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Izquierdo VP, Ovalle CP, Costa V, Leguízamo AM, Ordoñez JSF, Hani A. Pregnancy and Inflammatory Bowel Disease: A Special Combination. Middle East J Dig Dis 2023; 15:222-230. [PMID: 38523891 PMCID: PMC10955988 DOI: 10.34172/mejdd.2023.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 08/11/2023] [Indexed: 03/26/2024] Open
Abstract
Inflammatory bowel disease (IBD) comprises a spectrum of chronic immune-mediated diseases that affect the gastrointestinal tract. Onset typically occurs in early adulthood. The incidence of this disease has increased worldwide. Its prevalence has increased in Colombia and occurs predominantly in women. Considering that this disease is not curable, the main objective of management is to achieve remission. Many women are affected by IBD during different stages of their lives, including their reproductive life, pregnancy, and menopause. Because of this, the way the disease is managed in women of reproductive age can affect the course of IBD. Treatment and health maintenance strategies are very relevant; for patients with a desire to conceive, remission of the disease is very important at the time of conception and throughout the pregnancy to ensure adequate outcomes for both mother and fetus. Also, remission is necessary at least 3 months prior to conception. It is well known that active disease during conception and pregnancy is associated with adverse outcomes. In addition, active perianal disease is an indication of cesarean delivery, resulting in an increased risk of intestinal surgery and post-operative complications.
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Affiliation(s)
- Viviana Parra Izquierdo
- Gastroenterology and Rheumatology, Fundación Cardiovascular-Hospital Internacional de Colombia, Bucaramanga, Colombia
| | | | - Valeria Costa
- Gastroenterology, Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Ana María Leguízamo
- Gastroenterology, Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
| | | | - Albis Hani
- Gastroenterology, Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
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Vieujean S, De Vos M, Paridaens K, Daftary GS, Danese S, Peyrin-Biroulet L. Fertility and assisted reproductive technologies outcomes of women with non-surgically managed inflammatory bowel diseases: a systematic review. J Crohns Colitis 2022; 17:614-632. [PMID: 36322700 DOI: 10.1093/ecco-jcc/jjac170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND AIM In view of their frequent onset during childbearing years, the impact of inflammatory bowel diseases (IBD) on reproductive health is of important concern to young women and to the IBD physician. This study aims to assess the fertility and assisted reproductive technologies outcomes in non-surgically treated IBD female. METHODS A systematic review was conducted using MEDLINE, SCOPUS and EMBASE (until March 2022) to identify studies assessing fertility and assisted reproductive technologies outcomes in women with non-operated IBD, compared to non-IBD patients. Two reviewers independently selected studies, assessed risk of bias and extracted study data. RESULTS A total of 14 studies encompassing 18 012 patients with ulcerative colitis (UC) and 14 353 patients with Crohn's disease (CD) were included for analysis. The fertility rate in UC patients and in the general population was comparable, but UC patients tended to have fewer children, mainly by choice. On the contrary, the fertility of CD patients appeared to be reduced. Although a deliberate component cannot be not excluded, the disease itself could affect fertility. Disease activity was associated with reduced fertility in both UC and CD patients. In CD, the colonic involvement of the disease and perianal damage could be associated with subfertility, but data are less consistent. According to the only study reporting the assisted reproductive technologies outcomes, pregnancy rates after in vitro fertilization in subfertile non-operated UC patients and non-IBD patients were similar. CONCLUSION There is low-quality evidence from observational studies that patients with CD and relapsing UC may have impaired fertility. After assisted reproductive technologies, pregnancy rates of subfertile nonoperated UC patients were similar to those of the general population, although this observation requires further scrutiny in larger studies that should include UC and CD patients.
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Affiliation(s)
- Sophie Vieujean
- Hepato-Gastroenterology and Digestive Oncology, University Hospital CHU of Liège, Liège, Belgium
| | - Michel De Vos
- Centre for Reproductive Medicine, UZ Brussel, Brussels, Belgium
| | - Kristine Paridaens
- Ferring International Center S.A. Ch. De la Vergognausaz 50, 1162 Saint-Prex, Switzerland
| | - Gaurang S Daftary
- Ferring Pharmaceuticals A/S - International PharmaScience Center, Amager Strandvej 405, 2770 Kastrup, Denmark
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele Milano Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology NGERE (INSERM U1256), Nancy University Hospital, University of Lorraine, Vandœuvre-lès-Nancy, France
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Laube R, Yau Y, Selinger CP, Seow CH, Thomas A, Wei Chuah S, Hilmi I, Mao R, Ong D, Ng SC, Chen Wei S, Banerjee R, Ahuja V, Alharbi O, Leong RW. Knowledge and Attitudes Towards Pregnancy in Females with Inflammatory Bowel Disease: An International, Multi-centre Study. J Crohns Colitis 2020; 14:1248-1255. [PMID: 32191292 DOI: 10.1093/ecco-jcc/jjaa047] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Poor knowledge of inflammatory bowel disease [IBD] in pregnancy underlies unwarranted voluntary childlessness [VC], and risks poorer obstetric outcomes and adverse fetal outcomes. IBD is increasing worldwide but education on IBD issues might be heterogeneous based on cultural differences and variations in models of care. METHODS Consecutive female IBD subjects aged 18-45 years were prospectively recruited from two dedicated IBD-pregnancy clinics, two multidisciplinary IBD clinics and nine general gastroenterology clinics. Subjects completed the validated CCPKnow [score 0-17] with questions on demographics, medical history and pregnancy knowledge. The primary outcome was knowledge per clinic-type and per geographical region. RESULTS Surveys were completed by 717 subjects from 13 hospitals across ten countries. Dedicated IBD-pregnancy clinics had the highest knowledge, followed by multidisciplinary IBD clinics then general IBD clinics (median CCPKnow 10.0 [IQR: 8.0-11.0], 8.0 [IQR: 5.0-10.5] and 4.0 [IQR:2.0-6.0]; p < 0.001). Median CCPKnow scores in Western, Asian and Middle Eastern clinics were 9.0, 5.0 and 3.0 respectively [p < 0.001]. Dedicated IBD-pregnancy clinics, IBD support organization membership, childbearing after IBD diagnosis and employment independently predicted greater knowledge. Patient perception of disease severity [r = -0.18, p < 0.01] and consideration of VC [r = -0.89, p = 0.031] negatively correlated with CCPKnow score. The overall VC rate was 15.0% [95% CI: 12.2-18.2]. VC subjects had significantly lower pregnancy-specific IBD knowledge than non-VC subjects (median CCPKnow 4.0 [IQR: 2.0-6.0] and 6.0 [IQR: 3.0-9.0] respectively; p < 0.001). Pregnancy-specific IBD knowledge and dedicated IBD-pregnancy clinic attendance were significant negative predictors of VC. CONCLUSIONS In this large international study we identified predictors of pregnancy-specific IBD knowledge. Dedicated IBD-pregnancy clinics had the greatest IBD-related pregnancy knowledge and lowest VC rates, reflecting the benefits of pre-conception counselling.
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Affiliation(s)
- Robyn Laube
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Yunki Yau
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | | | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Amanda Thomas
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | - Sai Wei Chuah
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Ida Hilmi
- Division of Gastroenterology and Director of Endoscopy, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Ohio, USA
| | - David Ong
- Division of Gastroenterology and Hepatology, National University Hospital System, Singapore
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Hong Kong, China
| | - Shu Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, Taiwan
| | - Rupa Banerjee
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Othman Alharbi
- King Saud University, College of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Rupert W Leong
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
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Chisato K, Toshihide O. Health of women with inflammatory bowel disease: Coping with challenges from pregnancy to child rearing. ACTA ACUST UNITED AC 2015. [DOI: 10.5897/ijnm2014.0154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Borghesi J, Mario LC, Rodrigues MN, Favaron PO, Miglino MA. Immunoglobulin Transport during Gestation in Domestic Animals and Humans—A Review. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojas.2014.45041] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Safety of anti-TNF agents during pregnancy and breastfeeding in women with inflammatory bowel disease. Am J Gastroenterol 2013; 108:1426-38. [PMID: 23752881 DOI: 10.1038/ajg.2013.171] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Accepted: 04/30/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Anti-tumor necrosis factor (TNF) drugs are an effective therapeutic option in patients with inflammatory bowel disease (IBD). However, data regarding their safety during pregnancy and breastfeeding are scarce. The aim of this study was to critically review available data on the safety of anti-TNF therapy during pregnancy and breastfeeding in women with IBD. METHODS Bibliographical searches (MEDLINE) up to January 2013. RESULTS The studies included provided data from 462 women with IBD exposed to anti-TNF agents during pregnancy. Although these drugs cross the placenta from the end of the second trimester, they are low-risk in the short term. The use of anti-TNF agents after the second trimester leads to intra-uterine exposure. An increase in infections has recently been observed in infants exposed to immunomodulators plus anti-TNF drugs in utero, thus raising concerns about the consequences for the development of the immune system. Accordingly, it has recently been suggested that anti-TNF drugs should be stopped during the second trimester. Certolizumab is a Fab fragment of an anti-TNF monoclonal antibody, and, therefore, it may not be necessary to stop it during pregnancy. Anti-TNF drugs have been detected in breast milk, although in miniscule amounts. Case reports do not suggest toxicity; however, the effects of exposure on the neonate merit further investigation. CONCLUSIONS Anti-TNF drugs can cross the placenta from the latter part of the second trimester of gestation, although they seem to be safe, at least in the short term. Miniscule amounts of anti-TNF drugs are transferred in breast milk; therefore, a deleterious effect of this exposure on the neonate, although unlikely, cannot be excluded.
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Gisbert JP. Safety of immunomodulators and biologics for the treatment of inflammatory bowel disease during pregnancy and breast-feeding. Inflamm Bowel Dis 2010; 16:881-95. [PMID: 19885906 DOI: 10.1002/ibd.21154] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The aim of this article is to critically review available data regarding the safety of immunomodulators and biological therapies during pregnancy and breast-feeding in women with inflammatory bowel disease. Methotrexate and thalidomide can cause congenital anomalies and are contraindicated during pregnancy (and breast-feeding). Although thiopurines have a Food and Drug Administration (FDA) rating D, available data suggest that these drugs are safe and well tolerated during pregnancy. Although traditionally women receiving azathioprine or mercaptopurine have been discouraged from breast-feeding because of theoretical potential risks, it seems that these drugs may be safe in this scenario. Treatment with cyclosporine for steroid-refractory ulcerative colitis (UC) during pregnancy can be considered safe and effective, and the use of this drug should be considered in cases of severe UC as a means of avoiding urgent surgery. Breast-feeding is contraindicated for patients receiving cyclosporine. Biological therapies appear to be safe in pregnancy, as no increased risk of malformations has been demonstrated. Therefore, the limited clinical results available suggest that the benefits of infliximab and adalimumab in attaining response and maintaining remission in pregnant patients might outweigh the theoretical risks of drug exposure to the fetus. Stopping therapy in the third trimester may be considered, as it seems that transplacental transfer of infliximab is low prior to this. Certolizumab differs from infliximab and adalimumab in that it is a Fab fragment of an antitumor necrosis factor alpha monoclonal antibody, and therefore it may not be necessary to stop certolizumab in the third trimester. The use of infliximab is probably compatible with breast-feeding.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de la Princesa and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain.
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Hanauer SB. Exploring the controversial themes of IBD. Inflamm Bowel Dis 2009; 15 Suppl 1:S1-10. [PMID: 19693963 DOI: 10.1002/ibd.20945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Inflammatory bowel disease and pregnancy: evidence, uncertainty and patient decision-making. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 23:49-53. [PMID: 19172209 DOI: 10.1155/2009/531638] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Inflammatory bowel disease (IBD) often affects women during their child-bearing years. Management of a pregnant IBD patient, or a patient contemplating pregnancy, poses unique challenges and can be quite daunting. Knowledge of the basic interplay among disease, normal host physiology and pregnancy is vital to managing these patients. One of the most important advances in the management of IBD over the past decade has been the finding that normal pregnancy outcomes can be achieved when a woman enters the pregnancy in remission. New insights into the safety of a wider spectrum of drugs in these patients has allowed for increased success in IBD management. The evidence supporting medical interventions including biological therapy such as antibodies to tumour necrosis factor agents is reviewed. Once the treating physician understands this complex relationship, management of the pregnant IBD patient can often become a rewarding experience.
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Marteau P. IBD and pregnancy. Inflamm Bowel Dis 2008; 14 Suppl 2:S43-4. [PMID: 18816660 DOI: 10.1002/ibd.20565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Abstract
Irritable bowel syndrome and inflammatory bowel disease are gastrointestinal disorders affecting young adults. The peak incidence of irritable bowel syndrome and inflammatory bowel disease is in the late adolescence and early adult years, the time during which many women are planning and beginning their families. Since the potential for life-altering changes and pregnancy complications exist with these diseases, affected pregnant women present a challenge for the gastroenterologist, pregnancy provider, and nurses caring for them. This article outlines what is known about these diseases and their effect on fertility and pregnancy as well as their clinical management during pregnancy.
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Affiliation(s)
- Maryanne Bruno
- Perinatal Nurse Practitioner Services, Obstetrix Medical Group of Colorado, Presbyterian St Luke's Medical Center, Denver, CO 80218, USA.
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