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Nielsen OH, Gubatan JM, Kolho KL, Streett SE, Maxwell C. Updates on the management of inflammatory bowel disease from periconception to pregnancy and lactation. Lancet 2024; 403:1291-1303. [PMID: 38458222 DOI: 10.1016/s0140-6736(24)00052-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 12/29/2023] [Accepted: 01/09/2024] [Indexed: 03/10/2024]
Abstract
Inflammatory bowel disease (IBD) affects reproductive planning due to psychological effects and mechanical problems related to surgery. Children of people with IBD have an increased risk of about 10% if one parent has IBD and up to 33% if both parents have IBD. The fertility of people with IBD is similar to the general population, but fertility might be reduced in individuals with active IBD, ileal pouch-anal anastomosis, or perianal Crohn's disease. Flaring disease during pregnancy increases complications, such as preterm birth. Thus, disease management with appropriate medications can optimise outcomes. As most medications have minimal fetal risks, people with IBD should be informed about the risks of stopping medications and the importance of maintaining remission. A period of disease remission is advisable before pregnancy and could reduce the risks for both the pregnant person and the fetus. Flexible endoscopy, intestinal ultrasound, and gadolinium-free magnetic resonance enterography are safe during pregnancy. We provide state-of-the-art knowledge on the basis of the latest evidence to ensure successful pregnancy outcomes in controlled IBD.
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Affiliation(s)
- Ole Haagen Nielsen
- Department of Gastroenterology, Medical Section, Herlev Hospital, Copenhagen, Denmark; Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Denmark.
| | - John Mark Gubatan
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Kaija-Leena Kolho
- Department of Pediatrics, Children's Hospital, University of Helsinki, Helsinki, Finland
| | - Sarah Elizabeth Streett
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Cynthia Maxwell
- Department of Obstetrics and Gynaecology, Women's College Hospital, Sinai Health, University of Toronto, ON, Canada
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2
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Altshuler PC, Bradford E, van Swaay A, Rabice S, Gaffney R. Rectovaginal Fistula From Untreated Ulcerative Colitis in Pregnancy: A Case Report and Review of the Literature. Cureus 2023; 15:e40662. [PMID: 37485139 PMCID: PMC10356568 DOI: 10.7759/cureus.40662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/25/2023] Open
Abstract
Inflammatory bowel disease can have reproductive consequences depending on disease severity at the time of conception and antepartum management. A 37-year-old G1 with ulcerative pancolitis initially did not disclose her medical history to the obstetrics providers. She developed worsening hematochezia and microcytic anemia and declined antepartum treatment of ulcerative colitis. She then developed a rectovaginal fistula, underwent cesarean delivery but declined intraoperative management of the fistula, and started treatment after significant postpartum weight loss. She was ultimately lost to follow-up care. For patients with ulcerative colitis, a multidisciplinary team approach should be utilized to identify barriers to care, prevent disease progression, and optimize pregnancy outcomes. Delivery methods should be individualized to the patient, and further studies are necessary to establish guidelines.
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Affiliation(s)
- Paulina C Altshuler
- Obstetrics and Gynecology, Intermountain Healthcare/Saint Joseph Hospital, Denver, USA
| | - Eric Bradford
- General Surgery, Intermountain Healthcare/Saint Joseph Hospital, Denver, USA
| | - Annette van Swaay
- Obstetrics and Gynecology, Intermountain Healthcare/Saint Joseph Hospital, Denver, USA
| | - Sarah Rabice
- Female Pelvic Medicine and Reconstructive Surgery, University of Iowa, Iowa City, USA
| | - Rachel Gaffney
- Obstetrics and Gynecology, Intermountain Healthcare/Saint Joseph Hospital, Denver, USA
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3
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Laube R, Selinger CP, Seow CH, Christensen B, Flanagan E, Kennedy D, Mountifield R, Seeho S, Shand A, Williams AJ, Leong RW. Australian inflammatory bowel disease consensus statements for preconception, pregnancy and breast feeding. Gut 2023; 72:1040-1053. [PMID: 36944479 DOI: 10.1136/gutjnl-2022-329304] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/21/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Because pregnancy outcomes tend to be worse in women with inflammatory bowel disease (IBD) than in those without, we aimed to update consensus statements that guide the clinical management of pregnancy in patients with IBD. DESIGN A multidisciplinary working group was established to formulate these consensus statements. A modified RAND/UCLA appropriateness method was used, consisting of a literature review, online voting, discussion meeting and a second round of voting. The overall agreement among the delegates and appropriateness of the statement are reported. RESULTS Agreement was reached for 38/39 statements which provide guidance on management of pregnancy in patients with IBD. Most medications can and should be continued throughout pregnancy, except for methotrexate, allopurinol and new small molecules, such as tofacitinib. Due to limited data, no conclusion was reached on the use of tioguanine during pregnancy. Achieving and maintaining IBD remission before conception and throughout pregnancy is crucial to optimise maternofetal outcomes. This requires a multidisciplinary approach to engage patients, allay anxieties and maximise adherence tomedication. Intestinal ultrasound can be used for disease monitoring during pregnancy, and flexible sigmoidoscopy or MRI where clinically necessary. CONCLUSION These consensus statements provide up-to-date, comprehensive recommendations for the management of pregnancy in patients with IBD. This will enable a high standard of care for patients with IBD across all clinical settings.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, New South Wales, Australia
| | | | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Britt Christensen
- Gastroenterology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Emma Flanagan
- Department of Gastroenterology, University of Melbourne, Melbourne, Victoria, Australia
| | - Debra Kennedy
- MotherSafe, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Reme Mountifield
- Department of Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Sean Seeho
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Antonia Shand
- Department of Maternal Foetal Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Astrid-Jane Williams
- Department of Gastroenterology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Rupert W Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, New South Wales, Australia
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Concord, New South Wales, Australia
- The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
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4
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Donovan B, Spiel M. Inflammatory Bowel Disease in the Childbearing Adult and Newborn. Neoreviews 2023; 24:10-23. [PMID: 36587009 DOI: 10.1542/neo.24-1-e10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Inflammatory bowel disease (IBD) often affects people in their childbearing years and has implications for pregnancy outcomes, particularly as related to increased risk of preterm delivery and effects of immunosuppressive medications on the fetus. Ideally, people with IBD should attempt conception at a time when their disease is in remission to optimize pregnancy outcomes and reduce risks of flares. Generally, pregnant individuals should continue immunosuppressive medications throughout gestation in an attempt to control the disease. Maternal risks of IBD in pregnancy include exacerbated anemia, disease flare, cesarean delivery, and treatment risks. Fetal and neonatal risks include preterm birth, low birthweight, and medication exposures. There are too few clinical trials that include pregnant or breastfeeding patients to analyze the risk/benefit profile of immunosuppressive medications for IBD treatment during pregnancy, limiting the amount of data available to guide medical treatment in this population. More studies are needed on IBD therapies, particularly as more biologics are developed and become the mainstay of treatment. Neonatal clinicians should be aware of in utero medication exposure to help guide decisions regarding newborn care.
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Affiliation(s)
- Bridget Donovan
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA
| | - Melissa Spiel
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA
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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.
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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
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6
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Guerrero Vinsard D, Karagozian R, Wakefield DB, Kane SV. Maternal Outcomes and Pregnancy-Related Complications Among Hospitalized Women with Inflammatory Bowel Disease: Report from the National Inpatient Sample. Dig Dis Sci 2022; 67:4295-4302. [PMID: 34406586 DOI: 10.1007/s10620-021-07210-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/02/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Previous studies have been inconsistent in reporting the risk of pregnancy-related complications in women with IBD. We aimed to investigate the differences in frequencies of pregnancy-related complications requiring hospitalization in women with IBD compared to women without IBD. METHODS We performed a population-based, cross-sectional study using the 2014 USA National Inpatient Sample. Frequencies of ICD-9 codes for pregnancy-related complications in women aged 18-35 years with IBD were compared to women with no IBD controlling for confounders predisposing to pregnancy complications. Adjusted odds ratios were calculated for each outcome. RESULTS A total of 6705 women with IBD and a pregnancy complication were discharged from the hospital in 2014. In multivariate analyses, there was no statistically significant difference between women with and without IBD for: spontaneous abortion, post-abortion complications, ectopic pregnancy, hemorrhage, severe preeclampsia, eclampsia, early labor, polyhydramnios, hyperemesis, missed abortion, mental disorder during pregnancy, and forceps delivery. Women with IBD had significant lower odds for prolonged pregnancy, gestational diabetes, fetal distress, umbilical cord complications, obstetric trauma, mild preeclampsia, and hypertension. There was, however, higher odds for infectious and parasitic complications (OR 1.74, 95% CI 1.42-2.14, p < 0.0001), UTIs (OR 1.65, 95% CI 1.07-2.60, p = 0.02), and anemia (OR 5.26, 95% CI 4.01-6.90, p < 0.0001). CONCLUSIONS In this large population-based analysis, women with IBD had higher odds for certain infections such as UTIs and anemia during pregnancy when compared to women with no IBD. For other pregnancy-related complications, women with IBD had the same or lower odds than women with no IBD. These data are important to share with women with IBD considering pregnancy.
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Affiliation(s)
- Daniela Guerrero Vinsard
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 1ST St SW, Rochester, MN, 55905, USA.
| | - Raffi Karagozian
- Department of Gastroenterology and Hepatology, Tufts Medical Center, Boston, MA, USA
| | | | - Sunanda V Kane
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 1ST St SW, Rochester, MN, 55905, USA
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7
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A national study of pregnancy-related maternal and fetal outcomes in women with inflammatory bowel disease. Int J Colorectal Dis 2022; 37:1535-1543. [PMID: 35612619 DOI: 10.1007/s00384-022-04185-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS The incidence of inflammatory bowel disease (IBD) among women is highest during their reproductive years and current estimates suggest that the rate of conception is low in female IBD patients. The aim of our study was to assess the burden of adverse maternal and perinatal outcomes among female IBD patients. METHODS Using the national inpatient sample database from 2016 to 2018, we recruited all female patients above the age of 15 years admitted with a primary diagnosis of pregnancy and a secondary diagnosis of IBD. We adjusted our results for hospital and patient level variables including age, race, socioeconomic status, hypertension, diabetes mellitus, obesity, smoking, hyperlipidemia, alcohol use, and malnutrition. Multivariable regression analysis was used for analysis. RESULTS Pregnant women with IBD had greater odds of gestational diabetes (adjusted odds ratio [AOR] 1.55, 95% confidence interval [CI] 1.04-2.3, p 0.02), hypertensive complications (AOR 1.35, 95% CI 1.06-1.72, p 0.01), and pre-term delivery (AOR, 1.41 95% CI 1.13-1.76, p 0.003). Pregnancies with co-existent IBD were associated with fetal growth restriction (AOR 1.27, 95% CI 1-1.63, p 0.04) and fetal death (AOR 3.21, 95% CI 1.72-6.00, p < 0.01). Odds of experiencing postpartum hemorrhage or large for gestational age infant were comparable to general population. Crohn's disease was independently associated with increased odds of worse maternal and fetal outcome. IBD patients had increased mean length of stay by 0.14 days and increased mean hospital charges of $2741. CONCLUSIONS Women with IBD had greater likelihood of poor maternal and fetal outcomes and increased hospital resource utilization.
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8
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Wiestler M, Seidler U. Mit Morbus Crohn und Colitis ulcerosa sicher durch die Schwangerschaft. Geburtshilfe Frauenheilkd 2022. [DOI: 10.1055/a-1430-4878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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9
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Chaparro M, Donday MG, Abad-Santos F, Martín de Carpi FJ, Maciá-Martínez MÁ, Montero D, Acosta D, Brenes Y, Gisbert JP. The safety of drugs for inflammatory bowel disease during pregnancy and breastfeeding: the DUMBO registry study protocol of GETECCU. Therap Adv Gastroenterol 2021; 14:17562848211018097. [PMID: 34158835 PMCID: PMC8182220 DOI: 10.1177/17562848211018097] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/13/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Active disease during conception and pregnancy in women with inflammatory bowel disease (IBD) increases the risk of pregnancy complications and adverse neonatal outcomes. The use of IBD treatments during pregnancy should be weighed against their adverse effects on the neonate, but longer-term safety data and data on serious infection rates and malignancies postnatally are lacking, particularly for newer drugs, such as tofacitinib, vedolizumab and ustekinumab. METHODS This ongoing, prospective registry study being conducted at 70 centres in Spain is enrolling pregnant women who are ⩾18 years, are at any point in pregnancy up to the end of the second trimester and have a diagnosis of Crohn's disease, ulcerative colitis or unclassified IBD. Patients will receive treatment decided independently by their IBD specialist. Each incident gestation will be followed up through pregnancy and the first 4 years postnatally. Three cohorts will be compared: biologicals exposed, immunomodulatory exposed and non-exposed. The primary endpoint is the risk of severe infection in newborns postnatally up to 4 years of age; other endpoints include serious adverse events (SAEs) such as pregnancy and delivery complications, neonatal SAEs, development [Ages and Stages Questionnaire-3 (ASQ3)], and malignancy incidence, up to 4 years of age. IBD specialists will collect maternal data (baseline/end of each trimester/1 month post-delivery), neonatal birth data, and the SAE and ASQ3 data in children exposed during pregnancy, reported every 3 months by the mother. Statistical analysis will include summary statistics for quantitative variables, comparisons of qualitative variables with significance set at p < 0.025 and a binary logistic regression model to determine the risk factors for severe infections. RESULTS Enrolment began in September 2019 and study completion is expected in September 2028. CONCLUSIONS This prospective, controlled study will provide evidence on the long-term safety profile in children after intrauterine and lactation exposure to biological and immunomodulatory IBD treatments, including data on postnatal severe infections, development and malignancies. CLINICALTRIALSGOV IDENTIFIER NCT03894228.
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Affiliation(s)
| | - María G. Donday
- Inflammatory Bowel Disease Unit, Department of
Gastroenterology, Hospital Universitario de La Princesa, Instituto de
Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid
(UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y
Digestivas (CIBEREHD), Madrid, Spain
| | - Francisco Abad-Santos
- Clinical Pharmacology Department, Hospital
Universitario de La Princesa, Instituto Teófilo Hernando, Facultad de
Medicina, UAM, Instituto de Investigación Sanitaria La Princesa (IP),
CIBEREHD, Madrid, Spain,UICEC Hospital Universitario de La Princesa,
Plataforma SCReN (Spanish Clinical Research Network), IP, Madrid,
Spain
| | | | - Miguel Ángel Maciá-Martínez
- Pharmacoepidemiology and Pharmacovigilance
Division, Medicines for Human Use Department, Spanish Agency for Medicines
and Medical Devices (AEMPS), Madrid, Spain
| | - Dolores Montero
- Pharmacoepidemiology and Pharmacovigilance
Division, Medicines for Human Use Department, Spanish Agency for Medicines
and Medical Devices (AEMPS), Madrid, Spain
| | - Diana Acosta
- Inflammatory Bowel Disease Unit, Department of
Gastroenterology, Hospital Universitario de La Princesa, Instituto de
Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid
(UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y
Digestivas (CIBEREHD), Madrid, Spain
| | - Yanire Brenes
- Inflammatory Bowel Disease Unit, Department of
Gastroenterology, Hospital Universitario de La Princesa, Instituto de
Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid
(UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y
Digestivas (CIBEREHD), Madrid, Spain
| | - Javier P. Gisbert
- Inflammatory Bowel Disease Unit, Department of
Gastroenterology, Hospital Universitario de La Princesa, Instituto de
Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid
(UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y
Digestivas (CIBEREHD), Madrid, Spain
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Guerrero Vinsard D, Kane SV. Biologics and pregnancy: a clinician's guide to the management of IBD in pregnant women. Expert Rev Gastroenterol Hepatol 2021; 15:633-641. [PMID: 33440996 DOI: 10.1080/17474124.2021.1876562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Women with inflammatory bowel disease (IBD) endorse a tremendous amount of concern about medication exposure during pregnancy and their effects on the fetus. Medical providers caring for this patient population should be well informed and feel comfortable counseling their patients for the best pregnancy outcome possible.Areas covered: It is of particular importance to understand the implications of use of biologics in preconception, pregnancy, and postpartum timeframes. Herein, we aim to inform the clinician about the impact of uncontrolled inflammation during pregnancy, the mechanisms of biologic transport through the placenta, the effects of biologics in maternal and neonatal outcomes, and additional postpartum considerations such as breastfeeding and vaccination safety.Expert opinion: The groundwork already set by previous research in terms of safety of biologic therapy during pregnancy has been reassuring. With the advent of more mechanisms of action but similar protein structure, i.e. they are IgG1 antibodies; the authors anticipate the recommendation of continuation of therapy throughout pregnancy will be sustained.
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Affiliation(s)
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, MN, USA
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11
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Laube R, Paramsothy S, Leong RW. Review of pregnancy in Crohn's disease and ulcerative colitis. Therap Adv Gastroenterol 2021; 14:17562848211016242. [PMID: 34046084 PMCID: PMC8135214 DOI: 10.1177/17562848211016242] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/19/2021] [Indexed: 02/04/2023] Open
Abstract
Inflammatory bowel disease (IBD) frequently affects women of childbearing age and can have implications in pregnancy. Most women with IBD have comparable fertility with women in the general population. Fertility is reduced in women with active disease or previous ileal-pouch-anal anastomosis (IPAA) surgery and is temporarily reduced in men taking sulfasalazine. Women with IBD have an increased risk of preterm delivery, low birth weight, small-for-gestational-age infants and Cesarean section (CS) delivery, however, no increased risk of congenital abnormalities. These adverse outcomes are particularly prevalent for women with active IBD compared with those with quiescent disease. Conception should occur during disease remission to optimize maternal and fetal outcomes and reduce the risk of disease exacerbations during pregnancy. Pre-conception counseling is therefore pertinent to provide patient education, medication review for risk of teratogenicity and objective disease assessment. Most medications are safe during pregnancy and breastfeeding, with the exception of methotrexate, ciclosporin, allopurinol and tofacitinib. Delivery modality should be guided by obstetric factors in most cases; however, CS is recommended for women with active perianal disease and can be considered for women with inactive perianal disease or IPAA. In conclusion, most women with IBD have uncomplicated pregnancies. Active IBD is the predominant predictor of poor outcomes and disease exacerbations; therefore, maintenance of disease remission during and before pregnancy is crucial.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
| | - Sudarshan Paramsothy
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | - Rupert W. Leong
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2137, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
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12
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Kim MA, Kim YH, Chun J, Lee HS, Park SJ, Cheon JH, Kim TI, Kim WH, Park JJ. The Influence of Disease Activity on Pregnancy Outcomes in Women With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis. J Crohns Colitis 2021; 15:719-732. [PMID: 33175122 DOI: 10.1093/ecco-jcc/jjaa225] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Robust evidence regarding the impact of disease activity on pregnancy outcomes in women with inflammatory bowel disease [IBD] is crucial for both clinicians and patients in preparing a birth plan. We sought to perform a systematic review and meta-analysis to assess the pooled influences of disease activity on pregnancy outcomes in women with IBD. METHODS We searched MEDLINE, EMBASE and the COCHRANE library to identify articles comparing pregnancy outcomes between active and inactive IBD at the time of conception or during pregnancy. A meta-analysis was performed using a random-effects model to pool estimates and report odds ratios [ORs]. RESULTS A total of 28 studies were identified as eligible for the meta-analysis. In women with active IBD, the pooled ORs for low birth weight [LBW], preterm birth, small for gestational age [SGA], spontaneous abortion and stillbirths were respectively 3.81 (95% confidence interval [CI] 1.81-8.02), 2.42 [95% CI 1.74-3.35], 1.48 [95% CI 1.19-1.85], 1.87 [95% CI 1.17-3.0] and 2.27 [95% CI 1.03-5.04] compared to women with inactive IBD. In the subgroup analysis based on disease type, women with active ulcerative colitis had an increased risk of LBW, preterm birth and spontaneous abortion. Women with active Crohn's disease had a higher risk of preterm birth, SGA and spontaneous abortion. CONCLUSIONS Active IBD during the periconception period and pregnancy is associated with an increased risk of adverse pregnancy outcomes. Our data suggest that pregnancy should be planned when the disease is quiescent, and continuous disease control is important even during pregnancy.
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Affiliation(s)
- Min-A Kim
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Han Kim
- Department of Obstetrics and Gynecology, Severance Hospital, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Jaeyoung Chun
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Biostatics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Rottenstreich A, Shifman Z, Grisaru-Granovksy S, Mishael T, Koslowsky B, Bar-Gil Shitrit A. Factors Associated with Inflammatory Bowel Disease Flare During Pregnancy Among Women with Preconception Remission. Dig Dis Sci 2021; 66:1189-1194. [PMID: 32356256 DOI: 10.1007/s10620-020-06282-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 04/16/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND The factors associated with inflammatory bowel diseases (IBD) relapse throughout gestation in those with preconception remission remain unknown. AIMS We aimed to investigate disease and pregnancy course among IBD women with quiescent disease at conception. METHODS Women with IBD attending a multidisciplinary clinic for preconception, antenatal and postnatal treatment were prospectively recruited during 2011-2018. RESULTS Overall, 298 women with IBD with quiescent disease at the time of conception constituted the study cohort. Of these, 112 (37.6%) women experienced disease flare during pregnancy. The risk of disease relapse was higher in those with ulcerative colitis (UC) as compared to those with Crohn's disease (CD) (48.1% vs. 31.8%, P = 0.005). The proportion of women with prior IBD-related gastrointestinal surgery was lower in those who experienced disease flare up (13.4% vs. 26.3%, P = 0.009). The use of biologic therapy at the time of conception was associated with lower rates of disease relapse (25.0% vs. 43.9%, P = 0.001). In multivariate analysis, use of conventional medications or no treatment (aOR [95% CI]: 2.0 (1.12, 3.57), P = 0.02) and lack of prior history of IBD-related surgery (aOR [95% CI]: 3.13 (1.37, 7.14), P = 0.007) were independently positively associated with disease relapse. Rates of hospitalization during pregnancy (21.4% vs. 2.2%, P < 0.001) and preterm delivery (22.3% vs. 9.1%, P = 0.002) were higher, and birthweight was lower (median 2987 vs. 3153 grams, P = 0.05) in those with disease flare as compared to those who maintained remission. CONCLUSION Prior IBD-related surgery and biologic therapy were found as independent protective factors against relapse during pregnancy among women with quiescent disease at conception.
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Affiliation(s)
- Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem, 91120, Israel.
| | - Zlil Shifman
- IBD MOM Unit, Shaare Zedek Medical Center Affiliated with the Medical School, Digestive Diseases Institute, Hebrew University, Jerusalem, Israel
| | - Sorina Grisaru-Granovksy
- IBD MOM Unit, Shaare Zedek Medical Center Affiliated with the Medical School, Digestive Diseases Institute, Hebrew University, Jerusalem, Israel
| | - Tali Mishael
- IBD MOM Unit, Shaare Zedek Medical Center Affiliated with the Medical School, Digestive Diseases Institute, Hebrew University, Jerusalem, Israel
| | - Benjamin Koslowsky
- IBD MOM Unit, Shaare Zedek Medical Center Affiliated with the Medical School, Digestive Diseases Institute, Hebrew University, Jerusalem, Israel
| | - Ariella Bar-Gil Shitrit
- IBD MOM Unit, Shaare Zedek Medical Center Affiliated with the Medical School, Digestive Diseases Institute, Hebrew University, Jerusalem, Israel
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14
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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.
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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
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15
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Laube R, Paramsothy S, Leong RW. Use of medications during pregnancy and breastfeeding for Crohn's disease and ulcerative colitis. Expert Opin Drug Saf 2021; 20:275-292. [PMID: 33412078 DOI: 10.1080/14740338.2021.1873948] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: The peak age of diagnosis of inflammatory bowel disease (IBD) occurs during childbearing years, therefore management of IBD during pregnancy is a frequent occurrence. Maintenance of disease remission is crucial to optimize pregnancy outcomes, and potential maternal or fetal toxicity from medications must be balanced against the risks of untreated IBD.Areas covered: This review summarizes the literature on safety and use of medications for IBD during pregnancy and lactation.Expert opinion: 5-aminosalicylates, corticosteroids and thiopurines are safe for use during pregnancy, while methotrexate and tofacitinib should only be used with extreme caution. Anti-TNF agents (except certolizumab), vedolizumab, ustekinumab and tofacitinib readily traverse the placenta via active transport, therefore theoretically may affect fetal development. Certolizumab only undergoes passive transfer across the placenta, thus has markedly lower cord blood levels making it likely the safest biologic agent for infants. There is reasonable evidence to support the safety of anti-TNF monotherapy and combination therapy during pregnancy and lactation. Vedolizumab and ustekinumab are also thought to be safe in pregnancy and lactation, while tofacitinib is generally avoided due to teratogenic effects in animal studies.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia
| | - Sudarshan Paramsothy
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | - Rupert W Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
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16
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Ali MF, He H, Friedel D. Inflammatory bowel disease and pregnancy: fertility, complications and treatment. Ann Gastroenterol 2020; 33:579-590. [PMID: 33162735 PMCID: PMC7599341 DOI: 10.20524/aog.2020.0536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/27/2020] [Indexed: 12/30/2022] Open
Abstract
Inflammatory bowel disease (IBD) is commonly diagnosed and treated in the young population. Therefore, it is common that women anticipating or undergoing pregnancy will have to cope with the additional burden of their IBD. Pregnancy in an IBD patient also presents challenges for the practitioner, in that the usual diagnostic and therapeutic armamentarium of potential tests and therapies is disrupted. This review covers the implications of IBD for fertility, pregnancy and offspring, and discusses the management of IBD in pregnancy.
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Affiliation(s)
- Mohammad Fahad Ali
- Department of Gastroenterology and Hepatology, Guthrie Cortland Medical Center (Mohammad Fahad Ali)
| | - Harry He
- Department of Medicine, NYU Winthrop University Hospital (Harry He)
| | - David Friedel
- Department of Gastroenterology, NYU Winthrop University Hospital (David Friedel), USA
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17
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Selinger CP, Nelson-Piercy C, Fraser A, Hall V, Limdi J, Smith L, Smith M, Nasur R, Gunn M, King A, Mohan A, Mulgabal K, Kent A, Kok KB, Glanville T. IBD in pregnancy: recent advances, practical management. Frontline Gastroenterol 2020; 12:214-224. [PMID: 33912333 PMCID: PMC8040511 DOI: 10.1136/flgastro-2019-101371] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 04/27/2020] [Accepted: 05/04/2020] [Indexed: 02/04/2023] Open
Abstract
Inflammatory bowel disease (IBD) poses complex issues in pregnancy, but with high-quality care excellent pregnancy outcomes are achievable. In this article, we review the current evidence and recommendations for pregnant women with IBD and aim to provide guidance for clinicians involved in their care. Many women with IBD have poor knowledge about pregnancy-related issues and a substantial minority remains voluntarily childless. Active IBD is associated with an increased risk of preterm birth, low for gestation weight and fetal loss. With the exception of methotrexate and tofacitinib the risk of a flare outweighs the risk of IBD medication and maintenance of remission from IBD should be the main of care. Most women with IBD will experience a normal pregnancy and can have a vaginal delivery. Active perianal Crohn's disease is an absolute and ileal pouch surgery a relative indication for a caesarean section. Breast feeding is beneficial to the infant and the risk from most IBD medications is negligible.
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Affiliation(s)
| | | | - Aileen Fraser
- Gastroenterology, United Hospitals Bristol, Bristol, Avon, UK
| | - Veronica Hall
- Gastroenterology, Royal Bolton Foundation NHS Trust, Bolton, UK
| | - Jimmy Limdi
- Section of iBD- Division of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester, UK,Gastroenterology, Manchester Academic Health Science Centre, Manchester, UK
| | - Lyn Smith
- Gastroenterology, NHS Greater Glasgow and Clyde North Glasgow University Hospitals Division, Glasgow, UK
| | - Marie Smith
- Obstetrics, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Reem Nasur
- Obstetrics, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Melanie Gunn
- Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, UK
| | - Andrew King
- Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, UK
| | - Aarthi Mohan
- Obstetrics, United Hospitals Bristol, Bristol, Avon, UK
| | | | - Alexandra Kent
- Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK
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18
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Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H, Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68:s1-s106. [PMID: 31562236 PMCID: PMC6872448 DOI: 10.1136/gutjnl-2019-318484] [Citation(s) in RCA: 1209] [Impact Index Per Article: 241.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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Affiliation(s)
- Christopher Andrew Lamb
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas A Kennedy
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- University of Exeter, Exeter, UK
| | - Tim Raine
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Philip Anthony Hendy
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Philip J Smith
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Bu'Hussain Hayee
- King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Miranda C E Lomer
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gareth C Parkes
- Barts Health NHS Trust, London, UK
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Christian Selinger
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | | | - R Justin Davies
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Cathy Bennett
- Systematic Research Ltd, Quorn, UK
- Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | | | - Malcolm G Dunlop
- University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Omar Faiz
- Imperial College London, London, UK
- St Mark's Hospital, Harrow, UK
| | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Miles Parkes
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Jeremy Sanderson
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Daniel R Gaya
- Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Tariq H Iqbal
- Queen Elizabeth Hospital Birmingham NHSFoundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Stuart A Taylor
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Melissa Smith
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Matthew Brookes
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
- University of Wolverhampton, Wolverhampton, UK
| | - Richard Hansen
- Royal Hospital for Children Glasgow, Glasgow, UK
- University of Glasgow, Glasgow, UK
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19
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Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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20
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Lee S, Crowe M, Seow CH, Kotze PG, Kaplan GG, Metcalfe A, Ricciuto A, Benchimol EI, Kuenzig ME. The impact of surgical therapies for inflammatory bowel disease on female fertility. Cochrane Database Syst Rev 2019; 7:CD012711. [PMID: 31334846 PMCID: PMC6647933 DOI: 10.1002/14651858.cd012711.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Women with inflammatory bowel disease (IBD) may require surgery, which may result in higher risk of infertility. Restorative proctocolectomy with ileal anal pouch anastomosis (IPAA) may increase infertility, but the degree to which IPAA affects infertility remains unclear, and the impact of other surgical interventions on infertility is unknown. OBJECTIVES Primary objective• To determine the effects of surgical interventions for IBD on female infertility.Secondary objectives• To evaluate the impact of surgical interventions on the need for assisted reproductive technology (ART), time to pregnancy, miscarriage, stillbirth, prematurity, mode of delivery (spontaneous vaginal, instrumental vaginal, or Caesarean section), infant requirement for resuscitation and neonatal intensive care, low and very low birth weight, small for gestational age, antenatal and postpartum hemorrhage, retained placenta, postpartum depression, gestational diabetes, and gestational hypertension/preeclampsia. SEARCH METHODS We searched MEDLINE, Embase, CENTRAL, and the Cochrane IBD Group Specialized Register from inception to September 27, 2018, to identify relevant studies. We also searched references of relevant articles, conference abstracts, grey literature, and trials registers. SELECTION CRITERIA We included observational studies that compared women of reproductive age (≥ 12 years of age) who underwent surgery to women with IBD who had a different type of surgery or no surgery (i.e. treated medically). We also included studies comparing women before and after surgery. Any type of IBD-related surgery was permitted. Infertility was defined as an inability to become pregnant following 12 months of unprotected intercourse. Infertility at 6, 18, and 24 months was included as a secondary outcome. We excluded studies that included women without IBD and those comparing women with IBD to women without IBD.. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies and extracted data. We used the Newcastle-Ottawa Scale to assess bias and GRADE to assess the overall certainty of evidence. We calculated the pooled risk ratio (RR) and 95% confidence interval (CI) using random-effects models. When individual studies reported odds ratios (ORs) and did not provide raw numbers, we pooled ORs instead. MAIN RESULTS We identified 16 observational studies for inclusion. Ten studies were included in meta-analyses, of which nine compared women with and without a previous IBD-related surgery and the other compared women with open and laparoscopic IPAA. Of the ten studies included in meta-analyses, four evaluated infertility, one evaluated ART, and seven reported on pregnancy-related outcomes. Seven studies in which women were compared before and after colectomy and/or IPAA were summarized qualitatively, of which five included a comparison of infertility, three included the use of ART, and three included other pregnancy-related outcomes. One study included a comparison of women with and without IPAA, as well as before and after IPAA, and was therefore included in both the meta-analysis and the qualitative summary. All studies were at high risk of bias for at least two domains.We are very uncertain of the effect of IBD surgery on infertility at 12 months (RR 5.45, 95% CI 0.41 to 72.57; 114 participants; 2 studies) and at 24 months (RR 3.59, 95% CI 1.32 to 9.73; 190 participants; 1 study). Infertility was lower in women who received laparoscopic surgery compared to open restorative proctocolectomy at 12 months (RR 0.70, 95% CI 0.38 to 1.27; 37 participants; 1 study).We are very uncertain of the effect of IBD surgery on pregnancy-related outcomes, including miscarriage (OR 2.03, 95% CI 1.14 to 3.60; 776 pregnancies; 5 studies), use of ART (RR 25.09, 95% CI 1.56 to 403.76; 106 participants; 1 study), delivery via Caesarean section (RR 2.23, 95% CI 1.00 to 4.95; 20 pregnancies; 1 study), stillbirth (RR 1.96, 95% CI 0.42 to 9.18; 246 pregnancies; 3 studies), preterm birth (RR 1.91, 95% CI 0.67 to 5.48; 194 pregnancies; 3 studies), low birth weight (RR 0.61, 95% CI 0.08 to 4.83), and small for gestational age (RR 2.54, 95% CI 0.80 to 8.01; 65 pregnancies; 1 study).Studies comparing infertility before and after IBD-related surgery reported numerically higher rates of infertility at six months (before: 1/5, 20.0%; after: 9/15, 60.0%; 1 study), at 12 months (before: 68/327, 20.8%; after: 239/377, 63.4%; 5 studies), and at 24 months (before: 14/89, 15.7%; after: 115/164, 70.1%; 2 studies); use of ART (before: 5.3% to 42.2%; after: 30.3% to 34.3%; proportions varied across studies due to differences in which women were identified as at risk of using ART); and delivery via Caesarean section (before: 8/73, 11.0%; after: 36/75, 48.0%; 2 studies). In addition, women had a longer time to conception after surgery (two to five months; 2 studies) than before surgery (5 to 16 months; 2 studies). The proportions of women experiencing miscarriage (before: 19/123, 15.4%; after: 21/134, 15.7%; 3 studies) and stillbirth (before: 2/38, 5.3%; after: 3/80: 3.8%; 2 studies) were similar before and after surgery. Fewer women experienced gestational diabetes after surgery (before: 3/37, 8.1%; after: 0/37; 1 study), and the risk of preeclampsia was similar before and after surgery (before: 2/37, 5.4%; after: 0/37; 1 study). We are very uncertain of the effects of IBD-related surgery on these outcomes due to poor quality evidence, including confounding bias due to increased age of women after surgery.We rated evidence for all outcomes and comparisons as very low quality due to the observational nature of the data, inclusion of small studies with imprecise estimates, and high risk of bias among included studies. AUTHORS' CONCLUSIONS The effect of surgical therapy for IBD on female infertility is uncertain. It is also uncertain if there are any differences in infertility among those undergoing open versus laparoscopic procedures. Previous surgery was associated with higher risk of miscarriage, use of ART, Caesarean section delivery, and giving birth to a low birth weight infant, but was not associated with risk of stillbirth, preterm delivery, or delivery of a small for gestational age infant. These findings are based on very low-quality evidence. As a result, definitive conclusions cannot be made, and future well-designed studies are needed to fully understand the impact of surgery on infertility and pregnancy outcomes.
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Affiliation(s)
- Sangmin Lee
- University of CalgaryCommunity Health SciencesCalgaryABCanada
| | - Megan Crowe
- University of OttawaSchool of Epidemiology and Public HealthOttawaONCanada
| | - Cynthia H Seow
- University of CalgaryDepartment of MedicineTRW Building Rm 6D183280 Hospital Drive NWCalgaryABCanadaT2N 4Z6
| | - Paulo G Kotze
- Catholic University of Paraná (PUCPR)IBD Outpatients Clinic, Colorectal Surgery UnitCuritibaBrazil
| | - Gilaad G Kaplan
- University of CalgaryDepartment of MedicineTRW Building Rm 6D183280 Hospital Drive NWCalgaryABCanadaT2N 4Z6
| | - Amy Metcalfe
- University of CalgaryDepartment of Obstetrics & GynecologyCalgaryAlbertaCanada
| | - Amanda Ricciuto
- The Hospital for Sick ChildrenDivision of Gastroenterology, Hepatology & NutritionTorontoONCanada
| | - Eric I Benchimol
- The Children's Hospital of Eastern OntarioDivision of Gastroenterology Hepatology & Nutrition401 Smyth RoadOttawaONCanadaK1H 8L1
- University of OttawaDepartment of PediatricsOttawaONCanada
| | - M Ellen Kuenzig
- The Children's Hospital of Eastern OntarioDivision of Gastroenterology Hepatology & Nutrition401 Smyth RoadOttawaONCanadaK1H 8L1
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21
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Abstract
PURPOSE OF REVIEW Roughly half of the nearly 1.6 million people with inflammatory bowel disease (IBD) are women of reproductive age. Caring for women with IBD who are also pregnant can be challenging, particularly if with a disease flare or in remission, as there are special considerations needed. RECENT FINDINGS Despite older studies concluding potential risks associated with IBD medical therapies, more recent literature reports healthier maternal and birth outcomes associated with disease control and reduction in the inflammatory burden. Most IBD therapies should generally be continued throughout all three trimesters without interruption as this is associated with better outcomes. SUMMARY Active IBD increases risk of pregnancy complications and adverse pregnancy outcomes. Most medications have a favorable safety profile for use during pregnancy, regardless if in disease flare or remission. Short course corticosteroids for induction and management of flare is permitted. Thiopurines should not be started during pregnancy for a disease flare, but may be continued during pregnancy if previously on monotherapy. Biologics should be continued throughout pregnancy without interruption and timing of third trimester dosing made based on drug levels and estimated date of delivery. Risks/benefit assessment of therapies and disease control is important and should be individualized.
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22
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Linson EA, Hanauer SB. More Than a Tumor Marker…A Potential Role for Alpha-Feto Protein in Inflammatory Bowel Disease. Inflamm Bowel Dis 2019; 25:1271-1276. [PMID: 30624658 DOI: 10.1093/ibd/izy394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 11/05/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Human alpha-fetoprotein (hAFP) is a glycoprotein derived from the gut entoderm and expressed sequentially by cells of the yolk sac, fetal liver, and gastrointestinal tract. By adulthood, serum levels of alpha-fetoprotein (AFP) are undetectable in healthy, nonpregnant adults. Despite the clinical utilities of AFP monitoring in pregnancy and malignancy, much remains to be determined regarding its potential physiological functions. METHODS We focused on literature related to AFP's immunoregulatory role and its ability to modulate disease activity both in animal models of autoimmune disorders and in human clinical studies. RESULTS Evidence suggests that AFP plays an important role in immunoregulation by inducing T-cell suppressor activity, downregulating dendritic-like cell antigen expression, and impairing the function of macrophages. Studies evaluating AFP and its effects in rodent models of autoimmune diseases have shown that AFP is associated with downregulation of inflammation. Observations in studies of pregnant patients with immune-mediated inflammatory diseases have also described potential correlations between AFP expression and disease activity during different stages of pregnancy and postpartum. CONCLUSIONS We propose further prospective evaluations of AFP expression during pregnancy in inflammatory bowel disease patients to further correlate with disease activity and consider the potential of AFP as a novel therapeutic agent.
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Affiliation(s)
| | - Stephen B Hanauer
- Northwestern University, Feinberg School of Medicine, Chicago Illinois
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23
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Brunelli R, Perrone S, Perrone G, Galoppi P, De Stefano MG, Maragno AM, Cesarini M, De Carolis A, Masselli G, Vernia P. New-onset ulcerative colitis in pregnancy associated to toxic megacolon and sudden fetal decompensation: Case report and literature review. J Obstet Gynaecol Res 2019; 45:1215-1221. [PMID: 31064034 DOI: 10.1111/jog.13996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 04/14/2019] [Indexed: 12/15/2022]
Abstract
Ulcerative colitis (UC) is a chronic inflammatory disease rarely arising during gestation. Because the available information is based on case reports or small retrospective studies, diagnosis may be difficult and treatment is still controversial. A case of toxic megacolon developing in late pregnancy associated to a sudden fetal decompensation is described. Diagnostic and clinical topics of acute UC onset in pregnancy are debated.A primipara, 34 years old, 33/0 weeks of gestation, was admitted with a diagnosis of preterm labor, associated to acute bloody diarrhea (up to 10 daily motions) and cramping abdominal pain. A diagnosis of new-onset early-stage UC was made by sigmoidoscopy. An intensive care regimen including hydrocortisone, antibiotics and parenteral nutrition was immediately started. Magnetic resonance imaging of maternal abdomen, fostered by the worsening patient conditions, evidenced dilatation of the entire colon and a severely hampered of fetal muscular tone.Toxic megacolon complicated by superimposed Clostridium difficile infection was associated to a sudden fetal decompensation diagnosed by chance during maternal abdominal magnetic resonance imaging. An emergency cesarean section was mandatory. According to a senior surgeon's decision, total colectomy was not immediately performed following cesarean section with reference to the absence of colonic perforation. We obtained a good short-term maternal outcome and an uncomplicated neonatal course. Counseling of those patients must be focused on timely and multidisciplinary intervention in order to improve the course of maternal disease and to prevent fetal distress.
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Affiliation(s)
- Roberto Brunelli
- Department of Gynecological Obstetrical and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Seila Perrone
- Department of Gynecological Obstetrical and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Giuseppina Perrone
- Department of Gynecological Obstetrical and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Paola Galoppi
- Department of Gynecological Obstetrical and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Maria G De Stefano
- Department of Gynecological Obstetrical and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Anna M Maragno
- Department of Gynecological Obstetrical and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Monica Cesarini
- Division of Gastroenterology, Department of Internal Medicine and Medical Specialties, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Aurora De Carolis
- Division of Gastroenterology, Department of Internal Medicine and Medical Specialties, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Gabriele Masselli
- Radiology Dea Department, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Piero Vernia
- Division of Gastroenterology, Department of Internal Medicine and Medical Specialties, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
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de Lima A, Kanis SL, Escher JC, van der Woude CJ. Hepatitis B Vaccination Effective in Children Exposed to Anti-Tumour Necrosis Factor Alpha in Utero. J Crohns Colitis 2018; 12:948-953. [PMID: 29726943 DOI: 10.1093/ecco-jcc/jjy053] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 05/01/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Neonates exposed to tumour necrosis factor [TNF] alpha inhibitors in utero are born with detectable drug levels which can still be detected throughout the first year of life. Since 2011, the hepatitis B virus [HBV] vaccine is routinely administered to all newborns in the Netherlands. Adults treated with anti-TNF have been reported to respond inadequately to the HBV vaccine. The aim of this study was to compare anti-HB levels in anti-TNF-exposed children with non-exposed children following routine Dutch HBV vaccination. METHODS We performed a cross-sectional, controlled cohort study from 2014 to 2017 in a single, tertiary referral centre. Pregnant women treated with anti-TNF for inflammatory bowel disease [IBD] and their subsequent children were recruited from the IBD preconception outpatient clinic. Pregnant women not treated with anti-TNF for IBD and their subsequent children were eligible as controls. Adherence to the Dutch National Vaccination Programme was mandatory for participation in this study. A venous blood sample was obtained 1 month after final HBV vaccination. Anti-HB levels were measured by enzyme-linked immunosorbent assay. RESULTS Anti-HB levels at 12 months did not differ between the anti-TNF-exposed [n = 15] and the control group [n = 12] [> 1000 IU/l vs > 1000 IU/l, p = 0.59]. All children were successfully immunized against HBV, defined as anti-HB > 10 IU/l. Median anti-TNF levels determined in cord blood at birth were 9.0 µg/ml [interquartile range: 3.0-15.0 µg/ml] for infliximab and 0.4. µg/ml [interquartile range: 0.3-0.6 µg/ml] for adalimumab. There were no differences in general birth and health outcomes. CONCLUSION Children born with detectable anti-TNF levels can be effectively vaccinated against HBV.
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Affiliation(s)
- Alison de Lima
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Shannon L Kanis
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Johanna C Escher
- Department of Pediatrics, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, the Netherlands
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Gastro-intestinal surgery and fertility. J Visc Surg 2018; 155 Suppl 1:S49-S55. [PMID: 29857942 DOI: 10.1016/j.jviscsurg.2018.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In France, 10 to 15% of couples in the overall population have a fertility problem. Preservation of sexual and reproductive function should be a major concern for all patients capable of procreation who undergo treatment for gastro-intestinal disease. The gastro-intestinal diseases most often responsible for fertility disorders include chronic inflammatory diseases, intestinal cancer and hereditary diseases, such as the Lynch syndrome and familial adenomatous polyposis. Obesity is responsible for a 20% loss of fertility but the effects of bariatric surgery on fertility are controversial. Nonetheless, in the light of progress in surgical techniques and better knowledge of gastro-intestinal disease the negative impact of surgery on fertility warrants attention. Effectively, fertility can be preserved after certain major gastro-intestinal operations such as cytoreductive surgery with intraperitoneal chemotherapy, total coloprotectomy with ileo-anal anastomosis and rectosigmoid resection, as long as the patient's age permits and resection of the reproductive organs is not necessary.
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Affiliation(s)
- O. Haagen Nielsen
- Dept. of Medicine P, Division of Gastroenterology, and Dept. of Obstetrics and Gynaecology YA, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - B. Andreasson
- Dept. of Medicine P, Division of Gastroenterology, and Dept. of Obstetrics and Gynaecology YA, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - S. Bondesen
- Dept. of Medicine P, Division of Gastroenterology, and Dept. of Obstetrics and Gynaecology YA, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - O. Jacobsen
- Dept. of Medicine P, Division of Gastroenterology, and Dept. of Obstetrics and Gynaecology YA, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - S. Jarnum
- Dept. of Medicine P, Division of Gastroenterology, and Dept. of Obstetrics and Gynaecology YA, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Ito A, Iizuka B, Omori T, Nakamura S, Tokushige K. Relationship between the Clinical Course of Ulcerative Colitis during Pregnancy and the Outcomes of Pregnancy: A Retrospective Evaluation. Intern Med 2018; 57:159-164. [PMID: 29033411 PMCID: PMC5820031 DOI: 10.2169/internalmedicine.8550-16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective Little information is available on the relationship between the clinical course of ulcerative colitis (UC) and the outcomes of pregnancy and delivery in pregnant Japanese women. The aim of this retrospective study was to determine the factors that influence pregnancy and childbirth in middle-aged UC patients. Methods We studied 53 pregnancies in 45 pregnant women with UC who delivered at our department. They included 41 pregnancies that started while in UC remission and 12 pregnancies that started in the UC active phase. The following factors were evaluated: 1) the clinical course of UC; 2) the frequency and details of abnormal pregnancy/abnormal delivery; and 3) the course of pregnancy/delivery. We compared the clinical features, course of UC, and details of treatment between women with a normal pregnancy/delivery and those with an abnormal delivery. Results A comparison of the remission and acute groups showed lower clinical activity indices (CAIs) during pregnancy in the remission group and significantly higher rates of recurrence/exacerbation in the active group (75%) than in the remission group (7.3%). The respective CAIs in the first, second, and third trimesters were 3 and 6, 3 and 5, and 3 and 4, in the remission and active groups, respectively. Live infants were delivered in 51 (96%) pregnancies, with 7 (17%) abnormal pregnancies in the remission group and 4 (33.3%) in the active group (p>0.05). Abnormal delivery occurred in 16 of 53 (30.1%) pregnancies, and the rate was higher in the remission group than in the active group (p>0.05). In both groups, the most common abnormal event during pregnancy was delivery of low-birth-weight infants. Delivery was normal in 37 cases and abnormal in 16 cases. A multivariate analysis showed that a shorter UC disease duration (odds ratio=1.16) and higher CAI in the first trimester (odds ratio=1.49) were associated with an increased risk of abnormal pregnancy. Conclusion Our findings demonstrated that the clinical course of UC, as evaluated by the CAI, during pregnancy influenced the outcome of pregnancy and delivery.
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Affiliation(s)
- Ayumi Ito
- Department of Gastroenterology, Tokyo Women's Medical University, Japan
| | - Bunei Iizuka
- Department of Gastroenterology, Tokyo Women's Medical University, Japan
| | - Teppei Omori
- Department of Gastroenterology, Tokyo Women's Medical University, Japan
| | - Shinichi Nakamura
- Department of Gastroenterology, Tokyo Women's Medical University, Japan
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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.
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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
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Primary Care Evaluation and Management of Gastroenterologic Issues in Women. Obstet Gynecol Clin North Am 2017; 43:347-66. [PMID: 27212096 DOI: 10.1016/j.ogc.2016.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Gastrointestinal disorders often present to the primary care setting where initial preventive, diagnostic, and treatment strategies are implemented. This article reviews the presentation and diagnosis of common gastrointestinal disorders, including colorectal cancer, irritable bowel syndrome, peptic ulcer disease, gallbladder disorders, inflammatory bowel disease, gastroesophageal reflux, and Barrett's esophagus. We focus on the evaluation and management of these diseases in women.
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Abstract
OPINION STATEMENT Inflammatory bowel disease is frequently diagnosed before or during key childbearing years. One of the most important factors for a healthy pregnancy is having quiescent disease prior to conception and maintaining disease remission for the duration of the pregnancy. In order to achieve that, most women will need to continue their inflammatory bowel disease (IBD) treatment during pregnancy. One of the main concerns these women have is whether these medications will have adverse effects on their growing fetus. Aminosalicylates, antibiotics, and steroids are all relatively low risk for use during pregnancy and breastfeeding. Recent studies also support the safety of continuing immunomodulators and anti-tumor necrosis factor agents during pregnancy and with breastfeeding. There seems to be an increased risk for infection, however, with use of combination therapy including both a biologic agent and an immunomodulator. Less evidence is available on the use of anti-integrins in pregnancy; however, the current data suggest they may be safe as well. Conversations about a patient's desire for pregnancy should occur between the patient and provider on a regular basis prior to conception and particularly with any change in disease activity or change in the treatment regimen. This chapter will review the current evidence on the safety of IBD medications during pregnancy and lactation so that providers can more easily discuss the importance of medication adherence for disease remission with their patients who are contemplating conception.
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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.
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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
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Poturoglu S, Ormeci AC, Duman AE. Treatment of pregnant women with a diagnosis of inflammatory bowel disease. World J Gastrointest Pharmacol Ther 2016; 7:490-502. [PMID: 27867682 PMCID: PMC5095568 DOI: 10.4292/wjgpt.v7.i4.490] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/18/2016] [Accepted: 09/22/2016] [Indexed: 02/06/2023] Open
Abstract
The frequency of diagnosis of inflammatory bowel disease (IBD) has increased in younger populations. For this reason, pregnancy in patients with IBD is a topic of interest, warranting additional focus on disease management during this period. The main objective of this article is to summarize the latest findings and guidelines on the management of potential problems from pregnancy to the breastfeeding stage. Fertility is decreased in patients with active IBD. Disease remission prior to conception will likely decrease the rate of pregnancy-related complications. Most of the drugs used for IBD treatment are safe during both pregnancy and breastfeeding. Two exceptions are methotrexate and thalidomide, which are contraindicated in pregnancy. Anti-tumor necrosis factor agents are not advised during the third trimester as they exhibit increased transplacental transmission and potentially cause immunosuppression in the fetus. Radiological and endoscopic examinations and surgical interventions should be performed only when absolutely necessary. Surgery increases the fetal mortality rate. The delivery method should be determined with consideration of the disease site and presence of progression or flare up. Treatment planning should be a collaborative effort among the gastroenterologist, obstetrician, colorectal surgeon and patient.
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Pinder M, Lummis K, Selinger CP. Managing inflammatory bowel disease in pregnancy: current perspectives. Clin Exp Gastroenterol 2016; 9:325-335. [PMID: 27789969 PMCID: PMC5072556 DOI: 10.2147/ceg.s96676] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Inflammatory bowel disease (IBD) affects many women of childbearing age. The course of IBD is closely related to pregnancy outcomes with poorly controlled IBD increasing the risk of prematurity, low weight for gestation, and fetal loss. As such, women with IBD face complex decision making weighing the risks of active disease versus those of medical treatments. This review summarizes the current evidence regarding the safety and efficacy of IBD treatments during pregnancy and lactation aiming to provide up-to-date guidance for clinicians. Over 50% of women have poor IBD- and pregnancy-related knowledge, which is associated with views contrary to medical evidence and voluntary childlessness. This review highlights the effects of poor patient knowledge and critically evaluates interventions for improving patient knowledge and outcomes.
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Affiliation(s)
- Matthew Pinder
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust
| | - Katie Lummis
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust
| | - Christian P Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust; University of Leeds, Leeds, UK
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Selinger CP, Ghorayeb J, Madill A. What Factors Might Drive Voluntary Childlessness (VC) in Women with IBD? Does IBD-specific Pregnancy-related Knowledge Matter? J Crohns Colitis 2016; 10:1151-8. [PMID: 26989194 DOI: 10.1093/ecco-jcc/jjw078] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 03/12/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Inflammatory Bowel Disease (IBD) affects many women of childbearing age, and rates of voluntary childlessness (VC) exceed those of the general population by far. The factors surrounding VC remain incompletely understood. METHODS Female members of the patient organisation Crohn's and Colitis UK aged 18-45 years were invited to complete an online questionnaire collecting data on demographics, disease characteristics, Crohn's and Colitis pregnancy-specific disease-related knowledge (CCPKnow), and childlessness status. RESULTS A total of 1324 women (mean age 33 years) completed the survey: 776 (59%) were diagnosed with Crohn's disease (CD), 496 (38%) with ulcerative colitis (UC) and 4% with inflammatory bowel disease-unclassified (IBD-U); 40% had children (14% pre-diagnosis (I); 26% post-diagnosis (II)), 36% planned to have children at some stage (III), 7% reported fertility problems (IV), and 17% were classified as voluntarily childless (VC). VC was associated with poorer CCPKnow scores [5.98 vs. 7.47 in (III); p < 0.001], older age [35 years old vs. 28 years old in (II); p < 0.001], unemployment (9.7% VC; p < 0.001), being single (34.5% VC; p < 0.001) not seeking medical advice (p < 0.001), and diagnosis of CD (19.3% vs. 13.9% UC; p = 0.015). Women with VC had more hospital admissions [mean 2.85 vs. 2.17 (III); p = 0.03] and surgical interventions [mean 1.27 vs. 0.65 (III); p < 0.001] CONCLUSION The aetiology of VC in women with IBD is multifactorial. Women's choice regarding children appears related to disease burden. VC is also associated with poor knowledge (CCPKnow), and women may stay childless unnecessarily. Patient education programmes could help to reduce the rate of VC in women with IBD, through correcting misconceptions and alleviating patient concerns.
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Affiliation(s)
| | | | - Anna Madill
- School of Psychology, University of Leeds, Leeds, UK
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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.
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Gaidos JKJ, Kane SV. Overcoming challenges of treating inflammatory bowel disease in pregnancy. Expert Rev Clin Immunol 2016; 12:871-8. [PMID: 26981845 DOI: 10.1586/1744666x.2016.1166958] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Inflammatory bowel disease (IBD) is frequently diagnosed before or during the peak reproductive years. Overall management of inflammatory bowel disease is becoming more complex given the nuances involved with multiple mechanisms of action of the current treatment and need for therapeutic monitoring for safety and efficacy; another layer of complexity is added in the setting of a pregnancy. In this review, we have identified several key challenges that health care providers face when caring for patients with IBD during pregnancy. The goal of this review is to provide the most up-to-date evidence and provide our expert recommendations so that providers can more comfortably address patients' questions about pregnancy in IBD and the associated risks as well as optimize their care to ensure the best outcomes possible.
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Affiliation(s)
- Jill K J Gaidos
- a McGuire VA Medical Center , Virginia Commonwealth University , Richmond , VA , USA
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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.
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Fujikawa K, Endo Y, Mizokami A, Takahashi K, Tabuchi M, Ohba K, Nakamura H, Kawakami A. Successful Treatment with Adalimumab for Intestinal Behcet's Disease during Pregnancy. Intern Med 2016; 55:1375-8. [PMID: 27181551 DOI: 10.2169/internalmedicine.55.6590] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 36-year-old Japanese woman with intestinal Behcet's disease was admitted to our hospital due to a recurrent ileocecal ulcer. Because infliximab (IFX) showed secondary failure, IFX was switched to adalimumab (ADA). After the third injection of ADA, she was unexpectedly 4-weeks pregnant. ADA was continued until 20 gestational weeks. Remission of the disease activity was maintained during pregnancy, and the birth was uneventful. The ileocecal ulcer disappeared after her delivery. ADA was detected in the umbilical blood after 119 days from the last infusion. The placental transition and timing of neonatal vaccination should be considered in cases of pregnancy with TNF antibody therapy.
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Affiliation(s)
- Keita Fujikawa
- Department of Rheumatology, Japan Community Healthcare Organization (JCHO), Isahaya General Hospital, Japan
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Fischer T, Grab D, Grubert T, Hantschmann P, Kainer F, Kästner R, Kentenich C, Klockenbusch W, Lammert F, Louwen F, Mylonas I, Pildner von Steinburg S, Rath W, Schäfer-Graf UM, Schleußner E, Schmitz R, Steitz HO, Verlohren S. Maternale Erkrankungen in der Schwangerschaft. FACHARZTWISSEN GEBURTSMEDIZIN 2016. [PMCID: PMC7158353 DOI: 10.1016/b978-3-437-23752-2.00017-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Lee KM, Kim YS, Seo GS, Kim TO, Yang SK. Use of Thiopurines in Inflammatory Bowel Disease: A Consensus Statement by the Korean Association for the Study of Intestinal Diseases (KASID). Intest Res 2015; 13:193-207. [PMID: 26130993 PMCID: PMC4479733 DOI: 10.5217/ir.2015.13.3.193] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 04/29/2015] [Accepted: 05/06/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIMS For decades, thiopurines have been the mainstay of inflammatory bowel disease (IBD) treatment and will play an important role in the future. However, complex metabolism and various side effects limit the use of these potent drugs in clinical practice. The Korean Association for the Study of Intestinal Diseases developed a set of consensus statements with the aim of guiding clinicians on the appropriate use of thiopurines in the management of IBD. METHODS Sixteen statements were initially drafted by five committee members. The quality of evidence and classification of recommendation were assessed according to the Grading of Recommendations Assessment, Development and Evaluation system. The statements were then circulated to IBD experts in Korea for review, feedback, and then finalized and accepted by voting at the consensus meeting. RESULTS The consensus statements comprised four parts: (1) pre-treatment evaluation and management strategy, including value of thiopurine S-methyltransferase screening, dosing schedule, and novel biomarkers for predicting thiopurine-induced leukopenia; (2) treatment with thiopurines with regards to optimal duration of thiopurine treatment and long-term outcomes of combination therapy with anti-tumor necrosis factors; (3) safety of thiopurines, especially during pregnancy and lactation; and (4) monitoring side effects or efficacy of therapy using biomarkers. CONCLUSIONS Thiopurines are an effective treatment option for patients with IBD. Management decisions should be individualized according to the risk of relapse and adverse events.
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Affiliation(s)
- Kang-Moon Lee
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Geom Seog Seo
- Department of Internal Medicine, Digestive Disease Research Institute, Wonkwang University College of Medicine, Iksan, Korea
| | - Tae Oh Kim
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Orabona R, Valcamonico A, Salemme M, Manenti S, Tiberio GAM, Frusca T. Fulminant ulcerative colitis in a healthy pregnant woman. World J Gastroenterol 2015; 21:6060-6064. [PMID: 26019473 PMCID: PMC4438043 DOI: 10.3748/wjg.v21.i19.6060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 01/24/2015] [Accepted: 02/13/2015] [Indexed: 02/06/2023] Open
Abstract
This case report concerns a 25-year-old patient with 6-7 bloody stools/d, abdominal pain, tachycardia, and weight loss occurring during the third trimester of pregnancy. Severe ulcerative colitis complicated by toxic megacolon and gravidic sepsis was diagnosed by clinical evaluation, colonoscopy, and rectal biopsy that were performed safely without risk for the mother or baby. The patient underwent a cesarean section at 28+6 wk gestation. The baby was transferred to the neonatal intensive care unit of our hospital and survived without complications. Fulminant colitis was managed conservatively by combined colonoscopic decompression and medical treatment. Although current European guidelines describe toxic megacolon as an indication for emergency surgery for both pregnant and non-pregnant women, thanks to careful monitoring, endoscopic decompression, and intensive medical therapy with nutritional support, we prevented the woman from having to undergo emergency pancolectomy. Our report seems to suggest that conservative management may be a helpful tool in preventing pancolectomy if the patient’s condition improves quickly. Otherwise, surgery is mandatory.
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MESH Headings
- Adult
- Biopsy
- Cesarean Section
- Colitis, Ulcerative/complications
- Colitis, Ulcerative/diagnosis
- Colitis, Ulcerative/therapy
- Colonoscopy
- Decompression, Surgical/methods
- Female
- Gestational Age
- Humans
- Immunosuppressive Agents/therapeutic use
- Megacolon, Toxic/diagnosis
- Megacolon, Toxic/etiology
- Megacolon, Toxic/therapy
- Pregnancy
- Pregnancy Complications, Infectious/diagnosis
- Pregnancy Complications, Infectious/etiology
- Pregnancy Complications, Infectious/therapy
- Pregnancy Trimester, Third
- Premature Birth
- Sepsis/diagnosis
- Sepsis/etiology
- Severity of Illness Index
- Tomography, X-Ray Computed
- Treatment Outcome
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42
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van der Woude C, Ardizzone S, Bengtson M, Fiorino G, Fraser G, Katsanos K, Kolacek S, Juillerat P, Mulders A, Pedersen N, Selinger C, Sebastian S, Sturm A, Zelinkova Z, Magro F. The second European evidenced-based consensus on reproduction and pregnancy in inflammatory bowel disease. J Crohns Colitis 2015; 9:107-24. [PMID: 25602023 DOI: 10.1093/ecco-jcc/jju006] [Citation(s) in RCA: 305] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Trying to conceive and being pregnant is an emotional period for those involved. In the majority of patients suffering from inflammatory bowel disease, maintenance therapy is required during pregnancy to control the disease, and disease control might necessitate introduction of new drugs during a vulnerable period. In this updated consensus on the reproduction and pregnancy in inflammatory bowel disease reproductive issues including fertility, the safety of drugs during pregnancy and lactation are discussed.
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Affiliation(s)
- C.J. van der Woude
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
| | - S. Ardizzone
- Inflammatory Bowel Disease Unit, Department of Gastroenterology, ‘Luigi Sacco’ University Hospital, Milan, Italy
| | - M.B. Bengtson
- Department of Medicine, Vestfold Hospital Trust, Tønsberg, Norway
| | - G. Fiorino
- Department of Gastroenterology, IBD Center, IRCCS Istituto Clinico Humanitas, Rozzano, Italy
| | - G. Fraser
- eIBD Unit, Department of Gastroenterology, Rabin Medical Center and University of Tel-Aviv, Petah Tikva, Israel
| | - K. Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - S. Kolacek
- Children’s Hospital Zagreb, Zagreb University Medical School, Zagreb, Croatia
| | - P. Juillerat
- Department of Gastroenterology, Clinic for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - A.G.M.G.J. Mulders
- Department of Obstetrics and Gynecology, Erasmus MC, Rotterdam, The Netherlands
| | - N. Pedersen
- Gastroenterological Unit, Herlev University Hospital, Herlev, Denmark
| | - C. Selinger
- Department of Gastroenterology, St James’ University Hospital Leeds, Leeds, UK
| | - S. Sebastian
- Hull & East Yorkshire Hospitals and Hull & York Medical School, Hull, UK
| | - A. Sturm
- Department of Internal Medicine and Gastroenterology, Hospital Waldfriede, Berlin, Germany
| | - Z. Zelinkova
- Gastroenterology Unit, 5th Department of Internal Medicine, University Hospital, Bratislava, Slovakia
| | - F. Magro
- Department of Pharmacology & Therapeutics, University of Porto, Porto, Portugal
- MedInUP, Center for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal
- Department of Gastroenterology, Hospital de São João, Porto, Portugal
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44
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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: 13] [Impact Index Per Article: 1.3] [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.
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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
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Deepak P, Stobaugh DJ. Maternal and foetal adverse events with tumour necrosis factor-alpha inhibitors in inflammatory bowel disease. Aliment Pharmacol Ther 2014; 40:1035-43. [PMID: 25164260 DOI: 10.1111/apt.12936] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 01/30/2014] [Accepted: 08/07/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Transplacental transfer of tumour necrosis factor-alpha (TNF-α) inhibitors has been shown in mothers receiving therapy for inflammatory bowel disease (IBD). AIM To examine reports of adverse events of these medications in pregnancy. METHODS Individual Safety Reports of adverse events (Jan 2003-June 2012) were accessed from the Food and Drug Administration Adverse Event Reporting System. The study data set was constructed by searching for cases with an indication for medication usage of IBD. The data set was then queried for key terms indicating pregnancy, followed by elimination of cases with potentially teratogenic exposures (FDA category X concomitant medications) as well exposures to study medications through partner or if the medications were discontinued prior to pregnancy. Logistic regression analysis was performed to detect signals for maternal/foetal adverse events with TNF-α inhibitors and/or thiopurines (compared to aminosalicylates). RESULTS A total of 1097 individual Safety Reports in pregnant IBD patients were identified with the majority reported among patients receiving TNF-α inhibitor monotherapy (783 cases, 71.4%). Thiopurine monotherapy (OR 2.55, CI 0.95-6.88) and in combination with TNF-α inhibitors (OR 0.97, CI 0.49-1.93) were not associated with increased odds of maternal/foetal adverse events. Decreased odds for maternal/foetal adverse events were seen with TNF-α inhibitor monotherapy (overall) and specifically with certolizumab monotherapy (OR 0.11, CI 0.05-0.23). CONCLUSIONS In this analysis of adverse events from the Food and Drug Administration Adverse Event Reporting System, use of thiopurine monotherapy or in combination with TNF-α inhibitors was not associated with an increase in maternal/foetal adverse events. Certolizumab monotherapy was associated with a decrease in maternal/foetal adverse events.
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Affiliation(s)
- P Deepak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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46
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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.
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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.
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47
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Seirafi M, de Vroey B, Amiot A, Seksik P, Roblin X, Allez M, Peyrin-Biroulet L, Marteau P, Cadiot G, Laharie D, Boureille A, De Vos M, Savoye G, Rahier JF, Carbonnel F, Bonaz B, Colombel JF, Bouhnik Y. Factors associated with pregnancy outcome in anti-TNF treated women with inflammatory bowel disease. Aliment Pharmacol Ther 2014; 40:363-73. [PMID: 24980270 DOI: 10.1111/apt.12833] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 12/11/2013] [Accepted: 05/21/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND The safety of anti-tumour necrosis factor (TNF) agents during pregnancy is a major concern for child-bearing women and physicians. AIM To assess the impact of anti-TNF therapy on adverse pregnancy and foetal outcomes in women with inflammatory bowel disease (IBD). METHODS Pregnancies occurring during anti-TNF treatment or less than 3 months after its cessation in IBD patients followed in GETAID centres were recorded from January 2009 to December 2010. Ninety-nine pregnancies in women without anti-TNF treatment were identified from the CESAME registry. We compared pregnancy and neonatal outcomes by a case-control study. RESULTS In the 124 IBD patients followed, 133 pregnancies were reported. At the conception time, 23% of patients had active disease. Eighty-eight per cent (n = 117) of the 133 pregnancies followed until delivery resulted in 118 liveborns (one twin pregnancy). Complications were observed in 47 (35%) women and 24 (20%) newborns. In multivariate analysis, factors associated with pregnancy complications were: current smoking (P = 0.004), a B2 (stenotic) phenotype in CD women (P = 0.004), occurrence of a flare during pregnancy (P = 0.006) and a past history of complicated pregnancy (P = 0.007). Current smoking was the only factor associated with severe (i.e. potentially lethal) pregnancy complications (P = 0.02). Having IBD for more than 10 years prior to conception was associated with newborn complications (P = 0.007). No difference was found with the control group for any of the pregnancy and neonatal outcomes. CONCLUSION In our series, the safety profile of anti-TNF therapy during pregnancy and the neonatal period appears similar to control group of IBD women not treated with anti-TNF therapy.
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Affiliation(s)
- M Seirafi
- Beaujon University Hospital Paris VII University, Clichy, France; Geneva University Hospital, Geneva, Switzerland
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48
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Abstract
In the majority of patients with chronic gastrointestinal and liver diseases, maintenance therapy is required during pregnancy to control the disease, and disease follow-up or disease control might necessitate endoscopy. Evidence on the safety of drugs and imaging techniques during pregnancy is scarce and sometimes difficult to interpret. In this review we summarise existing literature with the aim of optimising counselling of patients with common chronic gastrointestinal and liver diseases who want to conceive.
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49
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Ng SW, Mahadevan U. My treatment approach to management of the pregnant patient with inflammatory bowel disease. Mayo Clin Proc 2014; 89:355-60. [PMID: 24582194 DOI: 10.1016/j.mayocp.2013.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/08/2013] [Accepted: 11/14/2013] [Indexed: 01/27/2023]
Abstract
Inflammatory bowel disease (IBD) is frequently diagnosed in women of childbearing age. Of paramount concern are questions about the effect of the disease on a woman's ability to conceive and carry the pregnancy safely to term, as well as the effect of the disease and its therapies on the health of the fetus. For health care providers, there is also the issue of medication dose adjustments and management of flares during pregnancy. Growing experience with IBD in pregnancy suggests that most women will have good outcomes; however, concerns and uncertainty remain for both the patient and the physician. This article outlines our approach to the treatment of these patients with respect to preconception counseling and management during pregnancy and the postpartum period.
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Affiliation(s)
- Susie W Ng
- Department of Medicine, Division of Gastroenterology, University of California, San Francisco
| | - Uma Mahadevan
- Department of Medicine, Division of Gastroenterology, University of California, San Francisco.
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50
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Abstract
IBD often affects patients during their peak reproductive years. Several drugs are available for the treatment of IBD and new drugs are continuously in the pipeline. As long-term administration of medications is often necessary, the safety of drug therapy during pregnancy and breast-feeding needs to be considered in daily clinical practice. The aim of this Review is to summarize the latest information concerning the safety of medications used to treat IBD during pregnancy and lactation, as well as their effect on fertility. Although only thalidomide and methotrexate are absolutely contraindicated during pregnancy and breast-feeding, alternatives to ciprofloxacin, natalizumab and sodium phosphate should also be considered for pregnant women. Breast-feeding is also discouraged while on treatment with ciclosporin, metronidazole and ciprofloxacin. However, therapy with 5-aminosalicylic acid preparations, glucocorticoids, thiopurines and TNF inhibitors are acceptable during pregnancy and lactation. Pregnant women who have symptomatic IBD or who require therapy should have the opportunity to discuss any associated risks to their pregnancy and infant with the appropriate consultants. By ensuring that the patient and her family are informed, the clinical outcome might be optimized.
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Affiliation(s)
- Ole Haagen Nielsen
- Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730 Herlev, Denmark
| | - Cynthia Maxwell
- Department of Obstetrics and Gynaecology, Maternal Fetal Medicine Division, Mount Sinai Hospital, University of Toronto, OPG-3, 600 University Avenue, Toronto, ON M5G 1X5, Canada
| | - Jakob Hendel
- Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730 Herlev, Denmark
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