new onset of the disease in young women in their reproductive years demands special concern from physicians involved in their treatment. Pregnant women with CD are considered high-risk patients, regardless of disease activity index, due to associated complications. Predominately described complications are premature birth, low birth weight, and congenital anomalies. To minimize the risk for adverse pregnancy/birth outcomes, it is recommended that remission be achieved before conception. Treatment of CD in pregnant women is similar to that among the nonpregnant population, and there is no valid reason to terminate it, since most of the drugs are proven to be safe. Women with CD who wish to conceive or are already pregnant need to be properly advised according to the newest guidelines on the subject, given by the European Crohn’s and Colitis Organization. Gynecological manifestations are another special feature of CD. They are important in that they may facilitate early recognition of the underlying disease, which usually stays unrecognized for years before intestinal manifestation; in this way, the underlying manifestations are often mistreated.
Collapse
Affiliation(s)
- Ivana Plavšić
- Health Center, County of Primorje-Gorski Kotar, Rijeka, Croatia, Rijeka, Croatia
| | | | | |
Collapse
|
28
|
Wispelwey BP, Sheiner E. Inflammatory bowel disease and preterm delivery. Arch Gynecol Obstet 2013; 288:725-30. [DOI: 10.1007/s00404-013-2989-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 07/30/2013] [Indexed: 12/28/2022]
|
29
|
Dotan I, Alper A, Rachmilewitz D, Israeli E, Odes S, Chermesh I, Naftali T, Fraser G, Shitrit ABG, Peles V, Reif S. Maternal inflammatory bowel disease has short and long-term effects on the health of their offspring: a multicenter study in Israel. J Crohns Colitis 2013; 7:542-50. [PMID: 23036507 DOI: 10.1016/j.crohns.2012.08.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 08/21/2012] [Accepted: 08/22/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND There are concerns about the effect of inflammatory bowel diseases (IBD) on fertility, pregnancy and pregnancy outcomes, but no long-term data on the health of offspring born to IBD mothers. The aims were to assess the short- and long-term effects of maternal IBD on the morbidity and development of their offspring. METHODS Female IBD patients and controls completed questionnaires on their pregnancy outcome, and their offspring's short- and long-term health and development. RESULTS IBD and control mothers (159 and 175, respectively) were recruited. Medical data of 412 IBD and 417 control offspring were recorded. IBD mothers had significantly more singleton pregnancies, their offspring's birth weight was significantly lower, and they breastfed significantly less compared to controls (P=0.028, 0.007, and <0.0001, respectively). There were significantly more congenital anomalies (mainly limb deformities) among the IBD offspring (P<0.035). Offspring born post-maternal IBD diagnosis, compared to pre-diagnosis, tended to have more neurodevelopmental problems (e.g., gross motor delay, P=0.03). IBD was significantly more prevalent in the offspring of IBD mothers, while allergies and atopic dermatitis were more frequent in offspring of control mothers. More offspring of IBD mothers taking medications during pregnancy were born preterm and had lower birth weights compared to offspring of IBD mothers not taking medications during pregnancy. Children of mothers taking steroids had the lowest birth weights, compared to those of IBD mothers taking 5ASAs or immunomodulators. CONCLUSIONS Maternal IBD affects pregnancy and the offspring's immediate and long-term morbidity, specifically, congenital anomalies and neurodevelopmental problems.
Collapse
Affiliation(s)
- Iris Dotan
- IBD Center, Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Ng SW, Mahadevan U. Management of inflammatory bowel disease in pregnancy. Expert Rev Clin Immunol 2013; 9:161-73; quiz 174. [PMID: 23390947 DOI: 10.1586/eci.12.103] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The management of inflammatory bowel disease (IBD) in women who are pregnant or contemplating pregnancy requires special considerations. Although many of the medications in IBD treatment are generally low risk, this is not the case for all agents, and substitution of medications or adjustments in dosage or dose timing may be needed. Furthermore, while women with IBD who have not had prior pelvic surgery are as likely to conceive as non-IBD counterparts, there is evidence to suggest that pregnancy outcomes may be worse in women with IBD, particularly if they have active disease during conception or pregnancy. Therefore, a thoughtful discussion between the patient and her healthcare team is critical to ensure awareness of the possible risks of pregnancy to the mother and her infant and how these risks can be minimized with a coordinated effort in counseling, monitoring and medication adherence.
Collapse
Affiliation(s)
- Susie W Ng
- Department of Gastroenterology, University of California, San Francisco, CA 94122, USA
| | | |
Collapse
|
31
|
Mañosa M, Navarro-Llavat M, Marín L, Zabana Y, Cabré E, Domènech E. Fecundity, pregnancy outcomes, and breastfeeding in patients with inflammatory bowel disease: a large cohort survey. Scand J Gastroenterol 2013; 48:427-32. [PMID: 23477328 DOI: 10.3109/00365521.2013.772229] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIM The aim was to assess the impact of inflammatory bowel disease (IBD) and its treatment on fertility, pregnancy outcomes, and breastfeeding. IBD is a chronic inflammatory condition that is usually diagnosed in young adulthood. Patients are often concerned about fertility and pregnancy outcomes. METHODS A structured questionnaire was posted to 850 adults with IBD followed-up on in a single center. RESULTS A total of 503 patients (59%) with a median age of 40 years and equally distributed for gender and type of IBD returned the questionnaire. Overall, 71% of the patients had a total of 659 children, 36% of whom were born after the diagnosis. A total of 132 miscarriages were registered, 46% after the diagnosis of IBD. Most childless patients stated that having no children was a personal decision, and only 6% of them were evaluated and diagnosed with infertility. Pregnancies after diagnosis of IBD had a higher probability of caesarean section and preterm delivery. IBD-related drug therapy was discontinued in 16% of the pregnancies, mainly as a result of medical advice. Babies born after the diagnosis of IBD were less often breastfed. CONCLUSIONS The infertility rate among IBD patients seems to be similar to that seen in the general population. However, a large proportion of patients chose to remain childless. Vaginal delivery and breastfeeding are less likely to occur in babies born after the diagnosis. Suitable information for patients to avoid unwarranted concerns about adverse reproductive outcomes, as well as improved obstetrical and perinatal management, still seems to be necessary.
Collapse
Affiliation(s)
- Míriam Mañosa
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, IBD Unit, Badalona, Catalonia, Spain.
| | | | | | | | | | | |
Collapse
|
32
|
Ananthakrishnan AN, Zadvornova Y, Naik AS, Issa M, Perera LP. Impact of pregnancy on health-related quality of life of patients with inflammatory bowel disease. J Dig Dis 2012; 13:472-7. [PMID: 22908973 DOI: 10.1111/j.1751-2980.2012.00618.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To examine the impact of pregnancy on health-related quality of life (HRQoL) of women with inflammatory bowel disease (IBD). METHODS This was a retrospective study in a tertiary referral center and included women with ≥2 short inflammatory bowel disease questionnaire (SIBDQ) scores obtained during their pregnancy. Regression models were used to identify independent factors influencing SIBDQ scores and changes of SIBDQ scores at different time points. RESULTS A total of 32 women (23 CD, 9 UC) with a mean age at pregnancy of 29.4 years and a mean disease duration of 7.8 years were included in the study. The mean pre-pregnancy SIBDQ score in our cohort was 49, which was significantly lower than the values during (55, P < 0.001) and post-pregnancy (53, P = 0.01). The score during pregnancy directly correlated with the pre-pregnancy SIBDQ score (correlation co-efficient 0.50, P = 0.003). Half of the patients had a ≥7-point increase in SIBDQ scores during pregnancy. Change in SIBDQ scores during pregnancy was inversely related to the pre-pregnancy score (-0.47, 95% CI -0.75 to -0.20) and changes in disease activity during pregnancy (-1.80, 95% CI -0.75 to -0.20). CONCLUSIONS Half of the pregnant women with IBD in our cohort experienced improvement in their HRQoL. Pre-pregnancy HRQoL is predictive of HRQoL during pregnancy, supporting the need for optimizing disease activity prior to conception.
Collapse
Affiliation(s)
- Ashwin N Ananthakrishnan
- Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | |
Collapse
|
33
|
Habal FM, Huang VW. Review article: a decision-making algorithm for the management of pregnancy in the inflammatory bowel disease patient. Aliment Pharmacol Ther 2012; 35:501-15. [PMID: 22221203 DOI: 10.1111/j.1365-2036.2011.04967.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 12/07/2011] [Accepted: 12/09/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Inflammatory bowel disease affects patients who are in their reproductive years. There are many questions regarding the management of IBD patients who are considering or who are already pregnant. These include the effect of the disease and the medications on fertility and on the pregnancy outcome. AIM To create an evidence-based decision-making algorithm to help guide physicians through the management of pregnancy in the IBD patient. METHODS A literature review using phrases that include: 'inflammatory bowel disease', 'Crohn's disease', 'ulcerative colitis', 'pregnancy', 'fertility', 'breast feeding', 'delivery', 'surgery', 'immunomodulators', 'azathioprine', 'mercaptopurine', 'biologics', 'infliximab', 'adalimumab', 'certolizumab'. CONCLUSIONS The four decision-making nodes in the algorithm for the management of pregnancy in the IBD patient, and the key points for each one are as follows: (i) preconception counselling - pregnancy outcome is better if patients remain in remission during pregnancy, (ii) contemplating pregnancy or is already pregnant - drugs used to treat IBD appear to be safe during pregnancy, with the exception of methotrexate and thalidomide, (iii) delivery and (iv) breast feeding - drugs used to treat IBD appear to be safe during lactation, except for ciclosporin. Another key point is that biological agents may be continued up to 30 weeks gestation. The management of pregnancy in the IBD patient should be multi-disciplinary involving the patient and her partner, the family physician, the gastroenterologist and the obstetrician.
Collapse
Affiliation(s)
- F M Habal
- Department of Medicine, University Health Network, University of Toronto, ON, Canada.
| | | |
Collapse
|
34
|
Bortoli A, Pedersen N, Duricova D, D'Inca R, Gionchetti P, Panelli MR, Ardizzone S, Sanroman AL, Gisbert JP, Arena I, Riegler G, Marrollo M, Valpiani D, Corbellini A, Segato S, Castiglione F, Munkholm P. Pregnancy outcome in inflammatory bowel disease: prospective European case-control ECCO-EpiCom study, 2003-2006. Aliment Pharmacol Ther 2011; 34:724-34. [PMID: 21815900 DOI: 10.1111/j.1365-2036.2011.04794.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) frequently affects women during their reproductive years. Pregnancy outcome in women with IBD is well described, particularly in retrospective studies. AIM To evaluate the pregnancy outcome in patients with IBD in a prospective European multicentre case-control study. METHODS Inflammatory bowel disease pregnant women from 12 European countries were enrolled between January 2003 and December 2006 and matched (1:1) to non-IBD pregnant controls by age at conception and number of previous pregnancies. Data on pregnancy and newborn outcome, disease activity and therapy were prospectively collected every third month using a standard questionnaire. Logistic regression analysis with odds ratio was used for statistical analyses. P value<0.05 was considered significant. RESULTS A total of 332 pregnant women with IBD were included: 145 with Crohn's disease (CD) and 187 with ulcerative colitis (UC). Median age (range) at conception was 31 years (15-40) in CD and 31 (19-42) in UC patients. No statistically significant differences in frequency of abortions, preterm deliveries, caesarean sections, congenital abnormalities and birth weight were observed comparing CD and UC women with their non-IBD controls. In CD, older age was associated with congenital abnormalities and preterm delivery; smoking increased the risk of preterm delivery. For UC, older age and active disease were associated with low birth weight; while older age and combination therapy were risk factors for preterm delivery. CONCLUSION In this prospective case-control study, women with either Crohn's disease or ulcerative colitis have a similar pregnancy outcome when compared with a population of non-inflammatory bowel disease pregnant women.
Collapse
|
35
|
Naganuma M, Kunisaki R, Yoshimura N, Nagahori M, Yamamoto H, Kimura H, Sako M, Kawaguchi T, Takazoe M, Yamamoto S, Matsui T, Hibi T, Watanabe M. Conception and pregnancy outcome in women with inflammatory bowel disease: A multicentre study from Japan. J Crohns Colitis 2011; 5:317-23. [PMID: 21683301 DOI: 10.1016/j.crohns.2011.02.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 02/03/2011] [Accepted: 02/03/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neither conceptions and pregnancy outcomes nor the safety of medications for childbearing inflammatory bowel disease (IBD) patients has been investigated in Asia. The aim of this study is to analyse conception and pregnancy outcomes of Japanese female IBD patients. METHODS We conducted a retrospective cohort study of pregnant IBD patients at 6 institutions. The incidences of abortion, Caesarean delivery, low birth weight (LBW) (<2500g), and congenital malformation were analysed in these patients. Risk factors associated with adverse outcomes in IBD patients were also assessed. RESULTS A total of 325 patients experienced 534 conceptions. Among these, 303 conceptions (57%) were observed during/after disease onset. Although conceptions and pregnancy outcomes after disease onset were comparable to the observed levels prior to disease onset in UC patients, the incidences of spontaneous abortion (OR 5.3; 95%CI 1.1-25.0) and Caesarean delivery (OR 4.8; 95%CI 1.5-15.0) were significantly higher in Crohn's disease (CD) patients whose conceptions occurred after disease onset compared to CD patients whose conceptions occurred before disease onset. The incidences of spontaneous abortion, LBW, and Caesarean delivery were higher in CD patients who had a history of surgery for perianal lesions than in those who did not have perianal lesions or who had ulcerative colitis (UC). In the IBD patients studied after disease onset, independent risk factors for spontaneous abortions included a history of previous treatment for sterility (OR 2.9; 95%CI 1.2-7.0). Independent risk factors for Caesarean operation (OR 4.1, 95% CI: 1.7-10.1) and LBW (OR 3.5, 95% CI: 1.3-9.1) included a history of bowel resection for the treatment of IBD. Congenital malformation was not associated with the factors of type of disease, smoking, and previous surgery. CONCLUSION In Japanese UC patients, conception and pregnancy outcomes after disease onset were comparable to the outcomes observed prior to disease onset, whereas CD appeared to be associated with adverse outcomes. Caesarean operation and LBW were more frequently observed in CD patients who had a history of surgery for perianal lesions and bowel resection.
Collapse
Affiliation(s)
- Makoto Naganuma
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Beaulieu DB, Kane S. Inflammatory bowel disease in pregnancy. World J Gastroenterol 2011; 17:2696-701. [PMID: 21734776 PMCID: PMC3122257 DOI: 10.3748/wjg.v17.i22.2696] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 06/15/2010] [Accepted: 06/22/2010] [Indexed: 02/06/2023] Open
Abstract
Crohn’s disease and ulcerative colitis affect women in their child-bearing years. Family planning has come to be a common discussion between the gastroenterologist and the inflammatory bowel disease (IBD) patient. Disease control prior to desired conception and throughout pregnancy is the most important thing to keep in mind when caring for the IBD patient. Continued medical management during pregnancy is crucial in optimizing outcomes. Studies indicate that quiescent disease prior to conception infer the best pregnancy outcomes, similar to those in the general population. Active disease prior to and during pregnancy, can lead to complications such as pre-term labor, low birth weight, and small for gestational age infants. Although there are no definitive long term effects of pregnancy on IBD, there are some limited studies that suggest that it may alter the disease course. Understanding the literature and its limitations is important in the modern era of IBD care. Educating the patient and taking a team approach with the obstetrician will help achieve successful outcomes for mother and baby.
Collapse
|
37
|
Raatikainen K, Mustonen J, Pajala MO, Heikkinen M, Heinonen S. The effects of pre- and post-pregnancy inflammatory bowel disease diagnosis on birth outcomes. Aliment Pharmacol Ther 2011; 33:333-9. [PMID: 21138456 DOI: 10.1111/j.1365-2036.2010.04538.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Inflammatory bowel diseases are frequent in women at their optimum age for reproduction. Possible effects on pregnancy are therefore of interest. AIM To assess pregnancy outcomes in 212 women: 135 of whom were diagnosed with inflammatory bowel disease before pregnancy and 77 after pregnancy. METHODS A clinical birth database was examined retrospectively. Odds ratios (ORs) for the main outcomes were calculated with 95% confidence intervals; these were adjusted for confounding factors. RESULTS Overall, pregnancy outcomes were good. No increased risk of preterm births or need for neonatal intensive care was observed. However, women with inflammatory bowel disease had more growth-retarded newborns, at an adjusted OR of 2.08 (1.26-3.44) and the mode of delivery was more frequently Caesarean section, with an OR of 2.75 (1.82-4.16). In the women who were diagnosed with inflammatory bowel disease after the pregnancy, we found no difference in the obstetric outcome as compared with the general obstetric population. CONCLUSIONS Most women with inflammatory bowel disease have a normal pregnancy outcome and, overall, inflammatory bowel disease during pregnancy poses low-to-moderate risks, the main concern being increased risk of impaired foetal growth. Normal maternal weight gain during pregnancy, possibly indicating a more stable disease, appeared to protect against adverse outcomes.
Collapse
Affiliation(s)
- K Raatikainen
- Department of Obstetrics and Gynaecology, Kuopio University Hospital, Finland.
| | | | | | | | | |
Collapse
|
38
|
Molnár T, Farkas K, Nagy F, Lakatos PL, Miheller P, Nyári T, Horváth G, Szepes Z, Marik A, Wittmann T. Pregnancy outcome in patients with inflammatory bowel disease according to the activity of the disease and the medical treatment: a case-control study. Scand J Gastroenterol 2010; 45:1302-6. [PMID: 20602569 DOI: 10.3109/00365521.2010.503967] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE There is limited data on pregnancy outcome in inflammatory bowel diseases (IBD) (Crohn's disease [CD] and ulcerative colitis [UC]) from Eastern Europe. The aim of our multicenter study was to compare the pregnancy outcomes and the data of infants in pregnancies before and after the diagnosis of IBD. PATIENTS AND METHODS 97 pregnancies in women with IBD (36 CD and 61 UC) and 70 pregnancies in the same women before the diagnosis of IBD (24 CD and 46 UC) were compared. The influence of disease activity and medical treatment during pregnancy on gestational age at birth, birth weight, health status of the newborns and the frequency of childhood diseases were analyzed. RESULTS Preterm birth and low birth weight were more common in IBD compared to those pregnancies delivered before the diagnosis of the disease (p = 0.008, p = 0.048). The occurrence of congenital abnormalities was not influenced by IBD, whereas childhood diseases occurred more frequently in the offspring of mothers with active UC. Disease activity in CD and UC during pregnancy did not predispose to abnormal birth outcome, compared to inactive disease. The type of medical treatment did not affect the pregnancy outcome in IBD. CONCLUSION Preterm birth and low birth weight were more common in IBD. The medical treatment of the active disease during pregnancy did not increase the frequency of abnormal birth outcomes. Medical maintenance treatment should be continued during pregnancy to avoid relapses, although IBD seems to be an independent risk factor for low birth weight and preterm birth.
Collapse
Affiliation(s)
- Tamás Molnár
- First Department of Medicine, University of Szeged, Szeged, Hungary.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Kwan LY, Mahadevan U. Inflammatory bowel disease and pregnancy: an update. Expert Rev Clin Immunol 2010; 6:643-57. [PMID: 20594137 DOI: 10.1586/eci.10.35] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Women with inflammatory bowel disease have similar rates of conception to the general population unless they have had pelvic surgery. Once pregnant, regardless of disease activity, they have an increased risk of adverse pregnancy outcome and should be followed as high-risk obstetric patients. Most medications are compatible with pregnancy and lactation, as described in this article. Ideally, women should discuss their plans for pregnancy with their physician prior to conception so that risks and benefits can be reviewed, medications adjusted and healthcare maintenance updated. Once pregnant, a multidisciplinary team of gastroenterologists, obstetricians and pediatricians should help to ensure the best care for the mother and child.
Collapse
Affiliation(s)
- Lola Y Kwan
- University of Rochester Medical Center, Rochester, NY, USA
| | | |
Collapse
|
40
|
Sato A, Naganuma M, Asakura K, Nishiwaki Y, Yajima T, Hisamatsu T, Iwao Y, Takebayashi T, Watanabe M, Hibi T. Conception outcomes and opinions about pregnancy for men with inflammatory bowel disease. J Crohns Colitis 2010; 4:183-8. [PMID: 21122503 DOI: 10.1016/j.crohns.2009.10.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2009] [Revised: 10/08/2009] [Accepted: 10/22/2009] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Patients with inflammatory bowel disease (IBD) who want to have children are anxious to receive medical treatment. The consensus regarding pregnancy has not been surveyed for male IBD patients. The present study was investigated opinions among male IBD patients about pregnancy, conception and neonatal outcomes for partners. METHODS Subjects comprised 364 of 386 patients enrolled (94.3%). Subjects received a questionnaire regarding their opinions and thoughts about pregnancy. The course of partner's conceptions and presence of neonatal malformations was also surveyed. RESULTS The rate of live births for partners of male IBD patients was 91.6% (219/239). Most patients with CD (29/33; 88%) had their children after surgery had been performed. The rate of expressing hopes to have a child tended to be higher for patients with UC (93/128; 73%) than for patients with CD (61/97; 63%; p=0.21). Furthermore, the rate of hesitation was significantly higher in CD patients (34/107; 32%) than in UC patients (38/188; 20%; p=0.03).Patients considered that safety of medication (51%) and maintenance of remission (41%) was more important than receiving no treatment for IBD (19%) when planning to conceive. Mesalamine and infliximab were more favorable at conception than sulfasalazine and immunomodulators. CONCLUSIONS This is the first report to survey the thinking of male IBD patients regarding pregnancy. Most male IBD patients considered "maintaining remission" as important at conception. Our study provides important information for IBD patients and for the treating physician when planning to conceive.
Collapse
Affiliation(s)
- Asaka Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Keio University, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Abstract
This review covers important questions that arise for physicians caring for women with inflammatory bowel disease. Fertility, pregnancy outcomes and the safety of medications in pregnancy and lactation are discussed.
Collapse
Affiliation(s)
- Uma Mahadevan
- Center for Colitis and Crohn's Disease, University of California, San Francisco, 2330 Post Street 610, San Francisco, CA 94115, USA
| |
Collapse
|
42
|
Abstract
This review covers important questions that arise for physicians caring for women with inflammatory bowel disease. Fertility, pregnancy outcomes and the safety of medications in pregnancy and lactation are discussed.
Collapse
Affiliation(s)
- Uma Mahadevan
- Center for Colitis and Crohn's Disease, University of California, San Francisco, 2330 Post Street 610, San Francisco, CA 94115, USA.
| |
Collapse
|
43
|
Cassina M, Fabris L, Okolicsanyi L, Gervasi MT, Memmo A, Tiboni GM, Di Gianantonio E, Clementi M. Therapy of inflammatory bowel diseases in pregnancy and lactation. Expert Opin Drug Saf 2009; 8:695-707. [DOI: 10.1517/14740330903357463] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
44
|
Nguyen GC, Boudreau H, Harris ML, Maxwell CV. Outcomes of obstetric hospitalizations among women with inflammatory bowel disease in the United States. Clin Gastroenterol Hepatol 2009; 7:329-34. [PMID: 19027089 DOI: 10.1016/j.cgh.2008.10.022] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Revised: 10/20/2008] [Accepted: 10/21/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pregnant women with Crohn's disease (CD) or ulcerative colitis (UC) are at increased risk of adverse outcomes compared with pregnant women without these disorders. We estimated the occurrence of pregnancies in women with CD and UC in the United States and compared outcomes between these patients and the non-inflammatory bowel disease (IBD) obstetric population. METHODS By using the 2005 Nationwide Inpatient Sample, we estimated the number of obstetric hospitalizations, deliveries, and Cesarean deliveries in women with CD, UC, and those without IBD. Outcomes included prevalences of Cesarean delivery, venous thromboembolism (VTE), blood transfusion, and malnutrition. RESULTS Of an estimated 4.21 million deliveries, 2372 and 1368 occurred in women with CD and UC, respectively. Compared with the non-IBD population, adjusted odds of Cesarean delivery were higher in women with CD (adjusted odds ratio [aOR], 1.72; 95% confidence interval [CI], 1.44-2.04) and UC (aOR, 1.29; 95% CI, 1.01-1.66). The risk of VTE was substantially higher in women with CD (aOR, 6.12; 95% CI, 2.91-12.9) and UC (aOR, 8.44; 95% CI, 3.71-19.2) vs the non-IBD population. Blood transfusions occurred more frequently in women with CD (aOR, 2.82; 95% CI, 1.51-5.26), whereas protein-calorie malnutrition occurred more frequently in women with CD (aOR, 20.0; 95% CI, 8.8-45.4) or UC (aOR, 60.8; 95% CI, 28.2-131.0). CONCLUSIONS Adverse pregnancy and maternal outcomes occur more frequently in women with IBD. Measures should be undertaken to reduce maternal complications such as VTE and malnutrition in women with these disorders.
Collapse
Affiliation(s)
- Geoffrey C Nguyen
- Mount Sinai IBD Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
| | | | | | | |
Collapse
|
45
|
Reddy D, Murphy SJ, Kane SV, Present DH, Kornbluth AA. Relapses of inflammatory bowel disease during pregnancy: in-hospital management and birth outcomes. Am J Gastroenterol 2008; 103:1203-9. [PMID: 18422816 DOI: 10.1111/j.1572-0241.2007.01756.x] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are few studies that describe the medical treatment and colitis response rates among patients with a severe relapse of inflammatory bowel disease (IBD) during pregnancy, and few studies of the effect of such a relapse on birth outcomes in these patients. OBJECTIVES To describe the treatment and response rates of severe colitis in pregnancy, and to assess the effects of a severe relapse of colitis during pregnancy on birth outcomes. METHODS We performed a case control study of pregnant patients with IBD hospitalized for a disease relapse at two large treatment centers between 1989 and 2001. Details of management of disease relapse and maternal and fetal outcomes were recorded. RESULTS Eighteen patients (11 ulcerative colitis, 6 Crohn's disease, 1 indeterminate colitis), mean age 28.6 yr (range 19-38) formed the study group; 41 age-matched pregnant IBD patients without disease relapse formed the control group. Study patients were hospitalized at a mean of 15.9-wk gestation (range 8-35) for a mean of 10.4 days (range 3-31). All 18 patients received IV hydrocortisone (mean dose 199 mg/day) and 7 patients (39%) either continued taking or were commenced on immunomodulators: IV cyclosporine (5 patients) and azathioprine/6-MP (3 patients). Fifteen patients (83%) had a clinical response to these medical treatments, 3 patients required colectomy. There were significant differences between study and control groups in gestation period (35.0 wk vs 38.7 wk, respectively, P= 0.0001) and birth weight (2,001 g vs 3,018 g, respectively, P < 0.0001). CONCLUSIONS Treatment with IV hydrocortisone and IV cyclosporine appears effective at inducing remission of colitis but their use must continue to be confined to severely ill patients being treated at specialized centers. Severe relapses of colitis during pregnancy increase the risk of preterm birth and low birth weight.
Collapse
Affiliation(s)
- Deepa Reddy
- Division of Gastroenterology, Mount Sinai Medical Center, One Gustave Levy Place, New York, New York, USA
| | | | | | | | | |
Collapse
|
46
|
Abstract
Inflammatory bowel disease (IBD) is a chronic disorder affecting young adults in their reproductive years. Many young women with IBD express concern about the effect their disease will have on fertility, pregnancy course and fetal development. This article presents an approach to management of IBD in the pregnant patient, including counseling and investigation, and summarizes existing data on the safety of medications used to treat IBD in pregnancy and breastfeeding.
Collapse
|
47
|
Abstract
Two maternal-fetal case presentations illustrate the possible association of active maternal ulcerative colitis during pregnancy and fetal brain injury resulting in long-term neurological sequelae. Thromboembolic complications may occur in the fetus based on similar mechanisms for stroke in children and adults with active inflammatory bowel disease. Identification of thrombophilia in the pregnant woman with active ulcerative colitis may better explain a pathophysiologic mechanism for long-term neurological morbidity in offspring.
Collapse
Affiliation(s)
- Mark S Scher
- Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA.
| |
Collapse
|
48
|
Abstract
Assessment of fetal growth and wellbeing is one of the major purposes of antenatal care. Some fetuses have smaller than expected growth in utero and while some of these fetuses are constitutionally small, others have failed to meet their growth potential, that is they are growth restricted. While severe growth restriction is uncommon, the consequences of it being undetected may include perinatal death or severe morbidity. It is, therefore, important to have strategies in place to detect the fetus at risk of growth restriction. These would include an assessment of 'prior risk' from maternal history and examination combined with the results of biochemical and ultrasound investigations, the most promising of which are uterine artery Doppler and biochemistry. We discuss some of the factors to consider when stratifying the obstetric population into degrees of likelihood for growth restriction, and discuss aspects of the management and outcome of pregnancies complicated by growth restriction.
Collapse
Affiliation(s)
- Andrew C G Breeze
- Division of Fetal-Maternal Medicine, Box 228, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | | |
Collapse
|
49
|
Mahadevan U, Sandborn WJ, Li DK, Hakimian S, Kane S, Corley DA. Pregnancy outcomes in women with inflammatory bowel disease: a large community-based study from Northern California. Gastroenterology 2007; 133:1106-12. [PMID: 17764676 DOI: 10.1053/j.gastro.2007.07.019] [Citation(s) in RCA: 248] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2006] [Accepted: 07/12/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The aim of this study was to determine whether pregnancy outcomes differ between women with and without inflammatory bowel disease (IBD) and to determine what risk factors adversely affect outcomes. METHODS We conducted a cohort study of all pregnant women within the Northern California Kaiser Permanente membership between the years 1995 and 2002. We abstracted the records of all pregnancies in women with IBD (exposed cohort) and a random sample of pregnancies from age-matched women without IBD (unexposed cohort) and evaluated risk factors for spontaneous abortion, complications of pregnancy, and adverse newborn events. RESULTS A total of 461 pregnant women with IBD were matched to 493 unexposed pregnant women. Women with IBD were more likely to have an adverse conception outcome (odds ratio, 1.65; 95% confidence interval, 1.09-2.48), an adverse pregnancy outcome (odds ratio, 1.54; 95% confidence interval, 1.00-2.38), or a pregnancy complication (odds ratio, 1.78; 95% confidence interval, 1.13-2.81); however, the difference between the 2 groups in adverse newborn outcomes was not statistically significant (odds ratio, 1.89; 95% confidence interval, 0.98-3.69). Independent predictors of an adverse outcome included a diagnosis of IBD, a history of surgery for IBD, and non-Caucasian ethnicity. Severity of disease and medical treatments were not associated with an adverse outcome. CONCLUSIONS Women with IBD are more likely to have an adverse outcome related to pregnancy. Disease activity and medical treatment did not predict adverse outcomes in a large, nonreferral population.
Collapse
Affiliation(s)
- Uma Mahadevan
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, California 94115, USA.
| | | | | | | | | | | |
Collapse
|
50
|
Nørgård B, Hundborg HH, Jacobsen BA, Nielsen GL, Fonager K. Disease activity in pregnant women with Crohn's disease and birth outcomes: a regional Danish cohort study. Am J Gastroenterol 2007; 102:1947-54. [PMID: 17573787 DOI: 10.1111/j.1572-0241.2007.01355.x] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES CD is associated with increased risk of adverse birth outcomes, but existing studies have not assessed the impact of disease activity during pregnancy. We examined the impact of disease activity on birth outcomes: LBW, preterm birth, LBW at term, and CAs. METHODS All births by CD women in North Jutland County, Denmark, from January 1, 1977 to December 31, 2005, were evaluated in a cohort study based on linkage between the Danish National Registry of Patients and the Medical Birth Registry. After identification of all births by CD women, review of medical records allowed collection of clinical details (including disease activity and drug therapy during pregnancy). The exposed cohort (N = 71) constituted pregnancies with low/moderate-high disease activity during pregnancy, and the unexposed cohort (N = 86) those with inactive disease. Logistic regression analyses were used to estimate the adjusted relative risks (with 95% confidence intervals) for adverse birth outcomes associated with disease activity in CD pregnancies. In subanalysis, we examined the impact of moderate-high activity. RESULTS In women with disease activity, the adjusted risks of LBW, LBW at term, preterm birth, and CAs were 0.2 (0.0-2.6), 0.4 (0.0-3.7), 2.4 (0.6-9.5), and 0.8 (0.2-3.8), respectively. The crude risk of preterm birth was 3.4 (1.1-10.6) in those with moderate-high disease activity. CONCLUSIONS Disease activity during pregnancy only increased the risk of preterm birth (especially in those with high disease activity). Further research is needed to assess the critical impact of disease activity in larger cohorts of CD women.
Collapse
Affiliation(s)
- Bente Nørgård
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | | | | |
Collapse
|