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Otero-Piñerio AM, Aykun N, Maspero M, Holubar S, Hull T, Lipman J, Steele SR, Lightner AL. The mode of delivery does not influence the occurrence of post-partum perianal disease flares in patients with inflammatory bowel disease. BMC Gastroenterol 2024; 24:34. [PMID: 38229023 DOI: 10.1186/s12876-023-03018-5] [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: 06/18/2023] [Accepted: 10/28/2023] [Indexed: 01/18/2024] Open
Abstract
INTRODUCTION Perianal disease occurs in up to 34% of inflammatory bowel disease (IBD) patients. An estimated 25% of women will become pregnant after the initial diagnosis, thus introducing the dilemma of whether mode of delivery affects perianal disease. The aim of our study was to analyze whether a cesarean section (C-section) or vaginal delivery influence perianal involvement. We hypothesized the delivery route would not alter post-partum perianal manifestations in the setting of previously healed perianal disease. METHODS All consecutive eligible IBD female patients between 1997 and 2022 who delivered were included. Prior perianal involvement, perianal flare after delivery and delivery method were noted. RESULTS We identified 190 patients with IBD who had a total of 322 deliveries; 169 (52%) were vaginal and 153 (48%) were by C-section. Nineteen women (10%) experienced 21/322 (6%) post-partum perianal flares. Independent predictors were previous abdominal surgery for IBD (OR, 2.7; 95% CI, 1-7.2; p = 0.042), ileocolonic involvement (OR, 3.3; 95% CI, 1.1-9.4; p = 0.030), previous perianal disease (OR, 22; 95% CI, 7-69; p < 0.001), active perianal disease (OR, 96; 95% CI, 21-446; p < 0.001) and biologic (OR, 4.4; 95% CI,1.4-13.6; p < 0.011) or antibiotic (OR, 19.6; 95% CI, 7-54; p < 0.001) treatment. Negative association was found for vaginal delivery (OR, 0.19; 95% CI, 0.06-0.61; p < 0.005). Number of post-partum flares was higher in the C-section group [17 (11%) vs. 4 (2%), p = 0.002]. CONCLUSIONS Delivery by C-section section was not protective of ongoing perianal disease activity post-delivery, but should be recommended for women with active perianal involvement.
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Affiliation(s)
- Ana M Otero-Piñerio
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - N Aykun
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - M Maspero
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Jeremy Lipman
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
- National Center for Regenerative Medicine, Cleveland, OH, USA.
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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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Leung KK, Tandon P, Govardhanam V, Maxwell C, Huang V. The Risk of Adverse Neonatal Outcomes With Maternal Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. Inflamm Bowel Dis 2021; 27:550-562. [PMID: 32469057 DOI: 10.1093/ibd/izaa122] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) may be at increased risk of adverse neonatal outcomes. The aim of this study was to determine pooled incidences and risk factors for these outcomes. METHODS Medline, Embase, and Cochrane Library were searched through May 2019 for studies reporting adverse neonatal outcomes in IBD. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS The pooled incidence of preterm birth, low birth weight, congenital anomalies, and infants transferred to the neonatal intensive care unit was 8.6% (95% CI, 7.0%-10.1%), 8.9% (95% CI, 7.3%-10.5%), 2.1% (95% CI, 1.6%-2.6%), and 4.9% (95% CI, 2.9%-6.9), respectively. Compared with healthy controls, patients with IBD were more likely to deliver infants with low birth weight (<2500 grams; OR, 2.78; 95% CI, 1.16-6.66) and infants admitted to the intensive care unit (OR, 3.33; 95% CI, 1.83-6.05). Patients with Crohn's disease had an increased incidence of congenital anomalies (OR, 3.03; 95% CI, 1.43-6.42). Among IBD patients, active disease was associated with increased incidence of preterm birth (OR, 2.06; 95% CI, 1.21-3.51), low birth weight (OR, 2.96; 95% CI, 1.54-5.70), and small for gestational age (OR, 2.62; 95% CI, 1.18-5.83). Antitumor necrosis factor (anti-TNF) use during pregnancy was associated with an increased incidence of neonatal intensive care unit admission (OR, 2.42; 95% CI, 1.31-4.45) and low birth weight (OR, 1.54; 95% CI, 1.01-2.35). CONCLUSIONS Patients with IBD, particularly with active disease or requiring anti-TNF therapy, may be at increased risk of developing adverse neonatal outcomes.
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Affiliation(s)
- Kristel K Leung
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Parul Tandon
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vivek Govardhanam
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Vivian Huang
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Foulon A, Chevreau J, Yzet C, Gondry J, Fumery M. [IBD and pregnancy: From conception to birth]. ACTA ACUST UNITED AC 2020; 48:514-519. [PMID: 32145453 DOI: 10.1016/j.gofs.2020.02.013] [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: 06/03/2019] [Indexed: 10/24/2022]
Abstract
Inflammatory Bowel Diseases (IBD) are chronic conditions affecting young people in their reproductive age. Patient misinformation can be responsible for a self-imposed infertility as well as a suboptimal observance during pregnancy. The aim of this work was to review the influence of IBD and pregnancy on one another at each gestational stage and according to current literature. IBD activity is a major influential factor. In case of a well-controlled IBD, fertility won't be affected and pregnancy will take place without increase risk of complications. With the exception of thalidomide and methotrexate, most of treatments used in IBD are compatible with pregnancy and breastfeeding. Each flare should be optimally managed. Vaginal delivery is a safe option except for patients with active anoperineal lesions. Cesarean section should be systematically discuss in patient with ileal pouch-anal anastomosis.
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Affiliation(s)
- A Foulon
- Centre de gynécologie-obstétrique, CHU Amiens-Picardie, 1, rue du Professeur-Christian-Cabrol, 80054 Amiens, France.
| | - J Chevreau
- Centre de gynécologie-obstétrique, CHU Amiens-Picardie, 1, rue du Professeur-Christian-Cabrol, 80054 Amiens, France
| | - C Yzet
- Service de gastro-entérologie, CHU Amiens-Picardie, 1, rue du Professeur-Christian-Cabrol, 80054 Amiens, France; Université Picardie-Jules-Vernes, UFR de médecine, 3, rue des Louvels, 80000 Amiens, France
| | - J Gondry
- Centre de gynécologie-obstétrique, CHU Amiens-Picardie, 1, rue du Professeur-Christian-Cabrol, 80054 Amiens, France; Université Picardie-Jules-Vernes, UFR de médecine, 3, rue des Louvels, 80000 Amiens, France
| | - M Fumery
- Service de gastro-entérologie, CHU Amiens-Picardie, 1, rue du Professeur-Christian-Cabrol, 80054 Amiens, France; Université Picardie-Jules-Vernes, UFR de médecine, 3, rue des Louvels, 80000 Amiens, France
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Tandon P, Govardhanam V, Leung K, Maxwell C, Huang V. Systematic review with meta-analysis: risk of adverse pregnancy-related outcomes in inflammatory bowel disease. Aliment Pharmacol Ther 2020; 51:320-333. [PMID: 31912546 DOI: 10.1111/apt.15587] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/19/2019] [Accepted: 10/28/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The effect of inflammatory bowel disease (IBD) on pregnancy-related outcomes remains unknown. AIM To determine the risk of adverse maternal, placental and obstetric outcomes in IBD METHODS: We searched Medline, Embase and Cochrane library through May 2019 for studies reporting adverse maternal, placental and obstetric outcomes in patients with IBD. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for these outcomes in patients with IBD compared to healthy controls. RESULTS Fifty-three studies were included (7917 IBD pregnancies and 3253 healthy control pregnancies). Caesarean delivery was more common in patients with IBD compared to healthy controls (OR 1.79, 95% CI, 1.16-2.77). This remained significant for UC (OR 1.80, 95% CI, 1.21-2.90) but not CD (OR 1.48, 95% CI, 0.94-2.34). Similarly, gestational diabetes occurred more commonly in IBD (OR 2.96, 95% CI, 1.47-5.98). The incidences of placental diseases were 2.0% (95% CI, 0.9%-3.1%) for pre-eclampsia, 3.3% (95% CI, 0%-7.2%) for placental abruption, 0.5% (95% CI, 0.2%-0.9%) for placenta previa and 0.3% (95% CI, 0%-0.5%) for chorioamnionitis. Patients with IBD were more likely to experience preterm prelabour rupture of membranes (OR 12.10, 95% CI, 2.15-67.98), but not early pregnancy loss (OR 1.63, 95% CI 0.49-5.43). Anti-tumour necrosis factor therapy was not associated with chorioamnionitis (OR 1.12, 95% CI, 0.16-7.67), early pregnancy loss (OR 1.49, 95% CI, 0.83-2.64) or placenta previa (OR 1.58, 95% CI, 0.30-8.47). CONCLUSIONS Gestational diabetes and preterm prelabour rupture of membranes occurs more commonly in patients with IBD, although the incidence of placental diseases remains low.
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Affiliation(s)
- Parul Tandon
- Division of Gastroenterology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Kristel Leung
- Division of Gastroenterology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Vivian Huang
- Division of Gastroenterology, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
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Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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Defining the Most Appropriate Delivery Mode in Women with Inflammatory Bowel Disease: A Systematic Review. Inflamm Bowel Dis 2017; 23:712-720. [PMID: 28426452 DOI: 10.1097/mib.0000000000001112] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION High cesarean section (CS) rates are observed in patients with inflammatory bowel disease (IBD), but limited data are available to support this decision. We conducted a comprehensive review to evaluate the most appropriate mode of delivery in women with IBD according to disease phenotype and activity, as well as surgical history. MATERIALS AND METHODS We searched MEDLINE (source PubMed) and international conference abstracts, and included all studies that evaluated digestive outcome after delivery in patients with IBD. RESULTS A total of 41 articles or abstracts were screened, and 18 studies were considered in this review, with sample sizes ranging from 4 to 229 patients and follow-up ranging from 2 months to 7.7 years. Pooled CS rates in patients without Perianal Crohn's disease (PCD), healed PCD or active PCD, were 27%, 43%, and 46%, respectively. Regarding the median rate of new PCD (3.0% [IQR, 1.5-11.5] versus 6.5% [0-19.7]) or PCD recurrence (13.5% [3.2-32.7] versus 45% [0-58]), no increase was observed in patients with vaginal delivery compared to CS, but for patients with an active disease, worsening of symptoms was noted in two-thirds of cases. Episiotomy, perianal tears, and instrumental delivery did not influence the incidence of PCD. In patients with ileal pouch anal anastomosis, uncomplicated vaginal delivery seemed to moderately influence pouch function, with no significant difference in terms of overall continence, daytime, or night-time stool frequency, or incontinence. However, these parameters seemed negatively impacted by a complicated vaginal delivery. CONCLUSIONS New long-term data from well-designed studies are needed, but our review suggests that systematic CS in patients suffering from IBD should probably be limited to women at risk of perineal tears and obstetric injuries, with an active PCD, or with ileal pouch anal anastomosis.
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Pinder M, Lummis K, Selinger CP. Managing inflammatory bowel disease in pregnancy: current perspectives. Clin Exp Gastroenterol 2016; 9:325-335. [PMID: 27789969 PMCID: PMC5072556 DOI: 10.2147/ceg.s96676] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Inflammatory bowel disease (IBD) affects many women of childbearing age. The course of IBD is closely related to pregnancy outcomes with poorly controlled IBD increasing the risk of prematurity, low weight for gestation, and fetal loss. As such, women with IBD face complex decision making weighing the risks of active disease versus those of medical treatments. This review summarizes the current evidence regarding the safety and efficacy of IBD treatments during pregnancy and lactation aiming to provide up-to-date guidance for clinicians. Over 50% of women have poor IBD- and pregnancy-related knowledge, which is associated with views contrary to medical evidence and voluntary childlessness. This review highlights the effects of poor patient knowledge and critically evaluates interventions for improving patient knowledge and outcomes.
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Affiliation(s)
- Matthew Pinder
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust
| | - Katie Lummis
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust
| | - Christian P Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust; University of Leeds, Leeds, UK
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Nguyen GC, Seow CH, Maxwell C, Huang V, Leung Y, Jones J, Leontiadis GI, Tse F, Mahadevan U, van der Woude CJ. The Toronto Consensus Statements for the Management of Inflammatory Bowel Disease in Pregnancy. Gastroenterology 2016; 150:734-757.e1. [PMID: 26688268 DOI: 10.1053/j.gastro.2015.12.003] [Citation(s) in RCA: 314] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The management of inflammatory bowel disease (IBD) poses a particular challenge during pregnancy because the health of both the mother and the fetus must be considered. METHODS A systematic literature search identified studies on the management of IBD during pregnancy. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. RESULTS Consensus was reached on 29 of the 30 recommendations considered. Preconception counseling and access to specialist care are paramount in optimizing disease management. In general, women on 5-ASA, thiopurine, or anti-tumor necrosis factor (TNF) monotherapy for maintenance should continue therapy throughout pregnancy. Discontinuation of anti-TNF therapy or switching from combination therapy to monotherapy may be considered in very select low-risk patients. Women who have a mild to moderate disease flare while on optimized 5-ASA or thiopurine therapy should be managed with systemic corticosteroid or anti-TNF therapy, and those with a corticosteroid-resistant flare should start anti-TNF therapy. Endoscopy or urgent surgery should not be delayed during pregnancy if indicated. Decisions regarding cesarean delivery should be based on obstetric considerations and not the diagnosis of IBD alone, with the exception of women with active perianal Crohn's disease. With the exception of methotrexate, the use of medications for IBD should not influence the decision to breast-feed and vice versa. Live vaccinations are not recommended within the first 6 months of life in the offspring of women who were on anti-TNF therapy during pregnancy. CONCLUSIONS Optimal management of IBD before and during pregnancy is essential to achieving favorable maternal and neonatal outcomes.
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Affiliation(s)
- Geoffrey C Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Cynthia H Seow
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Vivian Huang
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Yvette Leung
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Frances Tse
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Uma Mahadevan
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Mode of childbirth and long-term outcomes in women with inflammatory bowel diseases. Dig Dis Sci 2015; 60:471-7. [PMID: 25213079 PMCID: PMC4304947 DOI: 10.1007/s10620-014-3353-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 09/01/2014] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Inflammatory bowel diseases [IBD; Crohn's disease (CD), ulcerative colitis] often affect women in their reproductive years. Few studies have analyzed the impact of mode of childbirth on long-term IBD outcomes. METHODS We used a multi-institutional IBD cohort to identify all women in the reproductive age-group with a diagnosis of IBD prior to pregnancy. We identified the occurrence of a new diagnosis code for perianal complications, IBD-related hospitalization and surgery, and initiation of medical therapy after either a vaginal delivery or caesarean section (CS). Cox proportional hazards models adjusting for potential confounders were used to estimate independent effect of mode of childbirth on IBD outcomes. RESULTS Our cohort included 360 women with IBD (161 CS). Women in the CS group were likely to be older and more likely to have complicated disease behavior prior to pregnancy. During follow-up, there was no difference in the likelihood of IBD-related surgery (multivariate hazard ratio 1.75, 95 % confidence interval (CI) 0.40-7.75), IBD-related hospitalization (HR 1.39), initiation of immunomodulator therapy (HR 1.45), or anti-TNF therapy (HR 1.11). Among the 133 CD pregnancies with no prior perianal disease, we found no excess risk of subsequent new diagnosis perianal fistulae with vaginal delivery compared to CS (HR 0.19, 95 % CI 0.04-1.05). CONCLUSIONS Mode of delivery did not influence natural history of IBD. In our cohort, vaginal delivery was not associated with increased risk of subsequent perianal disease in women with CD.
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Abstract
BACKGROUND Crohn's disease (CD) often affects women during the reproductive years. Although several studies have examined the impact of pregnancy on luminal disease, limited literature exists in those with perianal CD. Decision regarding mode of delivery is a unique challenge in such patients due to concerns regarding the effect of pelvic floor trauma during delivery on preexisting perianal involvement. METHODS We performed a retrospective chart review of patients with CD with established perianal disease undergoing either vaginal delivery or caesarean section (C-section) at our institutions. We examined the occurrence of symptomatic perianal disease flares within 5 years after delivery in such women compared with nonpregnant CD controls. We also compared the occurrence of such flares between the 2 modes of delivery in women with established perianal CD. RESULTS We identified 61 pregnant patients with CD with established perianal disease (11 vaginal delivery, 50 through C-section) and 61 nonpregnant CD controls with perianal disease. One-third of the C-sections were primarily for obstetric indications. Six of the vaginal deliveries were complicated. Approximately, 36% of cases had a symptomatic perianal flare within 1 year after delivery. This was similar across both modes of delivery (P = 0.53) and similar to nonpregnant patients with CD. There was no difference in the rates of perianal surgical intervention or luminal disease flares in our population based on mode of delivery or between pregnant patients with CD and nonpregnant CD controls. CONCLUSIONS We observed no difference in risk of symptomatic perianal flares in patients with established perianal CD delivering vaginally or through C-section.
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12
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Abstract
BACKGROUND The optimal delivery method in patients with Crohn's disease is unknown, and there is no large-scale evidence on which to base decisions. OBJECTIVE The aim of this study was to compare delivery methods and outcomes in patients with and without Crohn's disease. DESIGN AND PATIENTS The Nationwide Inpatient Sample and International Classification of Diseases, Ninth Revision codes were used to identify childbirth deliveries. Patients were stratified by the presence or absence of Crohn's disease and perianal disease (anorectal fistula or abscess, rectovaginal fistula, anal fissure, and anal stenosis). SETTINGS A large population-cohort database was used for the analysis. MAIN OUTCOME MEASURES The primary outcomes measured were cesarean delivery and perineal lacerations. RESULTS Of 6,794,787 pregnant women who delivered, 2882 had a diagnosis of Crohn's disease. Rates of cesarean delivery were higher in patients who had Crohn's disease with (83.1%) and without (42.8%) perianal disease in comparison with patients who did not have Crohn's disease with (38.9%) and without (25.6%) perianal disease (p < 0.001). Rates of 4th degree perineal lacerations were similar between patients who had or did not have Crohn's disease without perianal disease (1.4% vs 1.3%), but these rates increased significantly in patients with perianal disease (12.3%, p < 0.001). On multivariate analysis, perianal disease (OR, 10.9; 95% CI, 8.3-4.1; p < 0.001) and smoking (OR, 1.6; 95% CI, 1.5-1.7; p < 0.001) were independently associated with higher rates of 4th degree laceration. Crohn's disease was not independently associated with 4th degree laceration. LIMITATIONS This was a retrospective study with the inherent limitations of large databases. CONCLUSIONS Patients with Crohn's disease have higher rates of cesarean delivery. Perianal disease predicts severe perineal laceration independent of the presence of Crohn's disease. In the absence of perianal disease, the method of delivery in women with Crohn's disease should be predicated on obstetric indication.
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Practical medical management of Crohn's disease. ISRN GASTROENTEROLOGY 2013; 2013:208073. [PMID: 24307950 PMCID: PMC3838825 DOI: 10.1155/2013/208073] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 09/01/2013] [Indexed: 12/14/2022]
Abstract
Crohn's disease is a chronic inflammatory disease of diagnostic and therapeutic challenges. After proper diagnosis, treatment decisions must be made on precise clinical judgment. During the course of the disease there are variable clinical features, so each case must be managed individually. Physicians who care for patients with Crohn's disease should be prepared for treatment options in different states of the disease and possible complications of both the disease and medications. This paper will focus on the management of Crohn's disease. We aim to discuss current treatment options in different presentations of the disease and to provide algorithmic management strategy.
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Aygun BK, Pinar GG, Sahin L, Ozkan ZS, Poyraz AK, Aygun C. Budd-Chiari syndrome following vaginal delivery in a patient with Crohn’s disease: a case report and review of the literature. CASE REPORTS IN PERINATAL MEDICINE 2013. [DOI: 10.1515/crpm-2012-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Introduction: The association of Budd-Chiari syndrome (BCS), Crohn’s disease (CD) and pregnancy is extremely rare. The successful medical treatment of BCS in the postpartum period in a woman with CD is presented.
Case report: A 28-year-old woman with CD presented with fever of 42°C and gross abdominal distention 2 days following delivery. On sonographic examination, massive ascites and hepatosplenomegaly were noted. Color Doppler ultrasonography and contrast-enhanced computed tomography revealed a thrombus in the suprahepatic inferior vena cava causing significant luminal obstruction. She was diagnosed with BCS. Medical treatment with spironolactone, furosemide, imipenem, metronidazole, and enoxaparin improved the clinical picture.
Conclusion: In a pregnant woman with CD, extreme thromboembolic events such as BCS might occur. If diagnosed early and treated in the acute phase, prognosis is fair.
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Affiliation(s)
- Banu Kumbak Aygun
- Department of Obstetrics and Gynecology, Firat University, Elazig, Turkey
| | | | - Levent Sahin
- Department of Obstetrics and Gynecology, Firat University, Elazig, Turkey
| | - Zehra Sema Ozkan
- Department of Obstetrics and Gynecology, Firat University, Elazig, Turkey
| | | | - Cem Aygun
- Department of Gastroenterology, Firat University, Elazig, Turkey
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Selinger CP, Leong RWL, Lal S. Pregnancy related issues in inflammatory bowel disease: evidence base and patients' perspective. World J Gastroenterol 2012; 18:2600-8. [PMID: 22690068 PMCID: PMC3369996 DOI: 10.3748/wjg.v18.i21.2600] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 09/09/2011] [Accepted: 09/16/2011] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) affects women of childbearing age and can influence fertility, pregnancy and decisions regarding breastfeeding. Women with IBD need to consider the possible course of disease during pregnancy, the benefits and risks associated with medications required for disease management during pregnancy and breastfeeding and the effects of mode of delivery on their disease. When indicated, aminosalicylates and thiopurines can be safely used during pregnancy. Infliximab and Adalimumab are considered probably safe during the first two trimesters. During the third trimester the placenta can be crossed and caution should be applied. Methotrexate is associated with severe teratogenicity due to its folate antagonism and is strictly contraindicated. Women with IBD tend to deliver earlier than healthy women, but can have a vaginal delivery in most cases. Caesarean sections are generally recommended for women with active perianal disease or after ileo-anal pouch surgery.While the impact of disease activity and medication has been addressed in several studies, there are minimal studies evaluating patients' perspective on these issues. Women's attitudes may influence their decision to have children and can positively or negatively influence the chance of conceiving, and their beliefs regarding therapies may impact on the course of their disease during pregnancy and/or breastfeeding. This review article outlines the impact of IBD and its treatment on pregnancy, and examines the available data on patients' views on this subject.
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Naganuma M, Kunisaki R, Yoshimura N, Nagahori M, Yamamoto H, Kimura H, Sako M, Kawaguchi T, Takazoe M, Yamamoto S, Matsui T, Hibi T, Watanabe M. Conception and pregnancy outcome in women with inflammatory bowel disease: A multicentre study from Japan. J Crohns Colitis 2011; 5:317-23. [PMID: 21683301 DOI: 10.1016/j.crohns.2011.02.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 02/03/2011] [Accepted: 02/03/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neither conceptions and pregnancy outcomes nor the safety of medications for childbearing inflammatory bowel disease (IBD) patients has been investigated in Asia. The aim of this study is to analyse conception and pregnancy outcomes of Japanese female IBD patients. METHODS We conducted a retrospective cohort study of pregnant IBD patients at 6 institutions. The incidences of abortion, Caesarean delivery, low birth weight (LBW) (<2500g), and congenital malformation were analysed in these patients. Risk factors associated with adverse outcomes in IBD patients were also assessed. RESULTS A total of 325 patients experienced 534 conceptions. Among these, 303 conceptions (57%) were observed during/after disease onset. Although conceptions and pregnancy outcomes after disease onset were comparable to the observed levels prior to disease onset in UC patients, the incidences of spontaneous abortion (OR 5.3; 95%CI 1.1-25.0) and Caesarean delivery (OR 4.8; 95%CI 1.5-15.0) were significantly higher in Crohn's disease (CD) patients whose conceptions occurred after disease onset compared to CD patients whose conceptions occurred before disease onset. The incidences of spontaneous abortion, LBW, and Caesarean delivery were higher in CD patients who had a history of surgery for perianal lesions than in those who did not have perianal lesions or who had ulcerative colitis (UC). In the IBD patients studied after disease onset, independent risk factors for spontaneous abortions included a history of previous treatment for sterility (OR 2.9; 95%CI 1.2-7.0). Independent risk factors for Caesarean operation (OR 4.1, 95% CI: 1.7-10.1) and LBW (OR 3.5, 95% CI: 1.3-9.1) included a history of bowel resection for the treatment of IBD. Congenital malformation was not associated with the factors of type of disease, smoking, and previous surgery. CONCLUSION In Japanese UC patients, conception and pregnancy outcomes after disease onset were comparable to the outcomes observed prior to disease onset, whereas CD appeared to be associated with adverse outcomes. Caesarean operation and LBW were more frequently observed in CD patients who had a history of surgery for perianal lesions and bowel resection.
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Affiliation(s)
- Makoto Naganuma
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
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17
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Smink M, Lotgering FK, Albers L, de Jong DJ. Effect of childbirth on the course of Crohn's disease; results from a retrospective cohort study in the Netherlands. BMC Gastroenterol 2011; 11:6. [PMID: 21269464 PMCID: PMC3042417 DOI: 10.1186/1471-230x-11-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Accepted: 01/26/2011] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Pregnant women with Crohn's disease needs proper counselling about the effect of pregnancy and childbirth on their disease. However, Literature about the effect of childbirth on Crohn's disease is limited. This study examined the effect of childbirth on the course of Crohn's disease and especially perianal Crohn's disease. METHODS This is a retrospective cohort study which was performed in a tertiary level referral hospital in the Netherlands. From the IBD database, female patients aged 18-80 years in 2004 were selected. Data analysis took place in the years 2005 and 2006. Eventually, 114 women with at least one pregnancy after the diagnosis of Crohn's disease were eligible for the study. Differences between groups were analyzed using Wilcoxon Mann Whitney tests and Chi-square analysis with 2 × 2 or 2 × 3 contingency tables. Two-tailed values were used and p values < 0.05 were considered statistically significant. RESULTS 21/114 women (18%) had active luminal disease prior to pregnancy, with significantly more pregnancy related complications compared to women with inactive luminal disease (Odds ratio 2.8; 95% CI 1.0 - 7.4). Caesarean section rate was relatively high (37/114, 32%), especially in patients with perianal disease prior to pregnancy compared to women without perianal disease (Odds ratio 4.6; 95% CI 1.8 - 11.4). Disease progression after childbirth was more frequent in patients with active luminal disease prior to pregnancy compared to inactive luminal disease (Odds ratio 9.7; 95% CI 2.1 - 44.3). Progression of perianal disease seems less frequent after vaginal delivery compared with caesarean section, in both women with prior perianal disease (18% vs. 31%, NS) and without prior perianal disease (5% vs 14%, NS). There were no more fistula-related complications after childbirth in women with an episiotomy or second degree tear. CONCLUSION A relatively high rate of caesarean sections was observed in women with Crohn's disease, especially in women with perianal disease prior to pregnancy. A protective effect of caesarean section on progression of perianal disease was not observed. However, this must be interpreted carefully due to confounder effect by indication for caesarean section.
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Affiliation(s)
- Marieke Smink
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, PO box 9101, 6500 HB, Nijmegen, The Netherlands
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Garrido E, Van Domselaar M, Morales S, López-Sanromán A. Enfermedad inflamatoria intestinal y gestación. GASTROENTEROLOGIA Y HEPATOLOGIA 2010; 33:517-29. [DOI: 10.1016/j.gastrohep.2009.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Accepted: 11/01/2009] [Indexed: 12/23/2022]
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Arai K, Takeuchi Y, Oishi C, Imawari M. The impact of disease activity of Crohn’s disease during pregnancy on fetal growth. Clin J Gastroenterol 2010; 3:179-81. [DOI: 10.1007/s12328-010-0158-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 05/21/2010] [Indexed: 12/27/2022]
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Abstract
Women with inflammatory bowel disease (IBD) and the physicians who care for them must make difficult decisions on issues of conception, pregnancy, and breastfeeding with very limited and often contradictory information. This review provides the most current information on the inheritance of IBD, fertility, pregnancy outcomes, the management of disease during pregnancy, and the safety of medications in pregnancy and breastfeeding. We would like to emphasize that the information presented here must be individualized to the specific situation of each patient, their acceptance of risk, and their degree of disease severity.
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Affiliation(s)
- Marla Dubinsky
- Department of Pediatrics, Inflammatory Bowel Disease Center, Cedars Sinai Medical Center, Los Angeles, California 90048, USA.
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21
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Crohn’s disease—a chameleon during pregnancy. Langenbecks Arch Surg 2008; 394:517-27. [DOI: 10.1007/s00423-008-0431-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Accepted: 10/22/2008] [Indexed: 01/28/2023]
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Abstract
Ulcerative colitis (UC) and Crohn's disease (CD) affect women of reproductive age. Surgical intervention is often required. Therefore, the implications of disease treatment and pregnancy need to be understood. The standard surgery for UC is proctocolectomy, followed by ileal pouch anal anastomosis (IPAA). This review summarises the literature describing the effects of IPAA on gynaecologic and sexual health, fertility, pregnancy, labour and delivery. The emerging role of laparoscopic IPAA and the limited role of ileo-rectal anastomosis (IRA) are discussed. The experience with emergency surgery in pregnant women with ulcerative colitis is also presented. The literature explores two key issues of pregnancy in CD: the possible effect of pregnancy decreasing resection rates, and the optimal mode of delivery, especially in the setting of perianal CD. These two issues together with the available literature describing stoma function during pregnancy and the foetal outcome after surgical therapy are presented.
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Affiliation(s)
- Alexandra Ilnyckyj
- Section of Gastroenterology, Faculty of Medicine, University of Manitoba, 409 Tache Avenue, Winnipeg, MB R2H 2A6, Canada.
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23
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Heetun ZS, Byrnes C, Neary P, O'Morain C. Review article: Reproduction in the patient with inflammatory bowel disease. Aliment Pharmacol Ther 2007; 26:513-33. [PMID: 17661756 DOI: 10.1111/j.1365-2036.2007.03397.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) affects mainly the young population. The effect of IBD and its treatment on fertility and pregnancy is therefore an important clinical consideration. AIM To review the best management of IBD in the reproductive and pregnant population. METHODS A MEDLINE and an EMBASE search were performed using mainly the search phrases 'pregnancy AND IBD,''sulphasalazine AND male fertility,''abdominal surgery AND female fertility,''AZA AND placenta' and 'infliximab AND pregnancy.' No language or date restrictions were placed. References of review articles were examined. RESULTS Overall male and female fertility are not affected by IBD. Sulphasalzine reduces male fertility. No other drugs used in IBD affect significantly fertility in humans. The risk of pregnancy-related complications and the disease behaviour during pregnancy depends mainly on disease activity at time of conception. Proactive treatment for maintenance of disease remission during gestation is recommended. Except for methotrexate, drugs used in IBD appear safe in pregnancy. Breast feeding should be encouraged. CONCLUSION The management of IBD in the young and pregnant population remains controversial because the literature comes mostly from retrospective studies. Further studies particularly large prospective trials are needed to guide clinicians in decision making.
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Affiliation(s)
- Z S Heetun
- Department of Gastroenterology, Adelaide and Meath Hospital, Trinity College, Tallaght, Dublin 24, Ireland.
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24
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Bortoli A, Saibeni S, Tatarella M, Prada A, Beretta L, Rivolta R, Politi P, Ravelli P, Imperiali G, Colombo E, Pera A, Daperno M, Carnovali M, de Franchis R, Vecchi M. Pregnancy before and after the diagnosis of inflammatory bowel diseases: retrospective case-control study. J Gastroenterol Hepatol 2007; 22:542-9. [PMID: 17376049 DOI: 10.1111/j.1440-1746.2006.04754.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Inflammatory bowel diseases (IBD) commonly affect women during the reproductive years. The aim of the present study was to evaluate the reproductive histories of patients with ulcerative colitis (UC) and Crohn's disease (CD) considering pregnancies occurring before and after the diagnosis. METHOD Case-control study evaluating IBD patients, interviewed by questionnaire about outcome of pregnancy and course of disease. RESULTS A total of 502 pregnancies from 199 patients in the prediagnosis group and 121 pregnancies from 90 patients in the post-diagnosis group were respectively compared with 996 and 204 pregnancies recorded in a control population. In prediagnosis pregnancies, CD was associated with increased risk of preterm delivery (odds ratio [OR] 4.62, 95% confidence interval [CI] 2.77-7.73; P < 0.001 vs controls and OR 3.52, 95% CI 1.75-7.07; P < 0.001 vs UC) and lower birthweight (P < 0.001 vs UC and controls). In post-diagnosis pregnancies, the rate of live births was lower, but not statistically significant in IBD (OR 0.22, 95% CI 0.04-1.25; P = 0.08) and the birthweight was significantly lower in CD than in UC (P < 0.03) and in controls (P < 0.02). In post-diagnosis pregnancies, a higher incidence of congenital abnormalities was found in IBD patients (5.5% vs 0.0%). The spontaneous abortion rate and therapeutic abortions were significantly higher in post than in prediagnosis pregnancies. Neither disease activity at conception nor treatment appeared to influence the outcome of pregnancy. CONCLUSIONS CD in the preclinical phase has some influence on pregnancy. In patients with IBD our data suggest that conception should not be discouraged. However, because of a modest increase in mild congenital abnormalities and abortions rates, pregnancy in IBD patients should be closely monitored.
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Takahashi KI, Funayama Y, Fukushima K, Shibata C, Ogawa H, Kumagai E, Sasaki I. Pregnancy and delivery in patients with enterostomy due to anorectal complications from Crohn's disease. Int J Colorectal Dis 2007; 22:313-8. [PMID: 16715249 DOI: 10.1007/s00384-006-0148-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Enterostomy is often undergone by patients with Crohn's disease (CD) due to severe anorectal lesions such as rectovaginal fistula (RVF). Reports of successful pregnancy and delivery, which are important determinants of quality of life for female CD patients with stoma, are limited. Thus, we investigated problems associated with pregnancy and delivery in female CD patients at our hospital. MATERIALS AND METHODS Between 1985 and 2003, five female CD patients with enterostoma carried seven pregnancies and delivered eight babies in our hospital. For this study, we investigated CD activity, fetal growth, stoma complications, and the outcome of delivery in these seven pregnancies. RESULTS Among the five patients, four underwent loop ileostomy and one loop sigmoidostomy for treatment of RVF or severe stricture of the rectum or sigmoid colon. Except for one case, no fertility treatment was done. During pregnancy, a flare-up was observed in one patient and was successfully treated with corticosteroids. Although home enteral or parenteral nutrition was required in two cases, fetal growth was within the normal range in all pregnancies. Preterm delivery occurred in one case with a twin pregnancy. The mean diameter of stoma increased during pregnancy (p<0.01), and a mucosal laceration of stoma by the edge of an ostomy appliance occurred in one case. All deliveries were safe, with six cesarean sections and one transvaginal delivery. After each delivery, the stoma returned to pre-pregnancy size. CONCLUSIONS Pregnancy and delivery in CD patients with stoma is safe and should be encouraged. However, special attention to disease activity, nutritional support, and stoma-related complications is recommended.
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Affiliation(s)
- Ken-ichi Takahashi
- Department of Surgery, Division of Gastrointestinal and Colorectal Surgery, Tohoku University Graduate School of Medicine, and Wound, Ostomy, and Continence Center, Tohoku University Hospital, Sendai, 980-8574, Japan.
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Ubiña-Aznar E, De Sola-Earle C, Rivera-Irigoin R, Fernández-Moreno N, Vera-Rivero F, Fernández-Pérez F, Navarro-Jarabo JM, García-Fernández G, Moreno-Mejías P, Pérez-Aisa A, Perea-Milla E. Enfermedad de Crohn y embarazo: un estudio descriptivo y retrospectivo. GASTROENTEROLOGIA Y HEPATOLOGIA 2006; 29:277-80. [PMID: 16733031 DOI: 10.1157/13087465] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To determine the behavior of Crohn's disease during pregnancy, as well as the influence of this disease on the presence of low birthweight neonates. MATERIAL AND METHODS A descriptive and retrospective study of all patients with Crohn's disease followed-up in the Hospital Costa del Sol was performed. A total of 124 pregnant women were included, classified in two groups: women who became pregnant before and those who became pregnant after Crohn's disease was diagnosed. In all patients, clinical and epidemiological data, disease activity during pregnancy and in the immediate postpartum period, type of assisted delivery, and neonatal birthweight were recorded. RESULTS A total of 66.1% of pregnancies occurred before Crohn's disease was diagnosed, 31.5% occurred after diagnosis and 2.4% coincided with disease onset. No significant differences were found between women with and without a diagnosis of Crohn's disease in type of assisted delivery or low birthweight (p = 0.064; p = 0.643). All non-smoking patients remained in the quiescent phase and did not present disease recurrences during pregnancy. Among smokers, the disease remained inactive in 61.1%, while chronic activity or recurrences were observed in 38.9% (p = 0.003). CONCLUSIONS The course of inflammatory bowel disease does not adversely affect pregnancy or the immediate postpartum period, nor does it increase the presence of low birthweight neonates or the number of cesarean deliveries performed.
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Affiliation(s)
- E Ubiña-Aznar
- Servicio de Aparato Digestivo, Hospital Costa del Sol, Marbella, Málaga, España.
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De Carolis S, Botta A, Fatigante G, Garofalo S, Ferrazzani S, Gasbarrini A, Caruso A. Celiac disease and inflammatory bowel disease in pregnancy. Lupus 2004; 13:653-8. [PMID: 15485096 DOI: 10.1191/0961203304lu1096oa] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
An adverse influence on reproductive life and obstetric complications are known to occur in women with celiac disease (clinical and subclinical disease) or inflammatory bowel diseases. Treatment can improve the pregnancy outcome; therefore, it is advisable that a clinical evaluation is performed by a joint team of obstetricians, internists and surgeons. The preconception clinical evaluation of the affected women is useful to focus on the different clinical aspects of the disease and to indicate specific therapeutic strategies. In this study a review of the literature regard to celiac disease and inflammatory bowel disease in pregnancy is presented.
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Affiliation(s)
- S De Carolis
- Institute of Obstetrics and Gynaecology, Catholic University, Rome, Italy.
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Abstract
We report the case of an adult with Crohn's disease and pulmonary sarcoidosis on the background of cystic fibrosis (CF). There is a recognized association between Crohn's colitis and CF, but cases of pulmonary sarcoidosis in CF are rare. There may be a pathogenic link between the two granulomatous disorders and CF with chronic immune stimulation leading to hyperimmunoglobulinemia, circulating immune complexes and subsequent granuloma formation.
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Affiliation(s)
- Catherine J Dobbin
- Department of Respiratory Medicine, E 11 South, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW 2050, Australia
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Crocker I, Lawson N, Fletcher J. Effect of pregnancy and obstructive jaundice on inflammatory diseases: the work of P S Hench revisited. Ann Rheum Dis 2002; 61:307-10. [PMID: 11874831 PMCID: PMC1754059 DOI: 10.1136/ard.61.4.307] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Hench considered that cortisone improved inflammatory joint symptoms during pregnancy and obstructive jaundice. However, the improved symptoms are probably due to changes in the proportions of fatty acids in plasma and inflammatory cell phospholipids. These changes decrease the superoxide anions and eicosanoids produced and also reduce tumour necrosis factor alpha production.
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Affiliation(s)
- I Crocker
- David Evans Medical Research Centre, Nottingham City Hospital NHS Trust, Hucknall Road, Nottingham NG5 1PB, UK
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Abstract
The peak age of onset for IBD coincides with the peak age for conception and pregnancy. Women with inactive IBD who become pregnant do not have increased complications compared with age-matched controls. Most medications for IBD are safe in pregnancy. The greatest danger to a normal conception and pregnancy is active disease, not the medicine used to treat it. This article outlines fertility in IBD, the effect of IBD on pregnancy, the effect of pregnancy on IBD, and the medical therapy available.
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Affiliation(s)
- Sonia Friedman
- Department of Medicine, Harvard Medical School, and Gastroenterology Division, Brigham and Women's Hospital, Boston, MA, USA
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Dominitz JA, Young JCC, Boyko EJ. Outcomes of infants born to mothers with inflammatory bowel disease: a population-based cohort study. Am J Gastroenterol 2002; 97:641-8. [PMID: 11926208 DOI: 10.1111/j.1572-0241.2002.05543.x] [Citation(s) in RCA: 152] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Limited population-based data on inflammatory bowel disease (IBD) and pregnancy outcomes exist. The purpose of this study is to determine the association between maternal IBD status and adverse pregnancy outcomes. METHODS Using computerized birth records of infants born to mothers with Crohn's disease (CD) or ulcerative colitis (UC) and mothers without diagnoses of IBD (no-IBD) in Washington State, we performed a cross-sectional retrospective study to determine gestational age, birth weight, and congenital malformations. RESULTS Preterm delivery was seen in 15.2% of CD births, 10.4% of UC births, and 7.2% of no-IBD births. Low birth weight was found in 16.8% of CD births, 7.6% of UC births, and 5.3% of no-IBD births. Smallness for gestational age was present in 15.2% of CD births, 10.5% of UC births, and 6.9% of no-IBD births. Only CD births were at significantly increased risk of preterm delivery (p < 0.0025), low birth weight (p < 0.001), and smallness for gestational age (p < 0.001). Congenital malformations were more commonly recorded in UC births than in controls (7.9% vs 1.7%, p < 0.001), whereas 3.4% of CD births had malformations recorded. Using multivariable logistic regression, CD births were more likely to be preterm (odds ratio [OR] = 2.3, 95% CI = 1.4-3.8) and have low birth weights (OR = 3.6, CI = 2.2-5.9) and smallness for gestational age (OR = 2.3, CI = 1.3-3.9). UC births were more likely to have congenital malformations reported (OR = 3.8, CI = 1.5-9.8). CONCLUSIONS Maternal IBD is associated with increased odds of preterm delivery, low birth weight, smallness for gestational age (CD), and reporting of congenital malformations (UC).
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Affiliation(s)
- Jason A Dominitz
- Department of Medicine, University of Washington School of Medicine, Health Services Research and Development, and VA Puget Sound Health Care System, Seattle, USA
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Ilnyckyji A, Blanchard JF, Rawsthorne P, Bernstein CN. Perianal Crohn's disease and pregnancy: role of the mode of delivery. Am J Gastroenterol 1999; 94:3274-8. [PMID: 10566729 DOI: 10.1111/j.1572-0241.1999.01537.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Elective cesarean section (CS) is a standard recommendation for pregnant women with perianal Crohn's disease. In this study we examined the mode of delivery for pregnant women with Crohn's disease and assessed the relationship between perianal disease activity and delivery mode. METHODS The University of Manitoba's Inflammatory Bowel Disease Database, a population-based database, was interfaced with a provincial birth database to compare the mode of delivery for women with Crohn's disease and ulcerative colitis to that of the general population for the years 1985-1995. To describe clinical issues related to perianal Crohn's disease in relation to mode of delivery, data were obtained from a subset of women with Crohn's disease who had given birth between 1985 and 1995 using a standardized questionnaire. Data regarding Crohn's disease and birth history were verified through chart review (93.8%) and corroboration with the personal physician (87.5%). RESULTS The total and (elective) CS rates were higher for Crohn's disease 20.9% (9.0%), and for UC 20.8% (9.3%) than the general population 15% (5.4%) (p < 0.01 for each). Among primiparous women, patients with Crohn's disease and UC were also significantly more likely to have CS than the general population. In the target group of 281 women, 52 had births in the years in question and were contactable. There were 54 vaginal births and 10 sections. Fifteen of 54 vaginal births were predated by perianal disease; 4 of 15 reported active perianal disease at birth; and all reported worsening of perianal symptoms postpartum. Those with inactive perianal disease (n = 11) had no relapse of perianal disease in 1 yr of follow-up postpartum. Of 39 vaginal deliveries with no known perianal disease, only 1 ultimately developed perianal disease within 1 yr of postpartum follow-up. CONCLUSIONS Women with inflammatory bowel disease undergo CS more often compared to the general population. For those with either no history of perianal disease or inactive perianal disease at birth, the risk of perianal disease relapse is very low and does not justify CS. Active perianal disease at time of delivery is an indication for CS.
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Affiliation(s)
- A Ilnyckyji
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
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Abstract
The management of inflammatory bowel disease during pregnancy is a particular challenge because adequate disease control before and during gestation is essential for both maternal and foetal health. As a practical problem this situation arises frequently, because a quarter of patients conceive after the diagnosis of their disease. Many of the clinical, biochemical, radiological and endoscopic investigations that are used to monitor and assess disease activity are difficult to use and interpret during pregnancy. Furthermore, patients and clinicians often have concerns about the safety of medical and surgical treatments for the foetus. This review is designed for the practising clinician, to guide the management of patients with inflammatory bowel disease before and during pregnancy. The literature is at times conflicting and data on some issues are scanty, therefore recommendations are based on the balance of evidence including, if necessary, extrapolation from other conditions.
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Affiliation(s)
- J M Subhani
- University Department of Medicine, Royal Free and University College Medical School, London, UK
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