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Tunney R, Liu E, Limdi JK. Pregnancy outcomes among women with inflammatory bowel disease: A UK tertiary centre experience. Indian J Gastroenterol 2024:10.1007/s12664-024-01657-4. [PMID: 39222194 DOI: 10.1007/s12664-024-01657-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/23/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Optimal management of inflammatory bowel disease (IBD) in pregnancy is associated with better pregnancy outcomes. We describe management of IBD during pregnancy and maternal and fetal outcomes of patients from a tertiary UK IBD centre. METHODS This is a retrospective observational cohort study of all pregnancies occurring between 2015 and 2021 in a large tertiary IBD centre in the UK. IBD activity and management prior to, during and after pregnancy were recorded along with pregnancy and neonatal outcomes. Associations between IBD-focused interventions and any adverse pregnancy outcomes, as well as the association between IBD severity and treatments and adverse maternofetal outcomes were assessed. RESULTS Pregnancies in 130 women with IBD were included for analysis. The mean maternal age at delivery was 30.5 (± 4.7) years. At conception, 73 women (56.2%) were in clinical remission and 24 (18.4%) were treated with a biologic agent. Active disease during pregnancy, measured by physician global assessment, was less frequent in women who were in clinical remission at conception, compared to those not in remission at conception (16/73 21.9% vs. 39/49 79.6%; data insufficient for eight women). Active IBD at conception was associated with pre-term birth (p = 0.04). Maternal corticosteroid use in any trimester was associated with low birth weight (T1 p = 0.02; T2 p = 0.005; T3 p = 0.007). Active disease (p = 0.008) and steroid use in the third trimester (p = 0.05) were both associated with neonatal infections up to six months after birth. CONCLUSION Women in clinical remission at the time of conception have favorable outcomes, consistent with prospective observational studies. Our observations emphasize the importance of high quality IBD care for women pre and post-partum in line with international recommendations.
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Affiliation(s)
- Ruth Tunney
- Department of Gastroenterology, Northern Care Alliance NHS Trust, Manchester, UK
| | - Eleanor Liu
- Department of Gastroenterology, Northern Care Alliance NHS Trust, Manchester, UK
| | - Jimmy K Limdi
- Department of Gastroenterology, Northern Care Alliance NHS Trust, Manchester, UK.
- University of Manchester, Manchester, UK.
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Tondreau A, Breuval C, Gondry J, Fumery M, Foulon A. Obstetric outcomes of patients with inflammatory bowel disease. Arch Gynecol Obstet 2024; 310:943-951. [PMID: 38834885 DOI: 10.1007/s00404-024-07521-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/15/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Inflammatory bowel diseases (IBD) are frequently diagnosed between the ages of 20 and 40, i.e. the most fertile period for women. The potential impact of IBD on pregnancy is therefore a frequent issue. STUDY OBJECTIVE To determine the impact of disease activity during pregnancy on the obstetric prognosis of women with IBD. METHODS Gastroenterological and obstetric data were collected for patients for all consecutive patients with IBD and pregnancy followed up at Amiens University Hospital (Amiens, France) between 2007 and 2021. Obstetrics outcome of patients with and without active disease were compared. RESULTS One hundred patients were included (81 with Crohn's Disease for 198 pregnancies, 19 with Ulcerative Colitis for 37 pregnancies). Patients with active IBD (21 patients, 24 pregnancies) were more likely to be admitted to hospital during pregnancy (66.6, vs. 5.2% in the inactive IBD group; p < 0.001), to give birth prematurely (mean term: 36.77 weeks of amenorrhoea (WA) vs. 38.7 WA, respectively; p = 0.02) and to experience very premature delivery (before 32 WA: 12.5 vs. 1.4%, respectively; p = 0.02). Patients with active disease had a shorter term at birth (38.4 WA, vs. 39.8 WA in the inactive disease group; p < 0.0001), a lower birth weight (2707 g vs. 3129 g, respectively; p = 0.01) and higher caesarean section rate (54.2 vs. 16.9%, respectively; p = 0.03). CONCLUSION Women with IBD patients are at risk of pregnancy related complications, especially when IBD is active. Controlling disease activity at conception and close monitoring of the pregnancy is essential to improve both gastroenterological and obstetric outcome.
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Affiliation(s)
- Ambre Tondreau
- Centre de Gynécologie-Obstétrique, CHU Amiens Picardie, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol Cedex 1, 80054, Amiens, France
| | - Coraline Breuval
- Centre de Gynécologie-Obstétrique, CHU Amiens Picardie, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol Cedex 1, 80054, Amiens, France
| | - Jean Gondry
- Centre de Gynécologie-Obstétrique, CHU Amiens Picardie, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol Cedex 1, 80054, Amiens, France
- Faculté de Médecine, Université Picardie Jules Verne, 3 rue des Louvels, 80000, Amiens, France
| | - Mathurin Fumery
- Faculté de Médecine, Université Picardie Jules Verne, 3 rue des Louvels, 80000, Amiens, France
- Service d'Hépato-Gastro-Entérologie, CHU Amiens Picardie, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Arthur Foulon
- Centre de Gynécologie-Obstétrique, CHU Amiens Picardie, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol Cedex 1, 80054, Amiens, France.
- Faculté de Médecine, Université Picardie Jules Verne, 3 rue des Louvels, 80000, Amiens, France.
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Ernest-Suarez K, Murguía-Favela LE, Constantinescu C, Fitzpatrick T, Top KA, Hu J, Jadavji T, Leung Y, Chan M, Panaccione R, Seow CH. Live Rotavirus Vaccination Appears Low-risk in Infants Born to Mothers With Inflammatory Bowel Disease on Biologics. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00677-3. [PMID: 39089515 DOI: 10.1016/j.cgh.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 06/22/2024] [Accepted: 07/03/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND & AIMS Biologic therapies in the context of inflammatory bowel disease and pregnancy lead to improved maternal and fetal outcomes. Placental transfer results in detectable drug concentrations in infants. Rotavirus infection results in diarrheal related hospitalizations; however, the live oral vaccine is not currently recommended in biologic exposed infants. The aim of this study was to assess the effect of maternal biologic therapies on the infant immune system and safety of live rotavirus vaccination in biologic-exposed infants. METHODS Biologic-exposed infants underwent standardized clinical assessments, drug concentration, and immune function testing (complete blood count, differential, immunoglobulin levels, extended B-cell and T-cell subset enumeration, Recent Thymic Emigrants, regulatory T-cell numbers, mitogen stimulation assays, and review of T-cell Receptor Excision Circles in the newborn screen). Rotavirus vaccine-specific adverse effects following immunizations up to 42 days post the last dose of the vaccine series were recorded. RESULTS There were 57 infants born to 52 mothers with inflammatory bowel disease exposed to infliximab (n = 21), adalimumab (n = 19), vedolizumab (n = 10), and ustekinumab (n = 7) in the third trimester for a median of 39 weeks (interquartile range, 38-39 weeks) at delivery. Immunologic assessments validated for age were normal in all infants despite median infliximab concentrations of 6.1 ug/mL (range, 0.4-28.8 ug/mL), adalimumab concentrations of 1.7 ug/mL (range, 0.7-7.9 ug/mL), ustekinumab concentrations of 0.6 ug/mL (range, 0-1.1), and undetectable for vedolizumab at 10.7 weeks (interquartile range, 9.4-12.4) of age. The live oral rotavirus vaccine series was provided to 50 infants with the first dose given at a median of 13 weeks of age. No adverse effects following immunization were reported. CONCLUSION Immune function testing was normal, and administration of live rotavirus vaccination appeared low-risk in biologic-exposed infants irrespective of circulating drug levels.
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Affiliation(s)
- Kenneth Ernest-Suarez
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Luis E Murguía-Favela
- Section of Hematology/Immunology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Cora Constantinescu
- Section of Infectious Diseases, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Tiffany Fitzpatrick
- Public Health, Ontario and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Karina A Top
- Department of Pediatrics, Dalhousie University and Canadian Center for Vaccinology, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Jia Hu
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Taj Jadavji
- Department of Microbiology, Immunology, and Infectious Diseases, and Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Yvette Leung
- Department of Medicine, Division of Gastroenterology, Physician Lead IBD and Pregnancy Clinic, University of British Columbia, Vancouver, British Columbia, Canada
| | - Melissa Chan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Inflammatory Bowel Disease Unit, Gastrointestinal Research, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Hussien M, Lorente-Ros M, Lam PH, Frishman WH, Aronow WS, Gupta R. Preparing the Heart for a New Baby: Management of Pregnancy in Heart Transplant Recipients. Cardiol Rev 2024:00045415-990000000-00305. [PMID: 39078143 DOI: 10.1097/crd.0000000000000758] [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] [Indexed: 07/31/2024]
Abstract
Heart transplant (HT) recipients are more frequently reaching childbearing age given improvement in median survival and outcomes after HT. Although most pregnancies in HT recipients have favorable outcomes, poor fetal outcomes and maternal complications such as hypertensive disorders of pregnancy are more common in HT recipients than in the general population. In this review, we summarize the current evidence to guide the management of pregnancy in HT recipients. Preconception counseling, focused on risk stratification and optimal timing of conception, is the first important step to optimize pregnancy outcomes. During pregnancy and in the postpartum period, frequent monitoring of graft function and immunosuppressive levels is recommended. Calcineurin inhibitors and corticosteroids should be the mainstay of treatment for both prevention and treatment of graft rejection. Delivery planning should follow usual obstetric indications, preferably with vaginal delivery at term using regional anesthesia. A multidisciplinary care team should be involved in management through all stages of pregnancy to ensure success.
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Affiliation(s)
- Merna Hussien
- From the Department of Cardiology, MedStar Washington Hospital Center, Georgetown University Medical Center, Washington, DC
| | - Marta Lorente-Ros
- From the Department of Cardiology, MedStar Washington Hospital Center, Georgetown University Medical Center, Washington, DC
| | - Phillip H Lam
- From the Department of Cardiology, MedStar Washington Hospital Center, Georgetown University Medical Center, Washington, DC
| | - William H Frishman
- Department of Medicine, New York Medical College, Westchester Medical Center, Valhalla, NY
| | - Wilbert S Aronow
- Departments of Cardiology and Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Richa Gupta
- From the Department of Cardiology, MedStar Washington Hospital Center, Georgetown University Medical Center, Washington, DC
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Lee S, Seow CH, Nerenberg K, Bertazzon S, Leung Y, Huang V, Whitten T, Coward S, Panaccione R, Kaplan GG, Metcalfe A. Despite Increased Disease Activity, Women who Attended a Dedicated Inflammatory Bowel Disease and Pregnancy Clinic Had Infants With Higher Apgar Scores: A Population-Based Study. Inflamm Bowel Dis 2024; 30:1071-1079. [PMID: 37499061 DOI: 10.1093/ibd/izad147] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Attendance at a subspecialty pregnancy clinic for women with inflammatory bowel disease (IBD) improves disease-specific pregnancy knowledge. We examined the impact of attendance at a dedicated IBD-pregnancy clinic on IBD and perinatal outcomes. METHODS Using linked administrative databases in Alberta, Canada (2012-2019), we identified 1061 pregnant women with IBD who delivered singleton liveborn infants in-hospital who did (n = 314) and did not attend (n = 747) the clinic. Propensity score weighted multivariable log-binomial and multinomial logistic regression models were used to determine the risk of IBD and perinatal outcomes. RESULTS The median number of clinic visits was 3 (Q1-Q3, 3-5), with 34.7% completing a preconception consultation. A greater proportion of women who attended lived near the clinic, were nulliparous, had a disease flare prior to pregnancy, and were on maintenance IBD medication (P < .05). Women who attended had increased risks of a disease flare during pregnancy (adjusted risk ratio [aRR], 2.02; 95% CI, 1.45-2.82), an IBD-related emergency department visit during pregnancy (aRR, 2.66; 95% CI, 1.92-3.68), and cesarean delivery (aRR, 1.78; 95% CI, 1.23-2.57). Despite this, clinic attendees had a decreased risk of delivering an infant with a low Apgar score at 1 minute (risk ratio [RR], 0.49; 95% CI, 0.32-0.76) and 5 minutes (RR, 0.32; 95% CI, 0.12-0.87). CONCLUSIONS Women who attended a dedicated IBD-pregnancy clinic were more likely to have a disease flare prior to pregnancy, reflecting a more severe disease phenotype, but had similar perinatal outcomes and infants with better Apgar scores at birth. Our study suggests the value of these subspecialty clinics in providing enhanced IBD-specific prenatal care.
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Affiliation(s)
- Sangmin Lee
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, Alberta, Canada
| | - Kara Nerenberg
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Stefania Bertazzon
- Department of Geography, University of Calgary, Calgary, Alberta, Canada
| | - Yvette Leung
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vivian Huang
- Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Tara Whitten
- Provincial Research Data Services, Alberta Health Services, Alberta, Canada
- Alberta Strategy for Patient Oriented Research Support Unit Data and Research Services Platform, Alberta, Canada
| | - Stephanie Coward
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, Alberta, Canada
| | - Amy Metcalfe
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
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6
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Takahashi S, Kakuta Y, Obara T, Ishikawa T, Nagai H, Shimoyama Y, Naito T, Moroi R, Shiga H, Mano N, Kinouchi Y, Masamune A. Prescribing in pregnant women with inflammatory bowel disease and its relationship to congenital malformations in Japan. J Gastroenterol Hepatol 2024; 39:1291-1298. [PMID: 38538533 DOI: 10.1111/jgh.16549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/25/2024] [Accepted: 03/09/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND AND AIM Inflammatory bowel disease (IBD) frequently affects younger patients and poses various challenges concerning pregnancy and childbirth. Maintaining good disease control throughout pregnancy is crucial, but expectant and pregnant patients may worry about the fetal impact of medications, leading to treatment discontinuation due to uncertainty about this issue. This study investigated the real-world drug-prescribing practices for pregnant patients with IBD in Japan and their potential connection to major congenital malformations (MCMs). METHODS Overall, 277 female IBD patients who gave birth between 2010 and 2019 were selected from the JMDC claims database. The prescribing patterns of IBD medications and MCMs in the patients' offspring were analyzed. RESULTS Among pregnant IBD patients, 74.4% received at least one medication from 90 days before pregnancy to 90 days after delivery. Trends in medication prescriptions during pregnancy in 2010-2019 revealed consistent use of oral 5-ASA, variable use of topical medications, a decrease in systemic steroids, and an increase in biologics. The prevalence of MCMs in children born to IBD-affected mothers did not differ significantly between those who did and did not receive IBD medications (8.6% vs 6.8%). Although circulatory system MCMs were slightly more common in the IBD medication group (4.9% vs 1.4%), this difference was not significant. Logistic regression analysis did not reveal an association between MCM risk and first-trimester use of IBD medications, including corticosteroids and biologics. CONCLUSIONS This study provides insights into medication patterns in pregnant IBD patients and suggests no increased risk of MCMs associated with first-trimester IBD medication use.
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Affiliation(s)
- Sayumi Takahashi
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoichi Kakuta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Taku Obara
- Division of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
- Department of Pharmaceutical Sciences, Tohoku University Hospital, Sendai, Japan
| | - Tomofumi Ishikawa
- Laboratory of Biomolecule and Pathophysiological Chemistry, Graduate School of Pharmaceutical Sciences, Tohoku University, Sendai, Japan
| | - Hiroshi Nagai
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yusuke Shimoyama
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takeo Naito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Rintaro Moroi
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hisashi Shiga
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Nariyasu Mano
- Department of Pharmaceutical Sciences, Tohoku University Hospital, Sendai, Japan
- Laboratory of Biomolecule and Pathophysiological Chemistry, Graduate School of Pharmaceutical Sciences, Tohoku University, Sendai, Japan
| | - Yoshitaka Kinouchi
- Student Healthcare Center, Institute for Excellence in Higher Education, Tohoku University, Sendai, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
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7
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Santos Pérez E, Calvo Moya M. General review on pregnancy in inflammatory bowel disease. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:369-373. [PMID: 35240849 DOI: 10.17235/reed.2022.8672/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
Given the age of maximum incidence of inflammatory bowel disease, aspects such as fertility and pregnancy are especially relevant in the management of these patients. This review article aims to provide a summarized description of the basic concepts that the gastroenterologist should know when assessing an IBD patient with procreative desires and/or who is pregnant. The review has been carried out selecting the most recent and relevant articles on these topics in order to offer updated information on the latest treatments available.
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Affiliation(s)
- Elena Santos Pérez
- Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro Majadahonda, España
| | - Marta Calvo Moya
- Gastroenterología y Hepatología, Hospital universitario Puerta de Hierro Majadahonda, España
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Simpson AN, Sutradhar R, Benchimol EI, Chan WC, Porter J, Moore S, Dossa F, Huang V, Maxwell C, Targownik L, Liu N, Baxter NN. Risk of Cesarean Delivery Among People With Inflammatory Bowel Disease According to Disease Characteristics: A Population-Based Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102463. [PMID: 38631434 DOI: 10.1016/j.jogc.2024.102463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 03/11/2024] [Accepted: 03/19/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVES It is unclear if use of cesarean delivery in people with inflammatory bowel disease (IBD) is guideline-concordant. We compared the odds of cesarean delivery among primiparous individuals with IBD versus without, overall, and by disease characteristics, as well as time to subsequent delivery. METHODS Retrospective matched population-based cohort study between 1 April 1994 and 31 March 2020. Primiparous individuals aged 15-55 years with IBD were matched to those without IBD on age, year, hospital, and number of newborns delivered. Primary outcome was cesarean delivery versus vaginal delivery. Multivariable conditional logistic regression analyses were performed to estimate the odds of cesarean delivery among individuals with and without IBD as a binary exposure, and a categorical exposure based on IBD-related indications for cesarean delivery. Time to subsequent delivery was evaluated using a Cox proportional hazard model. RESULTS We matched 7472 individuals with IBD to 37 360 individuals without (99.02% match rate). Individuals with IBD were categorised as having perianal (PA) disease (IBD-PA, n = 764, 10.2%), prior ileal pouch-anal anastomosis (n = 212, 2.8%), or IBD-Other (n = 6496, 86.9%). Cesarean delivery rates were 35.4% in the IBD group versus 30.4% in their controls (adjusted odds ratio 1.27; 95% CI 1.20-1.34). IBD-ileal pouch-anal anastomosis had a cesarean delivery rate of 66.5%, compared to 49.9% in IBD-PA and 32.7% in IBD-Other. There was no significant difference in the rate of subsequent delivery in those with and without IBD (adjusted hazard ratio 1.03; 95% CI 1-1.07). CONCLUSIONS The higher risk of cesarean delivery in people with IBD reflects guideline-concordant use. Individuals with and without IBD were equally likely to have a subsequent delivery with similar timing.
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Affiliation(s)
- Andrea N Simpson
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Institute for Clinical Evaluative Sciences (ICES), Toronto, ON; Li Ka Shing Knowledge Institute, St. Michael's Hospital/Unity Health Toronto, Toronto, ON; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - Eric I Benchimol
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON; Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, The Hospital for Sick Children (SickKids), University of Toronto, Toronto, ON; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON
| | - Wing C Chan
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON
| | - Joan Porter
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON
| | - Sarah Moore
- Department of Surgery, MacKenzie Health, Vaughan, ON
| | - Fahima Dossa
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vivian Huang
- Department of Gastroenterology, Sinai Health System, Toronto, ON
| | - Cynthia Maxwell
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Women's College Research Institute, Women's College Hospital, Toronto, ON
| | - Laura Targownik
- Department of Gastroenterology, Sinai Health System, Toronto, ON
| | - Ning Liu
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - Nancy N Baxter
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON; Li Ka Shing Knowledge Institute, St. Michael's Hospital/Unity Health Toronto, Toronto, ON; Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
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9
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Ikeda A, Kunisaki R, Aoki S, Yaguchi K, Madarame A, Nishio M, Ogashiwa T, Nakamori Y, Kimura H, Suzuki R, Saigusa Y, Maeda S. Appropriate Preconception Corticosteroid-Free Remission Period in Pregnant Women With Ulcerative Colitis. Inflamm Bowel Dis 2024; 30:726-734. [PMID: 36640130 DOI: 10.1093/ibd/izac270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND In women with inflammatory bowel disease, at least 3 months of preconception corticosteroid-free remission (CFREM) is recommended by experts in current consensus statements. However, data are lacking on the appropriate preconception remission period. We investigated the appropriate preconception CFREM period in women with ulcerative colitis to reduce maternal disease activity and adverse pregnancy outcomes (ie, preterm birth, low birth weight, and small for gestational age). METHODS We retrospectively examined 141 pregnancies in women with ulcerative colitis at 2 institutions. We categorized the patients into 3 subgroups by their preconception CFREM period (≥3 months, >0 to <3 months, and non-CFREM). We also investigated disease activity during pregnancy and postpartum and adverse pregnancy outcomes in each group. RESULTS During pregnancy, the rate of active disease was significantly lower in the ≥3 months and >0 to <3 months CFREM groups compared with that in the non-CFREM group (P < .001 and P = .0257, respectively). Postpartum, the rate of active disease was significantly lower in the ≥3 months CFREM group compared with that in the non-CFREM group (P = .0087). The preconception CFREM period of ≥3 months was an independent inhibitory factor for active disease during pregnancy and postpartum (adjusted odds ratio, 0.15; P = .0035; and adjusted odds ratio, 0.33; P = .027, respectively). Adverse pregnancy outcomes were less common in the >3 months CFREM group compared with those in the other groups, but this difference was not significant. CONCLUSIONS A preconception CFREM period of more than 3 months may be appropriate for better maternal and adverse pregnancy outcomes, as recommended in consensus statements.
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Affiliation(s)
- Aya Ikeda
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Reiko Kunisaki
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Shigeru Aoki
- Perinatal Center for Maternity and Neonates, Yokohama City University Medical Center, Yokohama, Japan
| | - Katsuki Yaguchi
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Akira Madarame
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Masafumi Nishio
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tsuyoshi Ogashiwa
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yoshinori Nakamori
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hideaki Kimura
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | | | - Yusuke Saigusa
- Department of Biostatistics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shin Maeda
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Schaafsma IJ, Hoogenboom FJ, Dijkstra G, Prins JR, Visschedijk MC. Vaginal delivery in women with perianal Crohn's disease: why not? AJOG GLOBAL REPORTS 2024; 4:100333. [PMID: 38655569 PMCID: PMC11035108 DOI: 10.1016/j.xagr.2024.100333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Pregnant women with active perianal Crohn's disease indicate a cesarean delivery according to the current European Crohn's and Colitis Organisation guidelines. This advice is based on the assumption that vaginal delivery leads to exacerbation of perianal disease and worsening of fecal continence. However, there is no strong evidence to support this. OBJECTIVE This study aims to examine the effects of the delivery method on perianal disease progression and fecal incontinence in women with perianal Crohn's disease. STUDY DESIGN In this retrospective cohort study, 102 women were selected from the 1000 inflammatory bowel disease cohort of a tertiary hospital in the Netherlands. All women are aged >18 years, have perianal Crohn's disease, and have given birth. In addition, all women completed a questionnaire. Fecal continence was scored using the Vaizey score. Using SPSS, descriptive analysis and linear regression analysis were performed, and P values <.05 were considered statistically significant. RESULTS The cesarean delivery rate within our cohort was 19.5%. Within the group of women who delivered at least one child vaginally (n=84), 25.5% reported alteration of fecal continence, compared with 13.1% in women who only had cesarean delivery (n=18). After a mean follow-up of 15 years, the median Vaizey score within the cesarean delivery group was 5, compared with 7 in the vaginal delivery group. Within the vaginal delivery group, 18.8% reported perianal disease progression, compared with 22.2% in the cesarean delivery group. No significant relation between mode of delivery and fecal continence or perianal disease progression was found (B, 0,97 [-1,19 to 3,14], P=.38). CONCLUSION Fecal incontinence and perianal disease progression after vaginal delivery in Crohn's disease women with active perianal fistula is not significantly increased in this retrospective cohort. This study opens the discussion for more tailored obstetric advice in women with perianal Crohn's disease.
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Affiliation(s)
- Irene J. Schaafsma
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands (Drs Schaafsma, Dijkstra and Visschedijk)
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands (Drs Schaafsma and Hoogenboom)
| | - Froukje J. Hoogenboom
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands (Drs Schaafsma and Hoogenboom)
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands (Drs Schaafsma, Dijkstra and Visschedijk)
| | - Jelmer R. Prins
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands (Dr Prins)
| | - Marijn C. Visschedijk
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands (Drs Schaafsma, Dijkstra and Visschedijk)
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11
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Huang W, Zhang X, Zhang L, Dai X, Chen H, Xie Q. Anti-tumor necrosis factor-α therapy may not be safe during pregnancy in women with inflammatory bowel disease: an updated meta-analysis and systematic review. BMC Pregnancy Childbirth 2024; 24:251. [PMID: 38589784 PMCID: PMC11000337 DOI: 10.1186/s12884-024-06443-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 03/25/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Inflammatory Bowel Disease (IBD) affects reproductive-aged women. Active disease can lead to decreased fertility. Although the vast majority of international guidelines recommend for the continuation of anti-TNF-α during pregnancy, recent studies have raised concerns about the safety of anti-tumor necrosis factor-α (TNF-α) therapy during pregnancy, both for patients and for physicians. METHODS Studies that evaluate the safety of anti-TNF-α therapy in pregnant women with IBD were identified using bibliographical searches. An updated meta-analysis was performed for pregnancy outcomes, such as live birth, abortion, still birth, preterm birth, low birth weight, congenital abnormalities, and neonatal infection. Odds ratio (OR) with 95% confidence interval (CI) are reported. Data on disease activity, timing of anti-TNF-α therapy were collected for further analysis. RESULTS Overall, 11 studies were screened from on-line databases and international meeting abstracts. An increased risk of abortion (OR, 1.33; 95% CI, 1.02-1.74; P = 0.04) and preterm birth (OR, 1.16; 95% CI, 1.05-1.28; P = 0.004), and a decreased risk of live birth (OR, 0.83; 95% CI, 0.74-0.94; P = 0.002]) were found in the anti-TNF-α therapy group compared with the control group (no use of anti-TNF-α therapy). The subgroup analyses based on the disease activity showed there is no significant association between the use of anti-TNF-α therapy during pregnancy on adverse pregnancy outcomes of abortion, preterm birth, and live birth. The rates of still birth, low birth weight, and congenital abnormalities in the anti-TNF-α therapy group were not significantly different from those in the control group. CONCLUSIONS Anti-TNF-α therapy does not increase the risks of still birth, low birth weight, and congenital abnormalities; however it may be assicated with increased risks of abortion and preterm birth, which are accompanied by a lower rate of live birth. Although these findings may be confounding by potential disease activity, they offer some opposite viewpoints with biologic agent use. Therefore, more studies are required to further confirm the safety of anti-TNF-α therapy in pregnancy with IBD.
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Affiliation(s)
- Wei Huang
- Department of Geriatric Medicine and Gastroenterology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xinxing Zhang
- Department of Geriatric Medicine and Gastroenterology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Li Zhang
- Department of Geriatric Medicine and Gastroenterology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaosong Dai
- Department of Geriatric Medicine and Gastroenterology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Heping Chen
- Department of Geriatric Medicine and Gastroenterology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Qin Xie
- Department of Geriatric Medicine and Gastroenterology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
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12
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Saad AF, Pacheco LD, Saade GR. Immunosuppressant Medications in Pregnancy. Obstet Gynecol 2024; 143:e94-e106. [PMID: 38227938 DOI: 10.1097/aog.0000000000005512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/07/2023] [Indexed: 01/18/2024]
Abstract
Pregnant patients are often on immunosuppressant medications, most commonly to manage transplantation or autoimmune disorders. Most immunosuppressant agents, including tacrolimus, corticosteroids, azathioprine, and calcineurin inhibitors, are safe during pregnancy and lactation. However, mycophenolic acid is associated with higher risks of birth defects and should be avoided in pregnancy. Tacrolimus, the commonly used drug in transplantation medicine and autoimmune disorders, requires monitoring of serum levels for dose adjustment, particularly during pregnancy. Although no pregnancy-specific therapeutic range exists, the general target range is 5-15 ng/mL, and pregnant patients may require higher doses to achieve therapeutic levels. Adherence to prescribed immunosuppressive regimens is crucial to prevent graft rejection and autoimmune disorder flare-ups. This review aims to provide essential information about the use of immunosuppressant medications in pregnant individuals. With a rising number of pregnant patients undergoing organ transplantations or having autoimmune disorders, it is important to understand the implications of the use of these medications during pregnancy.
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Affiliation(s)
- Antonio F Saad
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Inova Fairfax, Fairfax, Virginia; the Division of Surgical Critical Care, Department of Anesthesiology, University of Texas Medical Branch at Galveston, Galveston, Texas; and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
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13
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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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Hoxha T, Youssef M, Huang V, Tandon P. Inflammatory Bowel Disease and Breastfeeding: A Narrative Review. Inflamm Bowel Dis 2024:izae033. [PMID: 38439613 DOI: 10.1093/ibd/izae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Indexed: 03/06/2024]
Abstract
Inflammatory bowel disease (IBD) frequently affects women of childbearing age who may consider breastfeeding. Although breastfeeding has numerous benefits, there remain concerns regarding the safety of breastfeeding among women with IBD. Breastfeeding is important in developing the immune system of infants and has been shown to protect against the development of IBD. The risk of developing an increase in disease activity postpartum is the same regardless of breastfeeding status. Most IBD medications are also considered safe in breastfeeding and have no major risks to infants. Despite this, breastfeeding rates remain low among women with IBD, mostly due to concerns about the safety of IBD therapy with breastfeeding. Many women self-discontinue their IBD medications to breastfeed, and there is often uncertainty among health professionals to make recommendations about therapy. Dedicated IBD clinics can greatly support mothers during pregnancy and breastfeeding periods to enhance their knowledge, optimize their medication adherence, and improve their postpartum outcomes. This review aims to provide the most recent evidence-based literature regarding the safety of breastfeeding in women with IBD and the current recommendations about medical therapies with breastfeeding.
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Affiliation(s)
- Tedi Hoxha
- Division of Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael Youssef
- Division of Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vivian Huang
- Division of Gastroenterology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Parul Tandon
- Division of Gastroenterology and Hepatology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Kwon S, Judson MA. Clinical Pharmacology in Sarcoidosis: How to Use and Monitor Sarcoidosis Medications. J Clin Med 2024; 13:1250. [PMID: 38592130 PMCID: PMC10932410 DOI: 10.3390/jcm13051250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 04/10/2024] Open
Abstract
When sarcoidosis needs treatment, pharmacotherapy is usually required. Although glucocorticoids work reliably and relatively quickly for sarcoidosis, these drugs are associated with numerous significant side effects. Such side effects are common in sarcoidosis patients, as the disease frequently has a chronic course and glucocorticoid treatment courses are often prolonged. For these reasons, corticosteroid-sparing and corticosteroid-replacing therapies are often required for sarcoidosis. Unfortunately, many healthcare providers who care for sarcoidosis patients are not familiar with the use of these agents. In this manuscript, we provide a review of the pharmacotherapy of sarcoidosis. We discuss the mechanism of action, dosing, side-effect profile, approach to monitoring and patient counselling concerning glucocorticoids, and the common alternative drugs recommended for use in the recent European Respiratory Society (Lausanne, Switzerland) Sarcoidosis Treatment Guidelines. We also discuss the use of these agents in special situations including hepatic insufficiency, renal insufficiency, pregnancy, breastfeeding, vaccination, and drug-drug interactions. It is hoped that this manuscript will provide valuable practical guidance to clinicians who care for sarcoidosis patients.
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Affiliation(s)
- Sooyeon Kwon
- Samuel S. Stratton Veterans Affairs Medical Center, Albany, NY 12208, USA
| | - Marc A. Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY 12208, USA;
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16
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Li RX, Wu T, Li XF, Zhou H, Shi YT, Wang F, Liang J. Inadequate pregnancy-specific knowledge among patients with inflammatory bowel disease: A multicenter survey in China. J Dig Dis 2024; 25:100-108. [PMID: 38599672 DOI: 10.1111/1751-2980.13258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 02/03/2024] [Accepted: 02/15/2024] [Indexed: 04/12/2024]
Abstract
OBJECTIVES The perceptions and attitudes of inflammatory bowel disease (IBD) patients towards pregnancy may affect their fertility plan and disease progression. We performed a nationwide multicenter survey of pregnancy-related knowledge among gastroenterologists and IBD patients in China to investigate whether specific educational interventions could improve their understanding and broadly influence fertility plan. METHODS A cross-sectional questionnaire regarding pregnancy-specific knowledge was carried out among 63 IBD centers in China. Questionnaires were collected from 185 physicians and 609 patients. The patients then received education regarding pregnancy during IBD and filled in the same questionnaire again. Their knowledge regarding pregnancy during IBD was compared before and after education. RESULTS Compared to physicians, patients' knowledge regarding fertility (39.1% vs 70.8%), imaging examinations (22.8% vs 72.4%), endoscopy performed during pregnancy (19.9% vs 71.4%), and vaccination for infants (16.6% vs 46.5%) was significantly more limited (all P < 0.001). There was a lack of knowledge among gastroenterologists regarding the delivery mode (36.8%), medications (36.8%), and emergency surgery (26.5%) during pregnancy in patients with IBD. After education, the patients showed significant improvement in knowledge regarding medications (26.7% vs 51.7%), fertility (45.0% vs 63.3%), heritability (40.0% vs 58.3%), indications for emergency surgery (15.0% vs 53.3%), imaging examinations during pregnancy (20.0% vs 40.0%), and vaccinations for infants (26.7% vs 45.0%) (all P < 0.05). CONCLUSIONS Pregnancy-specific IBD knowledge needs to be improved among certain gastroenterologists and patients in China. Educational interventions can partially improve the knowledge levels of the patients.
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Affiliation(s)
- Rui Xia Li
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, Shaanxi Province, China
| | - Tong Wu
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, Shaanxi Province, China
| | - Xiao Fei Li
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, Shaanxi Province, China
| | - He Zhou
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, Shaanxi Province, China
| | - Yan Ting Shi
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, Shaanxi Province, China
| | - Fang Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, Shaanxi Province, China
| | - Jie Liang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Military Medical University, Xi'an, Shaanxi Province, China
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17
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Moriya K, Hara R, Tomooka F, Shimozato N, Nishimura N, Kawaratani H, Yoshiji H. Concurrent Ulcerative Colitis in a Pregnant Patient with Rheumatoid Arthritis. Intern Med 2024; 63:385-391. [PMID: 37316274 PMCID: PMC10901711 DOI: 10.2169/internalmedicine.1833-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/09/2023] [Indexed: 06/16/2023] Open
Abstract
We herein report a rare concurrent case of ulcerative colitis (UC) in a pregnant woman with rheumatoid arthritis (RA), which was well managed by biologics. When a 32-year-old woman with seropositive RA became pregnant, she began experiencing hematochezia; colonoscopy revealed diffuse inflammation with multiple ulcers. Based on clinical examinations and pathological assessments, she was diagnosed with severe UC. Although prednisolone had no curative effect and infliximab caused an infusion reaction, golimumab successfully induced remission with normal delivery. This case report describes the successful treatment of a pregnant woman with UC and RA through biologics administration.
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Affiliation(s)
- Kei Moriya
- Department of Gastroenterology and Hepatology, Nara Medical University, Japan
| | - Ryota Hara
- Department of Orthopedic Surgery, Nara Medical University, Japan
| | - Fumimasa Tomooka
- Department of Gastroenterology and Hepatology, Nara Medical University, Japan
| | - Naotaka Shimozato
- Department of Gastroenterology and Hepatology, Nara Medical University, Japan
| | - Norihisa Nishimura
- Department of Gastroenterology and Hepatology, Nara Medical University, Japan
| | - Hideto Kawaratani
- Department of Gastroenterology and Hepatology, Nara Medical University, Japan
| | - Hitoshi Yoshiji
- Department of Gastroenterology and Hepatology, Nara Medical University, Japan
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Meyer A, Miranda S, Drouin J, Weill A, Carbonnel F, Dray-Spira R. Safety of Vedolizumab and Ustekinumab Compared With Anti-TNF in Pregnant Women With Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00010-7. [PMID: 38199301 DOI: 10.1016/j.cgh.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND & AIMS Limited data are available on the consequences of prenatal exposure to vedolizumab and ustekinumab. We aimed to compare the safety of vedolizumab and ustekinumab with that of anti-tumor necrosis factor (TNF) in pregnant women with inflammatory bowel diseases (IBD). METHODS Using nationwide, comprehensive data of the EPI-MERES registry, we identified pregnancies in women with IBD in France, exposed to anti-TNF, vedolizumab, and ustekinumab between 2014 and 2021. We compared pregnancy outcomes and complications in the offspring according to treatment exposure during pregnancy. We applied a propensity score matching for maternal, IBD, and pregnancy characteristics. RESULTS Three hundred ninety-eight pregnancies exposed to vedolizumab were compared with 1592 pregnancies exposed to anti-TNF; 464 pregnancies exposed to ustekinumab were compared with 1856 pregnancies exposed to anti-TNF. Overall, compared with anti-TNF, neither vedolizumab nor ustekinumab was associated with increased risks of abortion, caesarean section, stillbirth, preterm birth, serious infections, malignancies, or congenital abnormality in children. Women exposed to ustekinumab had an increased risk of small for gestational age births. CONCLUSIONS Overall, the safety of vedolizumab and ustekinumab compared with anti-TNF use during pregnancy is reassuring. Further studies are needed to confirm these findings.
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Affiliation(s)
- Antoine Meyer
- EPI-PHARE, Épidémiologie des produits de santé, Saint-Denis, France; Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre & Université Paris-Saclay, Le Kremlin Bicêtre, France.
| | - Sara Miranda
- EPI-PHARE, Épidémiologie des produits de santé, Saint-Denis, France
| | - Jérôme Drouin
- EPI-PHARE, Épidémiologie des produits de santé, Saint-Denis, France
| | - Alain Weill
- EPI-PHARE, Épidémiologie des produits de santé, Saint-Denis, France
| | - Franck Carbonnel
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre & Université Paris-Saclay, Le Kremlin Bicêtre, France
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Monfared N, Gold M, Carbery I, Laube R, Selinger CP. Reproductive Safety Issues of Novel Small Molecules for the Treatment of Inflammatory Bowel Disease: A Systematic Review. J Clin Med 2023; 13:34. [PMID: 38202041 PMCID: PMC10780022 DOI: 10.3390/jcm13010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/08/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Maintenance of remission during pregnancy is vital for women with inflammatory bowel disease (IBD). The antenatal safety of novel small molecules for IBD is yet to be ascertained. We aimed to describe the current evidence on reproductive data regarding small-molecule drugs. We performed a systematic review searching Embase Classic + Embase and Ovid MEDLINE for reproductive outcomes for tofacitinib, filgotinib, upadacitininb, and ozanimod. Additionally, we asked the manufacturers for available data on file regarding reproduction. We analysed data from 10 sources; six studies and four manufacturer reports were identified from our search. Significant malformation risks were reported for tofacitinib, filgotinib, upadacitininb, and ozanimod in animal studies. In 126 tofacitinib-exposed pregnancies, there were 55 live births with 2 congenital malformations and 1 serious infant infection, 14 terminations, 15 miscarriages, and 42 outcomes unknown. In 50 filgotinib-exposed pregnancies, there were 20 healthy babies, 1 congenital malformation, 9 terminations, 10 miscarriages, and 10 outcomes unknown. In 78 upadacitinib-exposed pregnancies, there were 30 healthy babies, 15 terminations, 15 miscarriages, and 18 outcomes unknown. In 60 ozanimod-exposed pregnancies, there were 31 live births with 1 congenital malformation, 1 case of intra-uterine growth restriction, 1 case of neonatal icterus, 13 terminations, 9 miscarriages, and 8 unknown outcomes. Animal data suggest significant risks of malformations for tofacitinib, filgotinib, upadacitininb, and ozanimod. Human data from clinical trials and real-world observations do not show concerning data so far, but these are very limited. Currently, alternative treatments should be used for IBD during pregnancy.
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Affiliation(s)
| | | | | | | | - Christian P. Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals, Leeds LS9 7TF, UK; (N.M.); (M.G.); (R.L.)
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Chen J, Lin R, Guo G, Wu W, Ke M, Ke C, Huang P, Lin C. Physiologically-Based Pharmacokinetic Modeling of Anti-Tumor Necrosis Factor Agents for Inflammatory Bowel Disease Patients to Predict the Withdrawal Time in Pregnancy and Vaccine Time in Infants. Clin Pharmacol Ther 2023; 114:1254-1263. [PMID: 37620249 DOI: 10.1002/cpt.3031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023]
Abstract
Anti-tumor necrosis factor (anti-TNF) agents are widely applied for patients with inflammatory bowel disease (IBD); however, the timing of the last dosing for IBD pregnancy and time to elimination in anti-TNF agent-exposed infants is controversial. This study aimed to determine the optimal timing for the last dosing of anti-TNF agents (infliximab, adalimumab, and golimumab) in pregnant women with IBD, as well as to investigate the recommended vaccine schedules for infants exposed to these drugs. A physiologically-based pharmacokinetic (PBPK) model of anti-TNF agents was built for adults and extrapolated to pregnant patients, fetuses, and infants. The PBPK models successfully predicted and verified the pharmacokinetics (PKs) of infliximab, adalimumab, and golimumab in pregnancy, fetuses, and infants. The predicted PK data were within two-fold of the observed data. The simulated results were used as timing advice. According to the dose of administration, the suggested timing of the last dosing for infliximab, adalimumab, and golimumab is successfully provided based on PBPK predictions. PBPK models indicated that, for infants, the advocated timing of vaccination is 12, 8, and 5 months after birth for infliximab, adalimumab, and golimumab, respectively. Our study illustrated that PBPK models can provide a valuable tool to predict the PKs of large macromolecules in pregnant women, fetuses, and infants, ultimately informing drug-treatment decisions for pregnancy and vaccination regimens for infants.
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Affiliation(s)
- Jiarui Chen
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Rongfang Lin
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Guimu Guo
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wanhong Wu
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Meng Ke
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Chengjie Ke
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Pinfang Huang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Cuihong Lin
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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Tandon P, Huang VW, Feig DS, Saskin R, Maxwell C, Gao Y, Fell DB, Seow CH, Snelgrove JW, Nguyen GC. Differences in Healthcare Utilization in Women with and without Inflammatory Bowel Diseases During Preconception, Pregnancy and Postpartum: A Population-Based Cohort Study. J Crohns Colitis 2023; 17:1587-1595. [PMID: 37186150 DOI: 10.1093/ecco-jcc/jjad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Indexed: 05/17/2023]
Abstract
BACKGROUND AND AIMS Compared to those without inflammatory bowel disease [IBD], women with IBD may have increased healthcare utilization during pregnancy and postpartum, though this remains to be confirmed. We aimed to characterize this healthcare use between these groups. METHODS Administrative databases were accessed to identify women [aged 18-55 years] with and without IBD who had a live, singleton pregnancy between 2003 and 2018. Differences in emergency department [ED] visits, hospitalizations and prenatal care during 12 months preconception, pregnancy and 12 months postpartum were characterized. Multivariable negative binomial regression was performed to report incidence rate ratios [IRRs] with 95% confidence intervals [95% CIs]. Covariates included maternal age at conception, location of residence, socioeconomic status and maternal comorbidity. RESULTS In total, 6163 women with IBD [9158 pregnancies] and 1091 013 women without IBD [1729 411 pregnancies] were included. Women with IBD were more likely to visit the ED [IRR 1.13, 95% CI 1.08-1.18] and be hospitalized [IRR 1.11, 95% CI 1.01-1.21] during pregnancy, and visit the ED [IRR 1.21, 95% CI 1.15-1.27] and be hospitalized [IRR 1.18, 95% CI 1.05-1.32] during postpartum. On unadjusted analysis, women with IBD were more likely to be hospitalized for venous thromboembolic events. There was no difference in healthcare use in preconception. Finally, women with IBD also had a greater number of prenatal visits during pregnancy and were more likely to receive a first-trimester prenatal visit. CONCLUSION Women with IBD have increased healthcare utilization during pregnancy and postpartum. Efforts should be made to increase ambulatory care access during this period, which in turn may reduce this health-services utilization.
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Affiliation(s)
- Parul Tandon
- Mount Sinai Centre for Inflammatory Bowel Disease, Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Vivian W Huang
- Mount Sinai Centre for Inflammatory Bowel Disease, Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Denice S Feig
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Refik Saskin
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia Maxwell
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | | | - Deshayne B Fell
- ICES, Toronto, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Ontario, Canada
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - John W Snelgrove
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Geoffrey C Nguyen
- Mount Sinai Centre for Inflammatory Bowel Disease, Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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22
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Yeaman F, Stritzke A, Kuret V, Sharifi N, Seow CH, Metcalfe A, Leung Y. Thiopurine Exposure During Pregnancy is Not Associated With Anemia in Infants Born to Mothers With IBD. CROHN'S & COLITIS 360 2023; 5:otad066. [PMID: 37941596 PMCID: PMC10629965 DOI: 10.1093/crocol/otad066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Indexed: 11/10/2023] Open
Abstract
Background Thiopurines are commonly used to treat inflammatory bowel disease (IBD). Thiopurines are considered safe throughout pregnancy. However, a published study suggested the risk of neonatal anemia was increased if exposed to thiopurines in utero. This prospective cohort study aimed to determine if there is an increased risk of cytopenia among infants born to pregnant people with IBD, exposed or unexposed to thiopurines, compared to infants born to those without IBD. Methods Pregnant IBD patients, with and without thiopurine exposure, and one cohort of control individuals were recruited over a 5-year period. Consenting individuals completed a questionnaire and infants had a complete blood cell count at the newborn heel prick. Anemia was defined as hemoglobin (Hb) < 140g/L. Descriptive statistics were used to characterize the study population. Fisher exact tests were used to examine differences in outcomes between groups, a P-value of < 0.05 was deemed significant. Results Three cohorts were recruited: 19 IBD patients on thiopurines, 50 IBD patients not on thiopurines, and 37 controls (total of 106). Neonatal median Hb was not different with 177g/L (IQR 38g/L) for the IBD thiopurine group, 180.5g/L (IQR 40g/L) for the IBD non-thiopurine group, and 181g/L (IQR 37g/L) for the controls. Nineteen infants (18%) were cytopenic with 12 (11%) anemic, 6 (5.6%) thrombocytopenic, and 1 (0.94%) lymphopenic. Thiopurine exposure was only in one, mildly anemic, infant. Conclusions These findings further support physicians and IBD patients contemplating pregnancy that current guidelines recommending thiopurine adherence do not lead to increased perinatal risk of anemia or cytopenia.
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Affiliation(s)
- Fiona Yeaman
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Internal Medicine, University of Western Australia, Perth, WA, Australia
| | - Amelie Stritzke
- Department of Pediatrics University of Calgary, Calgary, AB, Canada
| | - Verena Kuret
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada
| | - Nastaran Sharifi
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences; University of Calgary, Calgary, AB, Canada
| | - Amy Metcalfe
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences; University of Calgary, Calgary, AB, Canada
| | - Yvette Leung
- Department of Medicine and Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
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23
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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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24
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Caballero-Mateos AM, Quesada-Caballero M, Cañadas-De la Fuente GA, Caballero-Vázquez A, Contreras-Chova F. IBD and Motherhood: A Journey through Conception, Pregnancy and Beyond. J Clin Med 2023; 12:6192. [PMID: 37834837 PMCID: PMC10573266 DOI: 10.3390/jcm12196192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
Inflammatory Bowel Disease (IBD) presents distinct challenges during pregnancy due to its influence on maternal health and pregnancy outcomes. This literature review aims to dissect the existing scientific evidence on pregnancy in women with IBD and provide evidence-based recommendations for clinical management. A comprehensive search was conducted across scientific databases, selecting clinical studies, systematic reviews, and other pertinent resources. Numerous studies have underscored an increased risk of complications during pregnancy for women with IBD, including preterm birth, low birth weight, neonates small for gestational age, and congenital malformations. Nevertheless, it's evident that proactive disease management before and throughout pregnancy can mitigate these risks. Continuation of IBD treatment during pregnancy and breastfeeding is deemed safe with agents like thiopurines, anti-TNF, vedolizumab, or ustekinumab. However, there's a call for caution when combining treatments due to the heightened risk of severe infections in the first year of life. For small molecules, their use is advised against in both scenarios. Effective disease management, minimizing disease activity, and interdisciplinary care are pivotal in attending to women with IBD. The emphasis is placed on the continual assessment of maternal and infant outcomes and an expressed need for further research to enhance the understanding of the ties between IBD and adverse pregnancy outcomes.
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Patel NB, Vinsard DG, Kattah AG, Kane SV. Decreased Risk of Preeclampsia in Women with Inflammatory Bowel Disease on Anti-Tumor Necrosis Factor Therapy. Dig Dis Sci 2023; 68:3557-3561. [PMID: 37402980 DOI: 10.1007/s10620-023-08016-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 06/18/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Evidence suggests that upregulation of tumor necrosis factor-alpha (TNF-α) plays a role in immune dysregulation in both preeclampsia and inflammatory bowel disease (IBD). AIMS We aimed to investigate whether anti-TNF therapy during pregnancy decreases the risk of preeclampsia in women with IBD. METHODS The study population included women with IBD and pregnancies who were followed at a tertiary care center from 2007 to 2021. Cases of preeclampsia were compared with controls with a normotensive pregnancy. Data on patient demographics, disease type and activity, pregnancy complications, and additional risk factors for preeclampsia were collected. The association between anti-TNF therapy and preeclampsia was analyzed using univariate analysis and multivariate logistic regression. RESULTS Women with preeclampsia were more likely to have a preterm delivery (44% vs. 12%, p < 0.001). More women without preeclampsia were exposed to anti-TNF therapy during pregnancy than women with preeclampsia (55% vs. 30%, p = 0.029). The majority of women (32/44) on anti-TNF therapy, either adalimumab or infliximab, continued to have some degree of exposure during the third trimester. Though not significant, multivariate analysis showed a trend towards a protective effect of anti-TNF therapy against developing preeclampsia if exposed during the third trimester (OR 0.39; 95% CI 0.14-1.12, p = 0.08). CONCLUSIONS In this study, anti-TNF therapy exposure was higher in IBD patients who did not develop preeclampsia than in those who did. While not significant, there was a trend towards a protective effect of anti-TNF therapy against preeclampsia if exposed during the third trimester.
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Affiliation(s)
- Nisha B Patel
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
| | | | - Andrea G Kattah
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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26
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Fitzpatrick T, Alsager K, Sadarangani M, Pham-Huy A, Murguía-Favela L, Morris SK, Seow CH, Piché-Renaud PP, Jadavji T, Vanderkooi OG, Top KA, Constantinescu C. Immunological effects and safety of live rotavirus vaccination after antenatal exposure to immunomodulatory biologic agents: a prospective cohort study from the Canadian Immunization Research Network. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:648-656. [PMID: 37390832 DOI: 10.1016/s2352-4642(23)00136-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND People with inflammatory or autoimmune diseases are recommended to continue immunomodulatory biologic agents throughout pregnancy. However, concerns regarding potential immunosuppression in infants exposed to biologic agents have led to recommendations to avoid live vaccines in the first 6-12 months of life. We aimed to examine whether live rotavirus vaccine could be administered safely to infants exposed to biologic agents, assessed in the Canadian Special Immunization Clinic (SIC) Network. METHODS In this prospective cohort study, infants exposed to biologic agents in utero were referred to one of six SIC sites in Canada for rotavirus vaccination recommendations. Children with other contraindications to rotavirus vaccination or older than 15 weeks were excluded. Clinical and laboratory evaluations were conducted according to a standard clinical pathway. Data were collected for relevant medical history, pregnancy outcomes, biologic agent exposure history, physical examination, laboratory results of the child, SIC recommendations for rotavirus vaccination, rotavirus vaccine series completion, and adverse events after immunisation. After parental consent, deidentified data were transferred to a central database for analysis. Children recommended for rotavirus vaccination were followed up for 8 months after series initiation to ascertain severe and serious adverse events, including severe diarrhoea, vomiting, and intussusception. FINDINGS Between May 1, 2017, and Dec 31, 2021, 202 infants were assessed and 191 eligible infants were enrolled (97 [51%] were female and 94 [49%] were male). When including those exposed to multiple agents, the most common biologic agents to which infants were exposed were infliximab (67 [35%] of 191), adalimumab (49 [26%]), ustekinumab (18 [9%]), and vedolizumab (17 [9%]). Biologic agent exposure continued into the third trimester for 178 (93%) infants. No clinically significant abnormalities in lymphocyte subsets, quantitative immunoglobulins, or mitogen responses were detected. After SIC assessment, rotavirus vaccination was recommended for 187 (98%) of 191 infants, all of whom were followed up. By end of follow-up on Aug 19, 2022, 168 (90%) infants had initiated rotavirus vaccination; 150 (80%) completed the series. No serious adverse events after immunisation were reported, but three (2%) infants required medical attention, one for vomiting and change in stools who was subsequently diagnosed with gastroesophageal reflux disease, one for rash on labia unrelated to vaccination, and one for vomiting and diarrhoea associated with a milk allergy. INTERPRETATION Findings from this study suggest that lymphocyte subsets and the safety of live rotavirus vaccination are generally not affected by in-utero exposure to biologic agents. Rotavirus vaccination can be offered to infants exposed to anti-TNF agents in utero. FUNDING Public Health Agency of Canada and Canadian Institutes of Health Research through the Canadian Immunization Research Network.
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Affiliation(s)
- Tiffany Fitzpatrick
- Canadian Center for Vaccinology, IWK Health, Halifax, NS, Canada; Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - Khaled Alsager
- Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada; Department of Pediatrics, University of Calgary, Calgary, AB, Canada; Pediatric Infectious Diseases Division, Pediatric Department, King Abdullah Specialized Children's Hospital, Ministry of National Guard Hospital Affairs, Riyadh, Saudi Arabia
| | - Manish Sadarangani
- Vaccine Evaluation Center, British Columbia Children's Hospital Research Institute, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Anne Pham-Huy
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Luis Murguía-Favela
- Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada; Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Shaun K Morris
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Tajdin Jadavji
- Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada; Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Otto G Vanderkooi
- Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada; Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Karina A Top
- Canadian Center for Vaccinology, IWK Health, Halifax, NS, Canada; Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada; Department of Pediatrics, Dalhousie University, Halifax, NS, Canada.
| | - Cora Constantinescu
- Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada; Department of Pediatrics, University of Calgary, Calgary, AB, Canada
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27
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Targownik LE, Bollegala N, Huang VW, Windsor JW, Kuenzig ME, Benchimol EI, Kaplan GG, Murthy SK, Bitton A, Bernstein CN, Jones JL, Lee K, Peña-Sánchez JN, Rohatinsky N, Ghandeharian S, Davis T, Weinstein J, Im JHB, Jannati N, Khan R, Matthews P, Jones May T, Tabatabavakili S, Jogendran R, Hazan E, Browne M, Meka S, Vukovic S, Jogendran M, Hu M, Osei JA, Wang GY, Sheekha TA, Dahlwi G, Goddard Q, Gorospe J, Nisbett C, Gertsman S, Sousa J, Morganstein T, Stocks T, Weber A, Seow CH. The 2023 Impact of Inflammatory Bowel Disease in Canada: The Influence of Sex and Gender on Canadians Living With Inflammatory Bowel Disease. J Can Assoc Gastroenterol 2023; 6:S55-S63. [PMID: 37674498 PMCID: PMC10478807 DOI: 10.1093/jcag/gwad011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
Sex (the physical and physiologic effects resulting from having specific combinations of sex chromosomes) and gender (sex-associated behaviours, expectations, identities, and roles) significantly affect the course of inflammatory bowel disease (IBD) and the experience of living with IBD. Sex-influenced physiologic states, like puberty, the menstrual cycle, pregnancy, and andropause/menopause may also impact and be impacted by IBD. While neither Crohn's disease nor ulcerative colitis is commonly considered sex-determined illnesses, the relative incidence of Crohn's disease and ulcerative colitis between males and females varies over the life cycle. In terms of gender, women tend to use healthcare resources at slightly higher rates than men and are more likely to have fragmented care. Women are more commonly prescribed opioid medications and are less likely than men to undergo colectomy. Women tend to report lower quality of life and have higher indirect costs due to higher rates of disability. Women are also more likely to take on caregiver roles for children with IBD. Women with IBD are more commonly burdened with adverse mental health concerns and having poor mental health has a more profound impact on women than men. Pregnant people with active IBD have higher rates of adverse outcomes in pregnancy, made worse in regions with poor access to IBD specialist care. The majority of individuals with IBD in Canada do not have access to a pregnancy-in-IBD specialist; access to this type of care has been shown to allay fears and increase knowledge among pregnant people with IBD.
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Affiliation(s)
- Laura E Targownik
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Natasha Bollegala
- Department of Gastroenterology, Women’s College Hospital, Toronto, Ontario, Canada
| | - Vivian W Huang
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Joseph W Windsor
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Gilaad G Kaplan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sanjay K Murthy
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada
| | - Alain Bitton
- Division of Gastroenterology and Hepatology, McGill University Health Centre IBD Centre, McGill University, Montréal, Quebec, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Jennifer L Jones
- Departments of Medicine, Clinical Health, and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kate Lee
- Crohn’s and Colitis Canada, Toronto, Ontario, Canada
| | - Juan-Nicolás Peña-Sánchez
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Noelle Rohatinsky
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Tal Davis
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jake Weinstein
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James H B Im
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nazanin Jannati
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Rabia Khan
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | | | - Tyrel Jones May
- Division of Gastroenterology and Hepatology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sahar Tabatabavakili
- Department of Gastroenterology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rohit Jogendran
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elias Hazan
- Department of Internal Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mira Browne
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Saketh Meka
- Department of Internal Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sonya Vukovic
- Department of Internal Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Manisha Jogendran
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Malini Hu
- Department of Gastroenterology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jessica Amankwah Osei
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Grace Y Wang
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tasbeen Akhtar Sheekha
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ghaida Dahlwi
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Quinn Goddard
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Julia Gorospe
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Cyanne Nisbett
- Faculty of Law, University of Victoria, Victoria, British Colombia, Canada
- School of Criminology, Simon Fraser University, Burnaby, British Colombia, Canada
| | - Shira Gertsman
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James Sousa
- Crohn’s and Colitis Canada, Toronto, Ontario, Canada
| | - Taylor Morganstein
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Taylor Stocks
- Crohn’s and Colitis Canada, Toronto, Ontario, Canada
| | - Ann Weber
- Department of Obstetrics and Gynecology, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Cynthia H Seow
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Neuroscience, McGill University, Montreal, Quebec, Canada
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28
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Selinger CP, Laube R, Steed H, Brookes M, BioResource NIHR, Leong RWL. Planning to conceive within a year is associated with better pregnancy-specific disease-related patient knowledge and better medication adherence in women of childbearing age with inflammatory bowel disease. Therap Adv Gastroenterol 2023; 16:17562848231193211. [PMID: 37667806 PMCID: PMC10475232 DOI: 10.1177/17562848231193211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/21/2023] [Indexed: 09/06/2023] Open
Abstract
Background Adherence to inflammatory bowel disease (IBD) medication is crucial to maintain remission, especially during pregnancy. Objective To examine the influence of family planning and pregnancy-related patient knowledge regarding IBD and pregnancy on adherence. Design Cross-sectional survey study. Methods We surveyed female patients with IBD aged 18-35 years, who at recruitment to the UK IBD BioResource had not had children. We elicited disease and treatment history, demographics and family planning status via an online questionnaire. Patient knowledge as assessed by the validated Crohn's and Colitis Pregnancy Knowledge Score (CCPKnow) and adherence by visual analogue scale (VAS). Results In 326 responders (13.8% response rate), good adherence (VAS ⩾ 80) was found in only 38.35%. Disease- and treatment-related factors were not significantly associated with good adherence, except for methotrexate (70.0% adherent of 10 exposed patients versus 37.2% non-exposed; p = 0.036). Patients planning pregnancy for the next year were more often adherent (59.0% versus 35.5%; p = 0.019) and knowledgeable (median CCPKnow 8 versus 7; p = 0.035) compared to those in other family planning categories. Pregnancy-related patient knowledge was significantly associated with adherence (Pearson correlation 0.141; p = 0.015). Adherent patients had significantly higher CCPKnow scores than non-adherent patients (median 8 versus 6; p = 0.009). On binary regression analysis, only planning to conceive within 12 months was independently associated with better adherence (p = 0.016), but not methotrexate exposure (p = 0.076) and CCPKnow (p = 0.056). Conclusions In a cohort of women of childbearing age with IBD overall medication, adherence was low. Planning to conceive within the next year was associated with better adherence and greater patient knowledge.
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Affiliation(s)
- Christian P. Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Bexley Wing, Leeds, LS9 7TF, UK
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
| | - Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
| | - Helen Steed
- Department of Gastroenterology, Royal Wolverhampton Hospital, Wolverhampton, UK
- Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
| | - Matthew Brookes
- Department of Gastroenterology, Royal Wolverhampton Hospital, Wolverhampton, UK
- Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
| | - NIHR BioResource
- Cambridge University Hospitals, Cambridge Biomedical Campus, Cambridge, UK
| | - Rupert W. L. Leong
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Concord Clinical School, University of Sydney, Sydney, NSW, Australia
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Wickenheisser NE, Craig AM, Kuller JA, Dotters-Katz SK. The Risks and Benefits of Monoclonal Antibody Therapy During Pregnancy and Postpartum: Maternal, Obstetric, and Neonatal Considerations. Obstet Gynecol Surv 2023; 78:429-437. [PMID: 37480293 DOI: 10.1097/ogx.0000000000001155] [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: 07/24/2023]
Abstract
Importance Autoimmune and rheumatologic conditions can lead to multiple adverse maternal, obstetric, and neonatal outcomes, especially if they flare during pregnancy. Although many medications to control these conditions exist, concerns regarding their safety often unnecessarily limit their use. Objective We aim to review the current evidence available describing the use of monoclonal antibody (mAb) therapeutics in pregnancy and postpartum and understand the impact of their use on the developing fetus and neonate. Evidence Acquisition Original research articles, review articles, case series and case reports, and pregnancy guidelines were reviewed. Results Multiple retrospective (including 1924 patients) and prospective studies (including 899 patients) of anti-tumor necrosis factor (TNF) agent use in pregnancy found no significant increase in rates of miscarriage, preterm birth, or congenital anomalies compared with controls. Most societies, including American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine, recommend initiation or continuation of TNF-α inhibitors during pregnancy for patients with autoimmune diseases. An increased risk of mild infections in newborns has been reported, although infections requiring hospitalizations are rare. Data suggest that breastfeeding while taking anti-TNF agents is safe for neonates. Less data exist for the use of other mAbs including anticytokine, anti-integrin, and anti-B-cell agents during pregnancy and postpartum. Conclusions and Relevance Current evidence suggests that the use of mAbs, particularly anti-TNF agents, is safe in pregnancy and postpartum, without significant adverse effects on the pregnant patient or infant. The benefits of ongoing disease control in pregnant patients result in favorable maternal and neonatal outcomes.
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Affiliation(s)
| | | | | | - Sarah K Dotters-Katz
- Associate Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
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30
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Avni Biron I, Hayat L, Ollech JE, Banai-Eran H, Narkis B, Houri O, Pauker MH, Shay V, Dotan I, Hadar E, Yanai H. Pregnancy Outcomes in a Cohort of Patients with Inflammatory Bowel Disease: Data from a Multidisciplinary Clinic in a Tertiary Center. J Clin Med 2023; 12:4120. [PMID: 37373814 DOI: 10.3390/jcm12124120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) can have an impact on pregnancy outcomes due to the effect of the disease activity and medication use. This study aimed to evaluate the pregnancy outcomes in IBD patients treated at a multidisciplinary clinic. METHODS This study was a retrospective cohort study including consecutive pregnant patients with IBD having a singleton gestation attending a multidisciplinary clinic between 2012 and 2019. The IBD activity and management throughout gestation were assessed. The pregnancy outcomes included: adverse neonatal and maternal outcomes, mode of delivery, and three integrative outcomes: (1) a favorable pregnancy outcome, (2) a poor pregnancy outcome, and (3) an unfavorable maternal outcome. The IBD pregnant cohort was compared with a cohort of non-IBD pregnant women delivering at the same shift. Multivariable logistic regression was used for risk assessment. RESULTS Pregnant women with IBD (141) and without (1119) were included. Mean maternal age was 32 [±4] years. Patients with IBD had a higher rate of nulliparity (70/141 (50%) vs. 340/1119 (30%), p < 0.001) and lower BMI (21.42 kg/m2 (19.18-23.44) vs. 22.48 (20.31-25.59), p = 0.002). All the other characteristics were comparable. Most patients with IBD 124/141 (88%) were in clinical remission at conception; with maintenance therapy in 117/141 patients (83%). A third of the patients, 43/141 (30.5%), were treated with biologics. Exacerbation occurred during pregnancy in 51/141 (36%). The majority of the maternal and neonatal outcomes and all the composite outcomes were comparable between the patients with IBD and the women without IBD. Cesarean delivery was more frequent in patients with IBD (49/141 (34.8%) vs. 270/1119 (24.1%), p = 0.021). IBD was not associated with composite outcomes. CONCLUSIONS In pregnant patients with IBD followed at a multidisciplinary clinic, the pregnancy outcomes were encouraging and comparable to those of the women without IBD.
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Affiliation(s)
- Irit Avni Biron
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Rabin Medical Center, Petah-Tikva 4919001, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Lior Hayat
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Jacob E Ollech
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Rabin Medical Center, Petah-Tikva 4919001, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Hagar Banai-Eran
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Rabin Medical Center, Petah-Tikva 4919001, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Bar Narkis
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah-Tikva 4941492, Israel
| | - Ohad Houri
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah-Tikva 4941492, Israel
| | - Maor H Pauker
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Rabin Medical Center, Petah-Tikva 4919001, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Vardit Shay
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Rabin Medical Center, Petah-Tikva 4919001, Israel
| | - Iris Dotan
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Rabin Medical Center, Petah-Tikva 4919001, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Eran Hadar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah-Tikva 4941492, Israel
| | - Henit Yanai
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Rabin Medical Center, Petah-Tikva 4919001, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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31
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Ahn SM, Joo YB, Kim YJ, Bang SY, Lee HS. Pregnancy Outcomes Associated With Biologic Agent Exposure in Patients With Several Rheumatic Diseases and Inflammatory Bowel Diseases. J Korean Med Sci 2023; 38:e172. [PMID: 37272561 DOI: 10.3346/jkms.2023.38.e172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 02/21/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND This study aimed to analyze pregnancy outcomes based on biologic agents use in women using the nationwide population-based database. METHODS The study used the claims database to identify women of childbearing age with several rheumatic (rheumatoid arthritis, juvenile idiopathic arthritis, ankylosing spondylitis, psoriatic arthritis) and inflammatory bowel diseases (Crohn's disease and ulcerative colitis) who had pregnancy-related codes between January 2010 and December 2019. We analyzed live births and adverse pregnancy outcomes based on the previous use of biologics. We also stratified the patients according to duration of biologic agent exposure before pregnancy and the use of biologics during pregnancy to analyze the pregnancy outcomes by subgroups. RESULTS We identified 4,787 patients with pregnancy events. Among them, 1,034 (21.6%) used biologics before pregnancy. Live birth rate was not different between the biologics group and biologics naïve group (75.0% vs. 75.2%). Multivariate analyses showed that biologics use was associated with higher risk of intrauterine growth retardation (odds ratio [OR], 1.780) and lower risk of gestational diabetes mellitus (OR, 0.776) compared with biologics naïve. Biologics use during pregnancy was associated with higher risk of preterm delivery (OR, 1.859), preeclampsia/eclampsia (OR, 1.762), intrauterine growth retardation (OR, 3.487), and cesarean section (OR, 1.831), but lower risk of fetal loss (OR, 0.274) compared with biologics naïve. CONCLUSIONS Although there was no difference in live birth rate between the biologics group and biologics naïve group, biologics use seems to be associated with several adverse pregnancy outcomes, especially in patients with biologics during pregnancy. Therefore, patients with biologics during pregnancy need to be carefully observed for adverse pregnancy outcomes.
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Affiliation(s)
- Soo Min Ahn
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Bin Joo
- Division of Rheumatology, Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
- Hanyang University Institute for Rheumatology Research, Seoul, Korea
| | - Yun Jin Kim
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University, Seoul, Korea
| | - So-Young Bang
- Division of Rheumatology, Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
- Hanyang University Institute for Rheumatology Research, Seoul, Korea
| | - Hye-Soon Lee
- Division of Rheumatology, Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
- Hanyang University Institute for Rheumatology Research, Seoul, Korea.
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32
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Kunisaki R, Ikeda A, Yaguchi K, Onishi M, Shibui S, Nishida D, Madarame A, Toritani K, Nakamori Y, Nishio M, Ogashiwa T, Fujii A, Kimura H, Suzuki R, Aoki S, Maeda S. To Be in Remission or in Corticosteroid-free Remission: That Is the Question for Women With Inflammatory Bowel Disease at Conception. Inflamm Bowel Dis 2023; 29:e20-e21. [PMID: 36880427 DOI: 10.1093/ibd/izad023] [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: 03/08/2023]
Affiliation(s)
- Reiko Kunisaki
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Aya Ikeda
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Katsuki Yaguchi
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Misa Onishi
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Shunsuke Shibui
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Daisuke Nishida
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Akira Madarame
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Kenichiro Toritani
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Yoshinori Nakamori
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Masafumi Nishio
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Tsuyoshi Ogashiwa
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Ayako Fujii
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Hideaki Kimura
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Ryoichi Suzuki
- Kannai-Suzuki Clinic, 3-63-1 Aioi-cho, Naka-ku, Yokohama 231-0012, Japan
| | - Shigeru Aoki
- Perinatal Center for Maternity and Neonates, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Shin Maeda
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
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Jogendran R, O'Connor K, Jeyakumar A, Tandon P, Nguyen GC, Maxwell C, Huang V. Optimizing maternal and neonatal outcomes through tight control management of inflammatory bowel disease during pregnancy: a pilot feasibility study. Sci Rep 2023; 13:8291. [PMID: 37217778 DOI: 10.1038/s41598-023-35332-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/16/2023] [Indexed: 05/24/2023] Open
Abstract
A home point-of care FCP test (IBDoc) and a self-reported clinical disease activity program (IBD Dashboard) may improve routine monitoring of IBD activity during pregnancy. We aimed to evaluate the feasibility of tight control management using remote monitoring in pregnant patients with IBD. Pregnant patients (< 20 weeks) with IBD were prospectively enrolled from Mount Sinai Hospital between 2019 and 2020. Patients completed the IBDoc and IBD Dashboard at three core time points. Disease activity was measured clinically using the Harvey-Bradshaw Index (mHBI) for CD and partial Mayo (pMayo) for UC, or objectively using FCP. A feasibility questionnaire was completed in the third trimester. Seventy-seven percent of patients (24 of 31) completed the IBDoc and IBD Dashboard at all core time points. Twenty-four patients completed the feasibility questionnaires. All survey respondents strongly preferred using the IBDoc over standard lab-based testing and would use the home kit in the future. Exploratory analysis identified discordance rates of more than 50% between clinical and objective disease activity. Tight control management using remote monitoring may be feasible among pregnant patients with IBD. A combination of both clinical scores and objective disease markers may better predict disease activity.
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Affiliation(s)
- Rohit Jogendran
- Division of Gastroenterology and Hepatology, IBD Clinical Research Program, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Katie O'Connor
- Division of Gastroenterology and Hepatology, IBD Clinical Research Program, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Ajani Jeyakumar
- Division of Gastroenterology and Hepatology, IBD Clinical Research Program, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Parul Tandon
- Division of Gastroenterology and Hepatology, IBD Clinical Research Program, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Geoffrey C Nguyen
- Division of Gastroenterology and Hepatology, IBD Clinical Research Program, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Cynthia Maxwell
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
- Women's College Hospital Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Vivian Huang
- Division of Gastroenterology and Hepatology, IBD Clinical Research Program, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
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34
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Brondfield MN, Mahadevan U. Inflammatory bowel disease in pregnancy and breastfeeding. Nat Rev Gastroenterol Hepatol 2023:10.1038/s41575-023-00758-3. [PMID: 37002407 DOI: 10.1038/s41575-023-00758-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 06/19/2023]
Abstract
Inflammatory bowel disease (IBD) has a peak age of diagnosis before the age of 35 years. Concerns about infertility, adverse pregnancy outcomes, and heritability of IBD have influenced decision-making for patients of childbearing age and their care providers. The interplay between the complex physiology in pregnancy and IBD can affect placental development, microbiome composition and responses to therapy. Current evidence has shown that effective disease management, including pre-conception counselling, multidisciplinary care and therapeutic agents to minimize disease activity, can improve pregnancy outcomes. This Review outlines the management of IBD in pregnancy and the safety of IBD therapies, including novel agents, with regard to both maternal and fetal health. The vast majority of IBD therapies can be used with low risk during pregnancy and lactation without substantial effects on neonatal outcomes.
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Affiliation(s)
- Max N Brondfield
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Uma Mahadevan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
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Alata Jimenez N, Castellano M, Santillan EM, Boulias K, Boan A, Arias Padilla LF, Fernandino JI, Greer EL, Tosar JP, Cochella L, Strobl-Mazzulla PH. Paternal methotrexate exposure affects sperm small RNA content and causes craniofacial defects in the offspring. Nat Commun 2023; 14:1617. [PMID: 36959185 PMCID: PMC10036556 DOI: 10.1038/s41467-023-37427-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 03/14/2023] [Indexed: 03/25/2023] Open
Abstract
Folate is an essential vitamin for vertebrate embryo development. Methotrexate (MTX) is a folate antagonist that is widely prescribed for autoimmune diseases, blood and solid organ malignancies, and dermatologic diseases. Although it is highly contraindicated for pregnant women, because it is associated with an increased risk of multiple birth defects, the effect of paternal MTX exposure on their offspring has been largely unexplored. Here, we found MTX treatment of adult medaka male fish (Oryzias latipes) causes cranial cartilage defects in their offspring. Small non-coding RNA (sncRNAs) sequencing in the sperm of MTX treated males identify differential expression of a subset of tRNAs, with higher abundance for specific 5' tRNA halves. Sperm RNA methylation analysis on MTX treated males shows that m5C is the most abundant and differential modification found in RNAs ranging in size from 50 to 90 nucleotides, predominantly tRNAs, and that it correlates with greater testicular Dnmt2 methyltransferase expression. Injection of sperm small RNA fractions from MTX-treated males into normal fertilized eggs generated cranial cartilage defects in the offspring. Overall, our data suggest that paternal MTX exposure alters sperm sncRNAs expression and modifications that may contribute to developmental defects in their offspring.
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Affiliation(s)
- Nagif Alata Jimenez
- Laboratory of Developmental Biology, Instituto de Investigaciones Biotecnológicas- Instituto Tecnológico de Chascomús (CONICET-UNSAM), Chascomús, Argentina
- Escuela de Bio y Nanotecnologías (UNSAM), Chascomús, Argentina
| | - Mauricio Castellano
- Functional Genomics Unit, Instituto Pasteur de Montevideo, Montevideo, Uruguay
- School of Science, Universidad de la República, Montevideo, Uruguay
| | - Emilio M Santillan
- Department of Molecular Biology and Genetics, Johns Hopkins University School of Medicine, Baltimore, MA, USA
| | - Konstantinos Boulias
- Department of Pediatrics, HMS Initiative for RNA Medicine, Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Agustín Boan
- Laboratory of Developmental Biology, Instituto de Investigaciones Biotecnológicas- Instituto Tecnológico de Chascomús (CONICET-UNSAM), Chascomús, Argentina
- Escuela de Bio y Nanotecnologías (UNSAM), Chascomús, Argentina
| | - Luisa F Arias Padilla
- Laboratory of Developmental Biology, Instituto de Investigaciones Biotecnológicas- Instituto Tecnológico de Chascomús (CONICET-UNSAM), Chascomús, Argentina
- Escuela de Bio y Nanotecnologías (UNSAM), Chascomús, Argentina
| | - Juan I Fernandino
- Laboratory of Developmental Biology, Instituto de Investigaciones Biotecnológicas- Instituto Tecnológico de Chascomús (CONICET-UNSAM), Chascomús, Argentina
- Escuela de Bio y Nanotecnologías (UNSAM), Chascomús, Argentina
| | - Eric L Greer
- Department of Pediatrics, HMS Initiative for RNA Medicine, Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Juan P Tosar
- Functional Genomics Unit, Instituto Pasteur de Montevideo, Montevideo, Uruguay
- School of Science, Universidad de la República, Montevideo, Uruguay
| | - Luisa Cochella
- Department of Molecular Biology and Genetics, Johns Hopkins University School of Medicine, Baltimore, MA, USA
| | - Pablo H Strobl-Mazzulla
- Laboratory of Developmental Biology, Instituto de Investigaciones Biotecnológicas- Instituto Tecnológico de Chascomús (CONICET-UNSAM), Chascomús, Argentina.
- Escuela de Bio y Nanotecnologías (UNSAM), Chascomús, Argentina.
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36
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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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37
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Kittleson MM, DeFilippis EM, Bhagra CJ, Casale JP, Cauldwell M, Coscia LA, D'Souza R, Gaffney N, Gerovasili V, Ging P, Horsley K, Macera F, Mastrobattista JM, Paraskeva MA, Punnoose LR, Rasmusson KD, Reynaud Q, Ross HJ, Thakrar MV, Walsh MN. Reproductive health after thoracic transplantation: An ISHLT expert consensus statement. J Heart Lung Transplant 2023; 42:e1-e42. [PMID: 36528467 DOI: 10.1016/j.healun.2022.10.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Ersilia M DeFilippis
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center, New York, New York
| | - Catriona J Bhagra
- Department of Cardiology, Cambridge University and Royal Papworth NHS Foundation Trusts, Cambridge, UK
| | - Jillian P Casale
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland
| | - Matthew Cauldwell
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, London, UK
| | - Lisa A Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, Pennsylvania
| | - Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Gaffney
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | | | - Patricia Ging
- Department of Pharmacy, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Kristin Horsley
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Francesca Macera
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy; Dept of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Joan M Mastrobattista
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine Houston, Texas
| | - Miranda A Paraskeva
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Lynn R Punnoose
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Quitterie Reynaud
- Cystic Fibrosis Adult Referral Care Centre, Department of Internal Medicine, Hospices civils de Lyon, Pierre Bénite, France
| | - Heather J Ross
- Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada; Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Mitesh V Thakrar
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
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38
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Pregnancy in Patients with Inflammatory Bowel Diseases-A Literature Review. Life (Basel) 2023; 13:life13020475. [PMID: 36836832 PMCID: PMC9961380 DOI: 10.3390/life13020475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/03/2023] [Accepted: 02/04/2023] [Indexed: 02/11/2023] Open
Abstract
In recent years, we have faced an increasing incidence of inflammatory bowel disease (IBD), especially among young people, affecting them during their reproductive years. The paucity of data and reduced knowledge regarding the evolution of the disease during pregnancy and the adverse effects of the therapy on the mother and infant increase voluntary childlessness in this group of patients. Depending on the type of IBD, severity and surgical or medical management, this can negatively affect the pregnancy. C-sections and the risk of low-birth-weight babies are higher in women with IBD, independent of active/inactive disease, while preterm birth, stillbirth and miscarriage are associated with disease activity. In the last period, medicinal therapy has evolved, and new molecules have been developed for better control of the lesions, but the effect on pregnancy and breastfeeding is still controversial. We conducted this review by studying the literature and recent research in order to have a better image of the practical management of IBD during pregnancy.
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39
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Ishige T, Shimizu T, Watanabe K, Arai K, Kamei K, Kudo T, Kunisaki R, Tokuhara D, Naganuma M, Mizuochi T, Murashima A, Inoki Y, Iwata N, Iwama I, Koinuma S, Shimizu H, Jimbo K, Takaki Y, Takahashi S, Cho Y, Nambu R, Nishida D, Hagiwara SI, Hikita N, Fujikawa H, Hosoi K, Hosomi S, Mikami Y, Miyoshi J, Yagi R, Yokoyama Y, Hisamatsu T. Expert consensus on vaccination in patients with inflammatory bowel disease in Japan. J Gastroenterol 2023; 58:135-157. [PMID: 36629948 PMCID: PMC9838549 DOI: 10.1007/s00535-022-01953-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 12/28/2022] [Indexed: 01/12/2023]
Abstract
Immunosuppressive therapies can affect the immune response to or safety of vaccination in patients with inflammatory bowel disease (IBD). The appropriateness of vaccination should be assessed prior to the initiation of IBD treatment because patients with IBD frequently undergo continuous treatment with immunosuppressive drugs. This consensus was developed to support the decision-making process regarding appropriate vaccination for pediatric and adult patients with IBD and physicians by providing critical information according to the published literature and expert consensus about vaccine-preventable diseases (VPDs) [excluding cervical cancer and coronavirus disease 2019 (COVID-19)] in Japan. This consensus includes 19 important clinical questions (CQs) on the following 4 topics: VPDs (6 CQs), live attenuated vaccines (2 CQs), inactivated vaccines (6 CQs), and vaccination for pregnancy, childbirth, and breastfeeding (5 CQs). These topics and CQs were selected under unified consensus by the members of a committee on intractable diseases with support by a Health and Labour Sciences Research Grant. Physicians should provide necessary information on VPDs to their patients with IBD and carefully manage these patients' IBD if various risk factors for the development or worsening of VPDs are present. This consensus will facilitate informed and shared decision-making in daily IBD clinical practice.
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Affiliation(s)
- Takashi Ishige
- Department of Pediatrics, Gunma University Graduate School of Medicine, 3-39-22, Showa-Machi, Maebashi, Gunma, 371-8511, Japan.
| | - Toshiaki Shimizu
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Kenji Watanabe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Japan
| | - Katsuhiro Arai
- Division of Gastroenterology, Center for Pediatric Inflammatory Bowel Disease, National Center for Child Health and Development, Tokyo, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Takahiro Kudo
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Reiko Kunisaki
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Daisuke Tokuhara
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Makoto Naganuma
- Department of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Tatsuki Mizuochi
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Atsuko Murashima
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center of Child Health and Development, Tokyo, Japan
| | - Yuta Inoki
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Naomi Iwata
- Department of Infection and Immunology, Aichi Children's Health and Medical Center, Obu, Japan
| | - Itaru Iwama
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Sachi Koinuma
- Japan Drug Information Institute in Pregnancy, National Center of Child Health and Development, Tokyo, Japan
| | - Hirotaka Shimizu
- Division of Gastroenterology, Center for Pediatric Inflammatory Bowel Disease, National Center for Child Health and Development, Tokyo, Japan
| | - Keisuke Jimbo
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Yugo Takaki
- Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Shohei Takahashi
- Department of Pediatrics, Kyorin University School of Medicine, Tokyo, Japan
| | - Yuki Cho
- Department of Pediatrics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Ryusuke Nambu
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Daisuke Nishida
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Shin-Ichiro Hagiwara
- Department of Pediatric Gastroenterology, Nutrition and Endocrinology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Norikatsu Hikita
- Department of Pediatrics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hiroki Fujikawa
- Division of Gastroenterology, Center for Pediatric Inflammatory Bowel Disease, National Center for Child Health and Development, Tokyo, Japan
| | - Kenji Hosoi
- Division of Gastroenterology, Tokyo Metro Children's Medical Center, Tokyo, Japan
| | - Shuhei Hosomi
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yohei Mikami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Jun Miyoshi
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Ryusuke Yagi
- Department of Pediatrics, Gunma University Graduate School of Medicine, 3-39-22, Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Yoko Yokoyama
- Department of Intestinal Inflammation Research, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
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40
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Dobson R, Rog D, Ovadia C, Murray K, Hughes S, Ford HL, Pearson OR, White S, Bonham N, Mathews J, Nelson-Piercy C, Brex P. Anti-CD20 therapies in pregnancy and breast feeding: a review and ABN guidelines. Pract Neurol 2023; 23:6-14. [PMID: 35803727 DOI: 10.1136/pn-2022-003426] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 02/02/2023]
Abstract
Neurologists increasingly use anti-CD20 therapies, including for women of childbearing age, despite these medications being unlicensed for use in pregnancy. Current evidence suggests that women can safely conceive while taking anti-CD20 therapy. Women should not be denied treatment during pregnancy when it is clinically indicated, although they should be counselled regarding live vaccinations for their infant. Women receiving regular ocrelizumab for multiple sclerosis should preferably wait 3 months before trying to conceive. There are few data around ofatumumab in pregnancy, and while there is probably a class effect across all anti-CD20 therapies, ofatumumab may need to be continued during pregnancy to maintain efficacy. We recommend that anti-CD20 therapies can be safely given while breast feeding. It is important to make time to discuss treatments with women of childbearing age to help them choose their most suitable treatment. Outcomes should be monitored in pregnancy registries.
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Affiliation(s)
- Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University, London, UK .,Department of Neurology, The Royal London Hospital, London, UK
| | - David Rog
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
| | - Caroline Ovadia
- Department of Women and Children's Health, King's College London, London, UK
| | - Katy Murray
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh, Edinburgh, UK.,Department of Neurology, Forth Valley Royal Hospital, Larbert, UK
| | - Stella Hughes
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Helen L Ford
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Department of Neurosciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | - Owen R Pearson
- Department of Neurology, Morriston Hospital, Swansea, UK
| | - Sarah White
- Department of Neurology, St George's Hospitals NHS Trust, London, UK
| | - Nicola Bonham
- Department of Neurology, Forth Valley Royal Hospital, Larbert, UK
| | - Joela Mathews
- Department of Neurology, The Royal London Hospital, London, UK
| | - Catherine Nelson-Piercy
- Department of Obstetrics, Guy's and St Thomas' Hospitals NHS Trust, London, UK.,Department of Obstetrics, King's College Hospital NHS Foundation Trust, London, UK
| | - Peter Brex
- Department of Neurology, King's College Hospital NHS Foundation Trust, London, UK
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41
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Torres J, Chaparro M, Julsgaard M, Katsanos K, Zelinkova Z, Agrawal M, Ardizzone S, Campmans-Kuijpers M, Dragoni G, Ferrante M, Fiorino G, Flanagan E, Gomes CF, Hart A, Hedin CR, Juillerat P, Mulders A, Myrelid P, O'Toole A, Rivière P, Scharl M, Selinger CP, Sonnenberg E, Toruner M, Wieringa J, Van der Woude CJ. European Crohn's and Colitis Guidelines on Sexuality, Fertility, Pregnancy, and Lactation. J Crohns Colitis 2023; 17:1-27. [PMID: 36005814 DOI: 10.1093/ecco-jcc/jjac115] [Citation(s) in RCA: 77] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Indexed: 02/02/2023]
Affiliation(s)
- Joana Torres
- Division of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal.,Division of Gastroenterology, Hospital da Luz, Lisboa, Portugal.,Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - María Chaparro
- Department of Gastroenterology, Hospital Universitario de La Princesa, IIS-Princesa, UAM, CIBEREHD, Madrid, Spain
| | - Mette Julsgaard
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Center for Molecular Prediction of Inflammatory Bowel Disease [PREDICT], Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Zuzana Zelinkova
- Department of Internal Medicine, Svet zdravia, Nemocnica Dunajska Streda, Slovakia.,Firstst Department of Internal Medicine of University Hospital and Slovak Medical University in Bratislava, Bratislava, Slovakia
| | - Manasi Agrawal
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Center for Molecular Prediction of Inflammatory Bowel Disease [PREDICT], Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Sandro Ardizzone
- Gastrointestinal Unit, Department of Biomedical and Clinical Sciences. University of Milan, Milan, Italy
| | - Marjo Campmans-Kuijpers
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Gabriele Dragoni
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences 'Mario Serio', University of Florence, Florence, Italy.,Gastroenterology Department, Careggi University Hospital, Florence, Italy
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Gionata Fiorino
- Department of Gastroenterology and Digestive Endoscopy, IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | - Emma Flanagan
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | | | - Ailsa Hart
- Inflammatory Bowel Diseases Unit, St Mark's Hospital, Harrow, UK
| | - Charlotte Rose Hedin
- Karolinska Institutet, Department of Medicine Solna, Stockholm, Sweden.,Karolinska University Hospital, Department of Gastroenterology, Dermatovenereology and Rheumatology, Stockholm, Sweden
| | - Pascal Juillerat
- Clinic for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland.,Crohn's and Colitis Center, Gastroenterology Beaulieu SA, Lausanne, Switzerland
| | - Annemarie Mulders
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Pär Myrelid
- Department of Surgery, Linköping University Hospital, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Aoibhlinn O'Toole
- Beaumont Hospital, Department of Gastroenterology, Royal College of Surgeons, Dublin, Ireland
| | - Pauline Rivière
- Gastroenterology Unit, Bordeaux University Hospital, Pessac, France
| | - Michael Scharl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | | | - Elena Sonnenberg
- Charité-Universitätsmedizin Berlin, Department of Gastroenterology, Infectious Diseases and Rheumatology, Germany
| | - Murat Toruner
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Jantien Wieringa
- Department of Paediatrics, Haaglanden Medical Center, The Hague, The Netherlands.,Department of Paediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C Janneke Van der Woude
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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42
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Rosiou K, Selinger CP. Obstetric Considerations in Pregnant Women with Crohn's Disease. J Clin Med 2023; 12:jcm12020684. [PMID: 36675613 PMCID: PMC9867236 DOI: 10.3390/jcm12020684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/03/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023] Open
Abstract
Crohn's disease affects many women of childbearing age. Fecundity rates are often lower than in the general population due to reduced fertility during active inflammation, effects of pelvic surgery or voluntary childlessness. Many women have concerns regarding the effects of pregnancy on their Crohn's, any potential effect of medication on the fetus, and passing on Crohn's disease to the offspring. International guidelines on reproduction for women with Crohn's disease provide evidence-based advice to patients and health care professionals. There is an increasing literature on the safety of advanced medication for Crohn's disease during pregnancy. This review article therefore focuses on obstetric considerations beyond medication safety. We provide information on fertility, factors affecting pregnancy and fetal outcomes, obstetric complications, factors influencing mode of delivery, management of intestinal stomas during pregnancy and general considerations around breast feeding.
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Affiliation(s)
| | - Christian P. Selinger
- Leeds Teaching Hospital NHS Trust, Gastroenterology, Leeds LS9 7TF, UK
- Research Institute at St James Hospital, University of Leeds, Leeds LS9 7TF, UK
- Correspondence:
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43
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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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44
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Lenti MV, Scribano ML, Biancone L, Ciccocioppo R, Pugliese D, Pastorelli L, Fiorino G, Savarino E, Caprioli FA, Ardizzone S, Fantini MC, Tontini GE, Orlando A, Sampietro GM, Sturniolo GC, Monteleone G, Vecchi M, Kohn A, Daperno M, D’Incà R, Corazza GR, Di Sabatino A. Personalize, participate, predict, and prevent: 4Ps in inflammatory bowel disease. Front Med (Lausanne) 2023; 10:1031998. [PMID: 37113615 PMCID: PMC10126747 DOI: 10.3389/fmed.2023.1031998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 03/14/2023] [Indexed: 04/29/2023] Open
Abstract
Inflammatory bowel disease (IBD), which includes Crohn's disease (CD) and ulcerative colitis (UC), is a complex, immune-mediated, disorder which leads to several gastrointestinal and systemic manifestations determining a poor quality of life, disability, and other negative health outcomes. Our knowledge of this condition has greatly improved over the last few decades, and a comprehensive management should take into account both biological (i.e., disease-related, patient-related) and non-biological (i.e., socioeconomic, cultural, environmental, behavioral) factors which contribute to the disease phenotype. From this point of view, the so called 4P medicine framework, including personalization, prediction, prevention, and participation could be useful for tailoring ad hoc interventions in IBD patients. In this review, we discuss the cutting-edge issues regarding personalization in special settings (i.e., pregnancy, oncology, infectious diseases), patient participation (i.e., how to communicate, disability, tackling stigma and resilience, quality of care), disease prediction (i.e., faecal markers, response to treatments), and prevention (i.e., dysplasia through endoscopy, infections through vaccinations, and post-surgical recurrence). Finally, we provide an outlook discussing the unmet needs for implementing this conceptual framework in clinical practice.
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Affiliation(s)
- Marco Vincenzo Lenti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | | | - Livia Biancone
- Unit of Gastroenterology, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine, A.O.U.I. Policlinico G.B. Rossi and University of Verona, Verona, Italy
| | - Daniela Pugliese
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Pastorelli
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Gionata Fiorino
- IBD Unit, Ospedale San Camillo-Forlanini, Rome, Italy
- Department of Gastroenterology, San Raffaele Hospital and Vita-Salute San Raffaele University,, Milan, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Flavio Andrea Caprioli
- Gastroenterology and Endoscopy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
| | - Sandro Ardizzone
- Gastroenterology and Digestive Endoscopy Unit, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Massimo Claudio Fantini
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
- Gastroenterology Unit, Azienda Ospedaliero-Universitaria (AOU) di Cagliari, Cagliari, Italy
| | - Gian Eugenio Tontini
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milano, Italy
| | - Ambrogio Orlando
- Inflammatory Bowel Disease Unit, Azienda Ospedaliera Ospedali Riuniti "Villa Sofia-Cervello" Palermo, Palermo, Italy
| | | | - Giacomo Carlo Sturniolo
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Giovanni Monteleone
- Unit of Gastroenterology, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
| | - Anna Kohn
- Gastroenterology Operative Unit, Azienda Ospedaliera San Camillo-Forlanini FR, Rome, Italy
| | - Marco Daperno
- Division of Gastroenterology, Ospedale Ordine Mauriziano di Torino, Turin, Italy
| | - Renata D’Incà
- Department of Gastroenterology, San Raffaele Hospital and Vita-Salute San Raffaele University,, Milan, Italy
| | - Gino Roberto Corazza
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
- *Correspondence: Antonio Di Sabatino,
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Shitrit ABG, Avni-Biron I. Editorial: ustekinumab during pregnancy-reassuring but still not enough. Authors' reply. Aliment Pharmacol Ther 2023; 57:160. [PMID: 36468216 DOI: 10.1111/apt.17282] [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]
Affiliation(s)
| | - Irit Avni-Biron
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel
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Laube R, Selinger C, Leong RW. Medication adherence in women with IBD of childbearing age likely associated with disease knowledge. Therap Adv Gastroenterol 2022; 15:17562848221144088. [PMID: 36545386 PMCID: PMC9761214 DOI: 10.1177/17562848221144088] [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: 08/10/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Medication adherence in inflammatory bowel disease (IBD) is crucial, particularly during pregnancy. Unplanned pregnancies are common; therefore, efforts to maximise adherence should not be restricted to pregnant women. OBJECTIVES We aimed to assess medication adherence in women with IBD of childbearing age, regardless of their reproduction plans. DESIGN We performed a multi-centre pilot questionnaire study of women with IBD age 18-45 years. METHODS Survey questions included patient demographics, disease history, and validated assessments of IBD and pregnancy knowledge, medication adherence and quality of life. The primary outcome was rates and predictors of medication adherence. RESULTS In all, 72 women [58.3% Crohn's disease (CD) and 37.5% ulcerative colitis] completed the survey. The median patient age was 30 years [interquartile range (IQR): 24.8-36.0) and 37.5% had children. Medication adherence was high (84%; median Medication Adherence Report Scale: 19.0/20; IQR: 17.0-20.0). Knowledge scores were adequate for both the Crohn's and Colitis Knowledge (CCKnow; median: 15.5/30; IQR: 12.3-18.0) and Crohn's and Colitis Pregnancy Knowledge (CCPKnow; median: 8.0/17; IQR: 4.0-11.0). Disease knowledge was predictive of high medication adherence (CCPKnow: p = 0.02; CCKnow: p ⩽ 0.01). Higher adherence was significantly associated with a diagnosis of CD (p = 0.01), exposure to biological agents (p = 0.03) and immunomodulators (p = 0.04), childbearing after diagnosis with IBD (p = 0.03), and correctly understanding the importance of delivery modality (p = 0.02) and IBD activity in pregnancy (p = 0.01). CONCLUSIONS Following dedicated education at the IBD clinic, medication adherence, disease-specific and pregnancy-specific knowledge in women with IBD of childbearing age tends to be high. Unplanned pregnancies are frequent; therefore, we should aim to maximise medication adherence in all women of childbearing age to optimise maternofoetal outcomes if unexpected pregnancies occur.
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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
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47
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Liu Z, Julsgaard M, Zhu X, Martin J, Barclay ML, Cranswick N, Gibson PR, Gearry RB, van der Giessen J, Connor SJ, Rosella O, Grosen A, Toong C, Flanagan E, Wieringa JW, Janneke van der Woude C, Bell SJ. Timing of Live Attenuated Vaccination in Infants Exposed to Infliximab or Adalimumab in Utero: A Prospective Cohort Study in 107 Children. J Crohns Colitis 2022; 16:1835-1844. [PMID: 35779236 DOI: 10.1093/ecco-jcc/jjac093] [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] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS For infants exposed in utero to anti-tumour necrosis factor-α [TNF] medications, it is advised that live-attenuated vaccinations be postponed until the drug is cleared, but little is known about time to clearance. To minimize delays before live-attenuated vaccination can be given, we aimed to develop a pharmacokinetic model to predict time-to-clearance in infants exposed during pregnancy. METHODS We prospectively followed in utero infliximab/adalimumab-exposed infants of mothers with inflammatory bowel disease across four countries between 2011 and 2018. Infants with a detectable anti-TNF umbilical-cord level and at least one other blood sample during the first year of life were included. RESULTS Overall, 107 infants were enrolled, including 166 blood samples from 71 infliximab-exposed infants and 77 samples from 36 adalimumab-exposed infants. Anti-TNF was detectable in 23% [n = 25] of infants at 6 months. At 12 months, adalimumab was not detected but 4% [n = 3] had detectable infliximab. A Bayesian forecasting method was developed using a one-compartment pharmacokinetic model. Model validation showed that the predicted clearing time was in accordance with the measured observations. A clinician-friendly online calculator was developed for calculating full anti-TNF clearing time: https://xiaozhu.shinyapps.io/antiTNFcalculator2/. CONCLUSIONS Almost one-quarter of infants born to mothers receiving anti-TNF during pregnancy have detectable anti-TNF at 6 months. To limit the time to live-attenuated vaccination in infants of mothers receiving anti-TNF during pregnancy, the results of a cord drug level at birth and a second sample ≥ 1 month thereafter can be used to estimate the time for full anti-TNF clearance in these children.
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Affiliation(s)
- Zheng Liu
- Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Hunter Medical Research Institute, Kookaburra Circuit, Australia.,Clinical Pharmacology, Department of Medicine, The Royal Children's Hospital Melbourne, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Mette Julsgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia
| | - Xiao Zhu
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, China.,School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Jennifer Martin
- Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Hunter Medical Research Institute, Kookaburra Circuit, Australia
| | - Murray L Barclay
- Departments of Gastroenterology & Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
| | - Noel Cranswick
- Clinical Pharmacology, Department of Medicine, The Royal Children's Hospital Melbourne, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Hospital, and Monash University, Melbourne, VIC, Australia
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Janine van der Giessen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Susan J Connor
- Department of Gastroenterology, Liverpool Hospital, Sydney.,South Western Sydney Clinical, University of NSW Sydney.,Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Ourania Rosella
- Department of Gastroenterology, Alfred Hospital, and Monash University, Melbourne, VIC, Australia
| | - Anne Grosen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Catherine Toong
- South Western Sydney Clinical, University of NSW Sydney.,Sydney South West Pathology Service, Liverpool Hospital, University of NSW, Sydney, Australia
| | - Emma Flanagan
- Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia
| | - Jantien W Wieringa
- Department of Pediatrics, Haaglanden Medical Center, the Hague, The Netherlands.,Department of Pediatrics, Division of Paediatric Infectious Diseases and Immunology, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sally J Bell
- Department of Gastroenterology, St Vincent's Hospital, and University of Melbourne, Melbourne, Australia.,Department of Gastroenterology, Monash Health, and School of Clinical Sciences Monash University, Melbourne, VIC, Australia
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Megna BW, Vaughn BP. Therapeutic Drug Monitoring in Practice for Inflammatory Bowel Disease. Curr Gastroenterol Rep 2022; 24:191-200. [PMID: 36459387 DOI: 10.1007/s11894-022-00854-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 06/17/2023]
Abstract
PURPOSE OF REVIEW To outline the development, rationale, and practical use of therapeutic drug monitoring in patients with inflammatory bowel disease. RECENT FINDINGS Therapeutic drug monitoring is traditionally discussed in terms of a proactive or reactive approach. However, these terms are not always consistently defined and can be confusing when translating research to clinical practice. Personalized approaches incorporating clinical context and precision medicine are emerging. Personalized therapeutic drug monitoring combines a structured and proactive strategy for monitoring biologic concentrations as well as identification of antidrug antibody development or subtherapeutic dosing in the setting of loss of response. Optimizing biologic therapy can improve outcomes and avoid loss of response. Why, when, and how we measure drug troughs and anti-drug antibodies is a moving target, though what is known is that the appropriate and evidence-based use of this practice prevents adverse events and improves outcomes in patients with inflammatory bowel disease.
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Affiliation(s)
- Bryant W Megna
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN, USA.
| | - Byron P Vaughn
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN, USA
- Inflammatory Bowel Disease Program, University of Minnesota, Minneapolis, MN, USA
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Ding N, Zhao L, Zhu L, Sun W, Li D, Li J, Zhang J, Zhang S. Management of biologics in pregnant, lactating patients with inflammatory bowel disease and the impact on neonatal vaccination: A systematic review of clinical practice guidelines and consensus statements. J Clin Pharm Ther 2022; 47:1952-1965. [PMID: 36452989 DOI: 10.1111/jcpt.13817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/25/2022] [Accepted: 10/07/2022] [Indexed: 12/03/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The management of biological agents during pregnancy poses challenges as maternal and infant safety must be addressed. This study aims to compare the recommendations of existing guidelines on managing the use of biologics during pregnancy, lactation for patients with inflammatory bowel disease, and the influence on neonatal vaccination. METHODS The PubMed, EMBASE, China National Knowledge Infrastructure, Wanfang database, China Science and Technology Journal Database and China Biomedical Database were systematically searched from the inception date to 11 May 2022, to screen all relevant guidelines. Quality assessment was performed using the guideline methodology reporting tool AGREE II. RESULTS AND DISCUSSION Fourteen guidelines and consensus statements with detailed recommendations were included. All guidance documents cover management comments during pregnancy, and most consider that biologics can be given safely during pregnancy but require suspension at the right time to protect the foetus. However, the roles of vedolizumab and ustekinumab are disputed. Five documents guide lactation and the use of most biologics during lactation is safe, but no guidelines recommend vedolizumab. Six papers provide recommendations for newborns' vaccination, suggesting a delay in infants' live vaccination schedule if their mothers are treated with biologics. WHAT IS NEW AND CONCLUSION Our study concluded that future guidelines could consider incorporating newer, more robust evidence to update recommendations. The development of future guidelines needs to consider the involvement of multidisciplinary experts, adequately report on the evidence retrieval process, and provide strategies for implementation. Besides, more research is needed to explore the use of biologics during pregnancy and lactation in patients with inflammatory bowel disease.
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Affiliation(s)
- Ning Ding
- Digestive Disease Center, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Luqing Zhao
- Digestive Disease Center, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Lingfei Zhu
- Clinical Medical College, Beijing University of Chinese Medicine, Beijing, China
| | - Weijia Sun
- Clinical Medical College, Beijing University of Chinese Medicine, Beijing, China
| | - Danyan Li
- Digestive Disease Center, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Jiake Li
- Clinical Medical College, Beijing University of Chinese Medicine, Beijing, China
| | - Jun Zhang
- Clinical Medical College, Beijing University of Chinese Medicine, Beijing, China
| | - Shengsheng Zhang
- Digestive Disease Center, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
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50
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Impact of Crohn's disease on obstetrical management. J Gynecol Obstet Hum Reprod 2022; 51:102480. [DOI: 10.1016/j.jogoh.2022.102480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 09/11/2022] [Accepted: 10/03/2022] [Indexed: 11/07/2022]
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