Inflammatory bowel disease in pregnancy

A Benefit-Risk Conceptual Framework for Biologic Use During Pregnancy: A Mini-Review

Recent reports related to in utero exposure of marketed immunosuppressive biologics led to clinical recommendations to delay live vaccinations for infants due to the concern of reduced vaccine effectiveness and/or increased risk of vaccine-related disease. These delays can increase the risk of children contracting vaccine preventable diseases, yet the alternative cessation of biologics during pregnancy may result in increased autoimmune disease activity for the pregnant person, raising complex benefit-risk (B-R) considerations and trade-offs. Our goal is to develop a conceptual framework for B-R assessment based on the key benefits and risks pregnant people would consider for themselves and their children when continuing (vs. discontinuing) a biologic during pregnancy. The proposed framework defines the decision contexts, key domains and attributes for potential benefits, and risks of biologic use during pregnancy, informed by a literature review of indications for biologics and refined with key clinical stakeholders. The framework includes both the pregnant person taking the biologic and the infant potentially exposed to the biologic in utero, with potential benefit and risk domains and attributes for each participant. To advance this conceptual framework, there are considerations of potential biases and uncertainty of available data that will be imperative to address when quantifying the B-R framework. For these reasons, we recommend the formation of a consortium to ensure development of a robust, validated framework that can be adopted in the healthcare setting.

Saudi consensus guidance for the management of inflammatory bowel disease during pregnancy

ABSTRACT

The management of inflammatory bowel disease (IBD) in pregnant women is challenging and must be addressed on a patient-by-patient basis. Optimal patient management requires a multidisciplinary team and clear evidence-based recommendations that cater to this subset of patients. In this article, we provide concise guidelines and clinical care pathway for the management of IBD in pregnant women. Our recommendations were developed by a multidisciplinary working group that includes experts from the Saudi Ministry of Health in collaboration with the Saudi Gastroenterology Association and the Saudi Society of Clinical Pharmacology. All recommendations are based on up-to-date information following an extensive literature review. A total of 23 evidence-based expert opinion recommendations for the management of IBD in pregnant women are herein provided.

Knowledge Gaps and Current Evidence Regarding Breastfeeding Issues in Mothers with Chronic Diseases

The prevalence of chronic maternal disease is rising in the last decades in the developed world. Recent evidence indicated that the incidence of chronic maternal disease ranges from 10 to 30% of pregnancies worldwide. Several epidemiological studies in mothers with chronic diseases have mainly focused on the risk for adverse obstetric outcomes. Evidence from these studies supports a correlation between maternal chronic conditions and adverse perinatal outcomes, including increased risk for preeclampsia, cesarean section, preterm birth, and admission in the Neonatal Intensive Care Unit (NICU). However, there is a knowledge gap pertaining to the management of these women during lactation. This review aimed at summarizing the available research literature regarding breastfeeding in mothers with chronic diseases. Adjusted and evidence-based support may be required to promote breastfeeding in women with chronic diseases; however, our comprehension of breastfeeding in this subpopulation is still unclear. The literature related to breastfeeding extends in various scientific areas and multidisciplinary effort is necessary to compile an overview of current evidence and knowledge regarding breastfeeding issues in mothers with chronic diseases.

Maternal Outcomes and Pregnancy-Related Complications Among Hospitalized Women with Inflammatory Bowel Disease: Report from the National Inpatient Sample

BACKGROUND AND AIMS

Previous studies have been inconsistent in reporting the risk of pregnancy-related complications in women with IBD. We aimed to investigate the differences in frequencies of pregnancy-related complications requiring hospitalization in women with IBD compared to women without IBD.

METHODS

We performed a population-based, cross-sectional study using the 2014 USA National Inpatient Sample. Frequencies of ICD-9 codes for pregnancy-related complications in women aged 18-35 years with IBD were compared to women with no IBD controlling for confounders predisposing to pregnancy complications. Adjusted odds ratios were calculated for each outcome.

RESULTS

A total of 6705 women with IBD and a pregnancy complication were discharged from the hospital in 2014. In multivariate analyses, there was no statistically significant difference between women with and without IBD for: spontaneous abortion, post-abortion complications, ectopic pregnancy, hemorrhage, severe preeclampsia, eclampsia, early labor, polyhydramnios, hyperemesis, missed abortion, mental disorder during pregnancy, and forceps delivery. Women with IBD had significant lower odds for prolonged pregnancy, gestational diabetes, fetal distress, umbilical cord complications, obstetric trauma, mild preeclampsia, and hypertension. There was, however, higher odds for infectious and parasitic complications (OR 1.74, 95% CI 1.42-2.14, p < 0.0001), UTIs (OR 1.65, 95% CI 1.07-2.60, p = 0.02), and anemia (OR 5.26, 95% CI 4.01-6.90, p < 0.0001).

CONCLUSIONS

In this large population-based analysis, women with IBD had higher odds for certain infections such as UTIs and anemia during pregnancy when compared to women with no IBD. For other pregnancy-related complications, women with IBD had the same or lower odds than women with no IBD. These data are important to share with women with IBD considering pregnancy.

A Dedicated Pregnancy Clinic Improves Reproductive Knowledge in Inflammatory Bowel Disease

BACKGROUND AND AIMS

Factors affecting pregnancy-related knowledge in women with inflammatory bowel disease (IBD) remain unknown. We aimed to determine these factors and to assess the impact of a dedicated pregnancy clinic on improving knowledge in women with IBD.

METHODS

Adult women with IBD attending the pregnancy IBD clinic at the University of Alberta from 2014 to 2018 were enrolled. Each patient completed the Crohn's and Colitis Pregnancy Knowledge (CCPKnow) questionnaire at baseline and after individualized education delivered at each clinic visit. Knowledge levels were defined as very good if CCPKnow scores ≥ 14. Mean CCPKnow scores were reported with standard deviations (SD) and compared using the paired T test.

RESULTS

The mean CCPKnow score in 117 patients at baseline was 9.65 (SD 4.18). Compared to those with disease duration < 5 years, those with disease duration > 5 years had higher rates of very good baseline knowledge (3.0% vs. 26.4%, p = 0.036). Similarly, those on preconception IBD-related therapy were more likely to have very good knowledge compared to those on no therapy (22.5% vs. 0%, p = 0.024). Fifty-one patients completed a post-clinic CCPKnow survey with a mean CCPKnow of 10.72 (SD 4.32). Participation in a pregnancy clinic improved reproductive knowledge in those with ulcerative colitis (p = 0.001), disease duration > 5 years (p = 0.017), those with at least a university education (p = 0.014) and those on IBD-related therapies (p = 0.026).

CONCLUSIONS

Increased disease duration and preconception IBD-related therapy may be associated with increased pregnancy-related knowledge. A dedicated pregnancy clinic can improve reproductive knowledge in women with IBD.

Inflammatory bowel disease in pregnancy: Developing a multidisciplinary care pathway in East London

Objectives

Evaluate the management of pregnant women with inflammatory bowel disease.

Method

We collected data from maternity records for women with IBD who gave birth at The Royal London Hospital between January 2018 and February 2019.

Results

Twenty-three pregnancies were identified where 8/23 (35%) women had a peri-conception flare and 7/23 (30%) had a flare during pregnancy. Two women received pre-conception counselling. The obstetric medicine team reviewed a patient on average three times and the gastroenterologists twice, during pregnancy. Nine women (39%) gave birth pre-term. Mean birthweight was lower in the group with active disease at conception compared with those in remission (2173 g vs. 2807 g, p = 0.03).

Conclusions

Women with IBD should all receive pre-conception counselling to reduce the risk of pregnancy complications. By developing a multidisciplinary care pathway for pregnant women with IBD (which includes a joint obstetric/gastroenterology clinic), this will ensure care is standardised throughout the pregnancy and puerperium.

Regional Variation in Pregnancy Outcomes amongst Women in Inflammatory Bowel Disease: A Population-Based Cohort Study

BACKGROUND

Women with inflammatory bowel disease (IBD) are at risk of certain pregnancy outcomes such as preterm delivery, infants small for gestational age (SGA), and Cesarean delivery. Whether regional variation in these outcomes exists remains unknown. We aimed to assess the geographical variation in these pregnancy outcomes in women with IBD.

METHODS

All pregnancies in women with and without IBD (2002-2013) were identified using Ontario health administrative datasets. Geographical variation in preterm delivery, infants SGA, and Cesarean delivery was assessed using age-adjusted odds ratios (aOR) with 95% confidence intervals (CI) comparing women with and without IBD, stratified by Ontario's 14 health-service regions, known as Local Health Integration Networks (LHINs).

RESULTS

1621 women with IBD (2466 pregnancies) and 855,425 women without IBD (1,280,493 pregnancies) were included. Women with IBD were more likely to have preterm delivery (aOR 1.56, 95% CI, 1.35-1.79), infants SGA (aOR 1.52, 95% CI, 1.23-1.88), and Cesarean section (aOR 1.34, 95% CI, 1.22-1.49). Significant geographical variation in these outcomes was detected, with the highest rates observed in the most northern rural areas (aOR for preterm delivery 2.78 (95% CI, 1.03-7.46), aOR for SGA 5.66 (95% CI, 1.67-19.14), and aOR for Cesarean delivery 2.48 (95% CI, 1.11-5.55)). There were no differences in these outcomes in women with and without IBD in more central urban LHINs.

CONCLUSION

Significant regional variation was detected in rates of adverse pregnancy outcomes and Cesarean delivery in women with IBD. Further study is required to determine specific reasons for this variation.

Adherence improvement in patients with ulcerative colitis: a multidisciplinary consensus document

OBJECTIVES

1)To analyze evidence about poor adherence / non-adherence including their prevalences, associated factors, and interventions in ulcerative colitis (UC) patients; 2)To provide a framework to improve poor adherence / non-adherence.

METHODS

A qualitative approach was applied. A literature review was performed using Medline. Primary searches were performed with Mesh and free texts to identify articles that analyzed prevalence, causes, associated factors, and interventions designed to improve poor adherence/ non-adherence in UC patients. The studies' quality was evaluated using the Oxford scale. The results were presented and discussed in a nominal group meeting, comprising a multidisciplinary committee of six gastroenterologists, one psychologist, one nurse, and one patient. Several overarching principles and recommendations were generated. A consensus procedure was implemented via a Delphi process during which each committee member produced a score ranging from 0 = totally disagree to 10 = totally agree. Agreement was considered if at least 70% of the participants voted ≥7.

RESULTS

The literature review included 75 articles. Non-adherence rates ranged from 7%-72%. We found a great variability in the methods employed to assess adherence, associated factors, and interventions designed to improve adherence. Overall, eight overarching principles and six recommendations were generated, all of them achieving the pre-established agreement level, including, among others, the identification, classification, and management of non-adherence.

CONCLUSIONS

Poor adherence / non-adherence are common in UC patients, being a relevant clinical concern. Health professionals should address this issue and actively involve the patients in implementing effective and individualized interventions to improve adherence.

Biologics and pregnancy: a clinician's guide to the management of IBD in pregnant women

Introduction: Women with inflammatory bowel disease (IBD) endorse a tremendous amount of concern about medication exposure during pregnancy and their effects on the fetus. Medical providers caring for this patient population should be well informed and feel comfortable counseling their patients for the best pregnancy outcome possible.Areas covered: It is of particular importance to understand the implications of use of biologics in preconception, pregnancy, and postpartum timeframes. Herein, we aim to inform the clinician about the impact of uncontrolled inflammation during pregnancy, the mechanisms of biologic transport through the placenta, the effects of biologics in maternal and neonatal outcomes, and additional postpartum considerations such as breastfeeding and vaccination safety.Expert opinion: The groundwork already set by previous research in terms of safety of biologic therapy during pregnancy has been reassuring. With the advent of more mechanisms of action but similar protein structure, i.e. they are IgG1 antibodies; the authors anticipate the recommendation of continuation of therapy throughout pregnancy will be sustained.

Impact of the coronavirus infectious disease (COVID-19) pandemic on the provision of inflammatory bowel disease (IBD) antenatal care and outcomes of pregnancies in women with IBD

BACKGROUND

The impact of COVID-19 on pregnant inflammatory bowel disease (IBD) patients is currently unknown. Reconfiguration of services during the pandemic may negatively affect medical and obstetric care. We aimed to examine the impacts on IBD antenatal care and pregnancy outcomes.

METHODS

Retrospective data were recorded in consecutive patients attending for IBD antenatal care including outpatient appointments, infusion unit visits and advice line encounters.

RESULTS

We included 244 pregnant women with IBD, of which 75 (30.7%) were on biologics in whom the treatment was stopped in 29.3% at a median 28 weeks gestation. In addition, 9% of patients were on corticosteroids and 21.5% continued on thiopurines. The care provided during 460 patient encounters was not affected by the pandemic in 94.1% but 68.2% were performed via telephone (compared with 3% prepandemic practice; p<0.0001). One-hundred-ten women delivered 111 alive babies (mean 38.2 weeks gestation, mean birth weight 3324 g) with 12 (11.0%) giving birth before week 37. Birth occurred by vaginal delivery in 72 (56.4%) and by caesarean section in 48 (43.6%) cases. Thirty-three were elective (12 for IBD indications) and 15 emergency caesarean sections. Breast feeding rates were low (38.6%). Among 244 pregnant women with IBD, 1 suspected COVID-19 infection was recorded.

CONCLUSION

IBD antenatal care adjustments during the COVID-19 pandemic have not negatively affected patient care. Despite high levels of immunosuppression, only a single COVID-19 infection occurred. Adverse pregnancy outcomes were infrequent.

Inflammatory bowel disease and pregnancy: fertility, complications and treatment

Inflammatory bowel disease (IBD) is commonly diagnosed and treated in the young population. Therefore, it is common that women anticipating or undergoing pregnancy will have to cope with the additional burden of their IBD. Pregnancy in an IBD patient also presents challenges for the practitioner, in that the usual diagnostic and therapeutic armamentarium of potential tests and therapies is disrupted. This review covers the implications of IBD for fertility, pregnancy and offspring, and discusses the management of IBD in pregnancy.

Safety of vedolizumab in the treatment of pregnant women with inflammatory bowel disease: a targeted literature review

BACKGROUND

Crohn's disease (CD) and ulcerative colitis (UC) commonly affect women in their childbearing years. Vedolizumab (VDZ) is approved for treatment of moderate-to-severe CD and UC, but there is a knowledge gap regarding its use during pregnancy. This targeted literature review describes available evidence on safety of VDZ in pregnant patients in order to offer physicians a detailed and balanced view on persistent data during their decision-making process for an individualized treatment concept.

METHODS

The search included literature from the MEDLINE database and abstracts of five gastroenterological conferences published until November 2019. Publications were included if pregnancy outcomes in women receiving VDZ or neonatal outcomes in newborns of women previously exposed to VDZ were reported.

RESULTS

Out of 196 initially identified records, 18 publications reporting results of five different studies were identified. In total, for 213 of 284 VDZ-exposed documented pregnancies the following pregnancy outcomes were reported: 167 live births (172 infants due to twin births), 1 stillbirth, 35 miscarriages, 10 elective terminations (1 due to detected Down syndrome). Furthermore, during pregnancy, the following complications were observed: seven cases of (pre) eclampsia, three cases of premature rupture of membranes and one case each of placenta previa, chorioamnionitis, pneumonia, first-trimester bleeding, cholestasis, sepsis, or neonatal intraventricular hemorrhage. Based on 172 infants, 30 preterm deliveries (17.4%), 9 cases of low birth weight (5.2%), 5 infections (2.9%), and 6 cases (3.8%) with congenital anomalies were reported.

CONCLUSION

There was no evidence for safety concerns regarding pregnancy outcomes associated with VDZ therapy. Due to the limited scope of included records, further research is needed to understand the safety profile regarding the use of VDZ during pregnancy.

Infertile patients with inflammatory bowel disease have comparable in vitro fertilization clinical outcomes to the general infertile population

To assess clinical outcomes of females diagnosed with Inflammatory Bowel Disease (IBD) and infertility, which underwent in vitro fertilization (IVF) with preimplantation genetic testing for aneuploidy. (PGT-A). Retrospective cohort study comparing clinical outcomes of patients with Inflammatory bowel disease who underwent IVF with PGT-A with a subsequent euploid single embryo transfer (SET) against a matched control group. Thirty-eight patients with an IBD diagnosis were compared to 114 controls. There was no significant difference in cycle outcomes among IBD and Control cohorts [implantation rate (71.0% vs. 78.0% (p = .68)], clinical pregnancy rate [50.0% vs. 60.5% (p = .68)], live birth [62.9% vs. 73.0% (p = .06)] multiple pregnancy rate [0% vs. 1.1% (p = .25)] and clinical pregnancy loss rate [10.5% vs. 5.7% (p = .54)]. An IBD diagnosis was not found to significantly modify the odds of implantation [adjusted OR = 0.6 (95% CI -1.2 to 0.8)]. Additionally, the odds of implantation in patients with IBD were not altered by having ulcerative colitis or Crohn's disease diagnosis. (OR = 0.4 95% CI 0.1-1.9). Patients diagnosed with IBD who undergo a SET have clinical outcomes comparable to the general infertile population. Patients and physicians can be reassured that an IBD diagnosis does not impair IVF treatment outcomes.SYNOPSISInfertile patients with inflammatory bowel disease who utilized a single, euploid blastocyst transfer had IVF success rates comparable to the general infertile population.

Physiological and psychological stress in pregnant women with quiescent inflammatory bowel disease: A pilot study using salivary biomarkers

Background

Pregnant women with inflammatory bowel disease (IBD) are more likely than the general pregnant population to experience adverse maternofetal outcomes, especially if the disease is active at the time of conception and during pregnancy. Elevated stress is often seen in patients with chronic diseases and could account for these outcomes. Salivary cortisol and alpha‐amylase (sAA) are novel biomarkers of stress, reflecting the hypothalamic‐pituitary‐adrenal (HPA) axis and sympathetic nervous system, respectively. Our aim in this pilot study was to assess stress differences between pregnant women with inactive IBD and matched controls using psychometric questionnaires and salivary biomarker measures.

Methods

Thirteen pregnant women with quiescent IBD (6 Crohn's disease, 7 ulcerative colitis) were matched (1:3) to 39 expectant mothers without IBD by parity and gestational age. Participants completed several psychometric questionnaires assessing stress, and salivary cortisol and sAA were collected as objective biomarkers of stress during pregnancy.

Results

Pregnant women with quiescent IBD did not demonstrate significant differences on any psychometric measures of stress or salivary biomarker measures when compared with controls (all P > 0.05). Pregnant women with quiescent IBD demonstrated similar cortisol and sAA awakening responses (both P > 0.05) and total levels of cortisol and sAA production (both P > 0.05) when compared with controls.

Conclusions

Pregnant women with well‐controlled IBD do not experience demonstrable differences in psychological stress or dysregulation of salivary stress biomarkers when compared with non‐IBD controls. The effect of chronic disease may be evaluated in future studies by including a comparative group of pregnant women with active IBD.

Systematic review with meta-analysis: risk of adverse pregnancy-related outcomes in inflammatory bowel disease

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.

What factors could influence physicians' management of women of childbearing age with chronic inflammatory disease? A systematic review of behavioural determinants of clinical inertia

BACKGROUND

Pregnancy represents a complex challenge to clinicians treating women with chronic inflammatory disease. Many clinicians face a situation of heightened sensitivity to the potential risks and uncertainties associated with the effect of pharmacological treatment on pregnancy outcomes. This may create an environment vulnerable to clinical inertia, whereby behavioural factors such as cognitive heuristics and biases, and other factors such as attitudes to risk and emotion can contribute. This systematic review was undertaken to assess if clinical inertia has been investigated/identified in this setting and took a behavioural science approach to identify and understand the potential determinants of clinical inertia in this treatment setting.

METHODS

A systematic literature search was conducted to identify publications which investigated or described clinical inertia or its determinants (e.g. heuristics, biases etc.). Results were coded for thematic analysis using two inter-related behavioural models: the COM-B model and the Theoretical Domains Framework.

RESULTS

Whilst studies investigating or describing clinical inertia in this treatment setting were not identified, the behavioural analysis revealed a number of barriers to the pharmacological management of women of fertile age affected by chronic inflammatory disease. Factors which may be influencing clinician's behaviour were identified in all domains of the COM-B model. The primary factors identified were a lack of knowledge of treatment guidelines and fears concerning the safety of medications for mother and fetus. Lack of experience of treating pregnant patients was also identified as a contributing factor to undertreatment.

CONCLUSION

Using a behavioural approach, it was possible to identify potential factors which may be negatively influencing clinician's behaviour in this treatment setting, although specific research was limited.

Noninvasive Methods For Assessing Inflammatory Bowel Disease Activity in Pregnancy: A Systematic Review

Active inflammatory bowel disease (IBD) may increase the risk of adverse outcomes during pregnancy. Our aim was to systematically review the role of noninvasive fecal tests, such as fecal calprotectin (FCP) and lactoferrin (FL), and laboratory tests including C-reactive protein (CRP), hemoglobin, and albumin in the assessment of IBD during pregnancy. A systematic search of electronic databases was performed through October 2018 for studies assessing the utility of fecal and laboratory tests in predicting IBD activity in pregnant patients. Active disease was defined based on routinely used clinical criteria such as the Harvey-Bradshaw Index or Mayo score for ulcerative colitis. Noninvasive test levels were stratified by the presence of active disease and by gestational period (preconception, first trimester, second trimester, and third trimester). Thirteen studies were included. Both FCP and FL levels were significantly higher in pregnant patients with IBD compared with those without IBD. FCP levels were also significantly higher in patients with active disease compared with those with the inactive disease during all gestational periods. Furthermore, 3 studies demonstrated no consistent correlation with serum CRP and active IBD during pregnancy. Similarly, serum albumin and hemoglobin levels did not correlate with disease activity in pregnant patients with IBD. Given the lack of high-quality evidence, only FCP appears to correlate with IBD activity in all gestational periods of pregnancy. The utility of the other noninvasive tests such as serum CRP, hemoglobin, and albumin remains to be determined in this population.

Inflammatory bowel disease during pregnancy: management of a disease flare or remission

PURPOSE OF REVIEW

Roughly half of the nearly 1.6 million people with inflammatory bowel disease (IBD) are women of reproductive age. Caring for women with IBD who are also pregnant can be challenging, particularly if with a disease flare or in remission, as there are special considerations needed.

RECENT FINDINGS

Despite older studies concluding potential risks associated with IBD medical therapies, more recent literature reports healthier maternal and birth outcomes associated with disease control and reduction in the inflammatory burden. Most IBD therapies should generally be continued throughout all three trimesters without interruption as this is associated with better outcomes.

SUMMARY

Active IBD increases risk of pregnancy complications and adverse pregnancy outcomes. Most medications have a favorable safety profile for use during pregnancy, regardless if in disease flare or remission. Short course corticosteroids for induction and management of flare is permitted. Thiopurines should not be started during pregnancy for a disease flare, but may be continued during pregnancy if previously on monotherapy. Biologics should be continued throughout pregnancy without interruption and timing of third trimester dosing made based on drug levels and estimated date of delivery. Risks/benefit assessment of therapies and disease control is important and should be individualized.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

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.

Continuous Anti-TNFα Use Throughout Pregnancy: Possible Complications For the Mother But Not for the Fetus. A Retrospective Cohort on the French National Health Insurance Database (EVASION)

OBJECTIVES

Inflammatory bowel diseases (IBD) need long-term treatment, which can influence pregnancies in young women. Uncontrolled IBD is associated with poor pregnancy outcomes. Despite the labeling of Anti-tumor necrosis factor (TNF) antibodies (anti-TNFα) which indicates that their use is not recommended during pregnancy, anti-TNFα are increasingly being used during pregnancy and may expose women and their fetuses to treatment-related complications. Existing recommendations on the timing of treatment during pregnancy are inconsistent. We aimed to assess the safety of anti-TNFα treatment in pregnant women with IBD, and up to the first year of life for their children.

METHODS

An exposed/non exposed retrospective cohort was conducted on the French national health system database SNIIRAM (Système National d'Information Inter-Régimes de l'Assurance Maladie). All IBD women who became pregnant between 2011 and 2014 were included. Women with concomitant diseases potentially treated with anti-TNFα were excluded. Anti-TNFα exposure (infliximab, adalimumab, golimumab or certolizumab pegol) during pregnancy was retrieved from the exhaustive prescription database in SNIIRAM. The main judgment criterion was a composite outcome of disease-, treatment- and pregnancy-related complications during pregnancy for the mother, and infections during the first year of life for children.

RESULTS

We analyzed data from 11,275 pregnancies (8726 women with IBD), among which 1457 (12.9%) pregnancies were exposed to anti-TNFα, mainly infliximab or adalimumab, with 1313/7722 (17.0%) suffering from Crohn's disease and 144/3553 (4.1%) from ulcerative colitis. After adjusting for disease severity, steroid use, age, IBD type, and duration and concomitant 6-mercaptopurine use, anti-TNFα treatment was associated with a higher risk of overall maternal complications (adjusted Odds Ratio (aOR) = 1.49; 95% confidence interval (CI): 1.31-1.67) and infections (aOR = 1.31; 95% CI: 1.16-1.47). Maintaining anti-TNFα after 24 weeks did not increase the risk of maternal complication, but interrupting the anti-TNFα increased relapse risk. No increased risk for infection was found in children (aOR = 0.89; 95% CI: 0.76-1.05) born to mother exposed to anti-TNFα during pregnancy.

CONCLUSIONS

Anti-TNFα treatment during pregnancy increased the risk of maternal complications compared to unexposed; however, discontinuation before week 24 increased the risk of disease flare. There was no increased risk for children exposed to anti-TNFα up to 1 year of life.

Chronic pain, pain severity and analgesia use in Australian women of reproductive age

BACKGROUND

The increasing prevalence and adverse outcomes associated with opioid analgesia use in women of reproductive age have become a significant public health issue internationally, with use during pregnancy potentially affecting maternal and infant health outcomes.

OBJECTIVE

This study aims to provide national estimates of chronic pain, pain severity and analgesia use in Australian women of reproductive age by pregnancy status.

METHOD

Data were obtained from the Australian Bureau of Statistics 2011-12 National Health Survey (n=20,426). Weighting was applied to sample data to obtain population estimates. For this study data were analysed for pregnant (n=166, N=192,617) and non-pregnant women (n=4710, N=5,256,154) of reproductive age (15-49 years).

RESULTS

Chronic or reoccurring pain was reported in 5.1% of pregnant women and 9.7% of non-pregnant women, and 0.7% and 2.6% of pregnant and non-pregnant women reported recent opioid analgesia use respectively. Moderate-to-very severe pain was more common in pregnant than non-pregnant women taking opioid analgesics, and no pain and very mild-to-mild pain in non-pregnant women.

CONCLUSION

Approximately 1 in 20 pregnant Australian women have chronic or reoccurring pain. Opioid analgesia was used by around 1% of Australian pregnant women during a two-week period, with use associated with moderate-to-very severe pain. Given that the safety of many analgesic medications in pregnancy remains unknown, pregnant women and health professionals require accurate, up-to-date information on the risks and benefits of analgesic use during pregnancy. Further evidence on the decision-making processes of pregnant women with pain should assist health professionals maximise outcomes for mothers and infants.

When Your Pregnancy Echoes Your Illness: Transition to Motherhood With Inflammatory Bowel Disease

Our aim is to provide an understanding of the experience of women with inflammatory bowel disease (IBD) who have made the transition to motherhood. A total of 22 mothers with IBD were recruited from around the United Kingdom. Semi-structured interviews were conducted and analyzed using thematic analysis. The central concept- Blurred Lines-offers a novel frame for understanding the transition to motherhood with IBD through identifying parallels between having IBD and becoming, and being, a mother. Parallels clustered into three main themes: Need for Readiness, Lifestyle Changes, and Monitoring Personal and Physical Development. Hence, women with IBD are in some ways well prepared for the challenges of motherhood even though, as a group, they tend to restrict their reproductive choices. We recommend health professionals initiate conversations about reproduction early and provide a multidisciplinary approach to pregnancy and IBD in which women have confidence that their ongoing treatment will be integrated successfully with their maternity care.

Systematic review: advice lines for patients with inflammatory bowel disease

OBJECTIVE

Advice lines for patients with inflammatory bowel diseases (IBD) have been introduced internationally. However, only a few publications have described the advice line service and evaluated the efficiency of it with many results presented as conference posters. A systematic synthesis of evidence is needed and the aim of this article was to systematically review the evidence of IBD advice lines.

MATERIALS AND METHODS

A broad systematic literature search was performed to identify relevant studies addressing the effect of advice lines. The process of selection of the retrieved studies was undertaken in two phases. In phase one, all abstracts were review by two independent reviewers. In phase two, the full text of all included studies were independently reviewed by two reviewers. The included studies underwent quality assessment and data synthesis.

RESULTS

Ten published studies and 10 congress abstracts were included in the review. The studies were heterogeneous both in scientific quality and in the focus of the study. No rigorous evidence was found to support that advice lines improve disease activity in IBD and correspondingly no studies reported worsening in disease activity. Advice lines were found to be health economically beneficial with clear indications of the positive impact of advice lines from the patient perspective.

CONCLUSION

The levels of evidence of the effect of advice lines in IBD are low. However, the use of advice lines was found to be safe, and cost-effective. Where investigated, patients with IBD overwhelmingly welcome an advice line with high levels of patient satisfaction reported.

Predictors of Cesarean Delivery in Pregnant Women with Inflammatory Bowel Disease

Aim

Pregnant women with Crohn’s disease (CD) or ulcerative colitis (UC) are likelier to undergo Cesarean delivery than women without IBD. Active perianal disease is the only IBD-related indication for Cesarean delivery. We sought to identify clinical factors contributing to these high rates.

Methods

We conducted a retrospective cohort study of 369 pregnant women with IBD who delivered at our institution between 2006 and 2014. We used logistic regression to identify clinical predictors of Cesarean delivery.

Results

The Cesarean delivery rate among women with CD and UC were 52% and 48%, respectively. Thirty of Cesarean deliveries (54%) in CD and UC patients were performed emergently, respectively. Among those with CD, the strongest predictors of Cesarean delivery were history of perianal disease (adjusted odds ratio [aOR), 13.6; 95% CI: 3.87–47.5) and prior Cesarean delivery (aOR, 22.2; 95% CI: 6.16–80.2). Among women who underwent Cesarean delivery because of perianal disease, only 42% had active perianal symptoms during pregnancy. In UC patients, history of colectomy was a predictor of Cesarean delivery (aOR, 5.08; 95% CI: 1.95–13.2). Cesarean delivery increased the postpartum length of stay by 1.1 days on average for both CD and UC patients, reflecting a 57% and 90% increase over vaginal delivery after adjusting for confounders.

Conclusions

The decision to perform Cesarean delivery for women with IBD is complex involving IBD-related and obstetric factors and is ideally made by a multidisciplinary team that includes input from a gastroenterologist and obstetrician.

Vedolizumab exposure in pregnancy: outcomes from clinical studies in inflammatory bowel disease

BACKGROUND

Vedolizumab is a gut-selective immunoglobulin G₁ monoclonal antibody to α₄ β₇ integrin for the treatment of Crohn's disease (CD) and ulcerative colitis (UC). Prospective clinical studies of vedolizumab in pregnancy have not been conducted; therefore, existing safety data of vedolizumab in pregnancy were examined.

AIM

To assess pregnancy outcomes in females and partners of males who received vedolizumab.

METHODS

All pregnancy data collected during the clinical programme (from 14 May 2007 to 27 June 2013) and in the post-marketing setting (to 19 November 2015) were analysed.

RESULTS

Across six studies, there were 27 pregnancies in female participants and 19 pregnancies in partners of male participants. Among 24 vedolizumab-treated females (23 with CD/UC, one healthy volunteer), there were 11 live births, five elective terminations, four spontaneous abortions and four undocumented outcomes. A congenital corpus callosum agenesis anomaly was reported in one live birth from a healthy volunteer with extensive obstetric history exposed to single-dose vedolizumab 79 days before estimated conception. Of 19 pregnancies in partners of male participants, there were 11 live births, two spontaneous abortions, three elective terminations and three undocumented outcomes. Post-marketing reports recorded 81 pregnancies, resulting in four live births, 11 spontaneous abortions and 66 pregnancies that were on-going or reported undocumented outcomes.

CONCLUSIONS

Initial analysis, limited by sample size and follow-up, identified no new safety concerns for pregnancy outcomes in females directly or indirectly exposed to vedolizumab. However, vedolizumab should be used during pregnancy only if the benefits to the mother outweigh the risks to the mother/unborn child.

Management of Inflammatory Bowel Disease During Pregnancy

Inflammatory bowel disease (IBD) usually affects women during their reproductive years and many concerns arise among these young patients. Pre-pregnancy consultation with a multi-disciplinary team is very important. The team should make patients aware of the critical importance of ensuring that conception occurs during a period of disease remission. Conception during an IBD flare-up results in disease activity or even exacerbates disease in two-thirds of women. Exacerbation of the disease is associated with increased frequency of maternal and fetal complications. Drug therapy constitutes a considerable source of patient anxiety but most drugs used for treating IBD are considered safe. Therefore, continuing pharmacological therapy during pregnancy is necessary to maintain disease control. Optimization of pre-conception nutritional status and smoking cessation are also emphasized. The general guideline for most patients, except for active perianal disease patients, is to aim for vaginal delivery in the absence of obstetric contraindications. Consistent, ongoing follow-up, as detailed in this review, should allay the anxieties and fears surrounding continuing immunosuppressive drugs during pregnancy, allowing each patient to attain the optimal conditions for achieving her goal of holding a healthy baby.

Reproduction and Growth in a Murine Model of Early Life-Onset Inflammatory Bowel Disease

Studies in transgenic murine models have provided insight into the complexity underlying inflammatory bowel disease (IBD), a disease hypothesized to result from an injurious immune response against intestinal microbiota. We recently developed a mouse model of IBD that phenotypically and histologically resembles human childhood-onset ulcerative colitis (UC), using mice that are genetically modified to be deficient in the cytokines TNF and IL-10 (“T/I” mice). Here we report the effects of early life onset of colon inflammation on growth and reproductive performance of T/I mice. T/I dams with colitis often failed to get pregnant or had small litters with pups that failed to thrive. Production was optimized by breeding double homozygous mutant T/I males to females homozygous mutant for TNF deficiency and heterozygous for deficiency of IL-10 (“T/I-het” dams) that were not susceptible to spontaneous colon inflammation. When born to healthy (T/I-het) dams, T/I pups initially gained weight similarly to wild type (WT) pups and to their non-colitis-susceptible T/I-het littermates. However, their growth curves diverged between 8 and 13 weeks, when most T/I mice had developed moderate to severe colitis. The observed growth failure in T/I mice occurred despite a significant increase in their food consumption and in the absence of protein loss in the stool. This was not due to TNF-induced anorexia or altered food consumption due to elevated leptin levels. Metabolic studies demonstrated increased consumption of oxygen and water and increased production of heat and CO₂ in T/I mice compared to their T/I-het littermates, without differences in motor activity. Based on the clinical similarities of this early life onset model of IBD in T/I mice to human IBD, these results suggest that mechanisms previously hypothesized to explain growth failure in children with IBD require re-evaluation. The T/I mouse model may be useful for further investigation of such mechanisms and for development of therapies to prevent reproductive complications and/or growth failure in humans with IBD.

Fertility and Contraception in Women With Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) carries a high burden in women during their reproductive years, and family planning issues are often a significant cause of concern. Fertility is normal in women with nonsurgically treated ulcerative colitis and similar or slightly reduced in women with Crohn's disease. Women who undergo ileal pouch anastomosis have reduced fertility. Fertility is likely worsened by disease activity but unaffected by medications used to treat IBD. Infertile patients with IBD respond as well as non-IBD patients to in vitro fertilization (IVF). Despite normal fertility, patients with IBD have fewer children due to concerns regarding infertility, disease inheritance, congenital abnormalities, and disease-related sexual dysfunction. Patients rarely discuss these issues with a physician. When discussion does occur, it may lead to changes in decision-making. Contraceptives are an important part of family planning, particularly during times of high disease activity. All forms of contraceptives are acceptable in patients with IBD, although there are specific considerations. The risks of combined oral contraceptives outweigh the benefits in patients with active disease and patients with prior or high risk for thromboembolism. Oral contraceptives and IBD are independently associated with an increased risk for thromboembolism, although it is not known whether this effect is compounding. Depot medroxyprogesterone acetate injection should be avoided in patients with or at risk for osteopenia. Intrauterine devices and implants are the most effective form of contraception and should be a first-line recommendation. The use of oral contraceptives is associated with the development of IBD, although there is no increased risk of disease relapse with the use of any form of contraceptive.

Decreased fertility rates in 9639 women diagnosed with inflammatory bowel disease: a United Kingdom population-based cohort study

BACKGROUND

Clinical studies have reported reduced fertility in women with inflammatory bowel disease (IBD).

AIM

To compare fertility rates in women with IBD to those in women without IBD and assess whether the relative fertility differed following IBD diagnosis, flares and surgery.

METHODS

Women aged 15-44 years in 1990-2010 were identified from a UK primary care database. We estimated overall and age-specific fertility rates by 5-year age bands for women with and without IBD. We used Poisson regression to calculate adjusted fertility rate ratios (AFRR), adjusted for age, smoking and socioeconomic deprivation.

RESULTS

There were 46.2 live births per 1000 person-years [95% confidence interval (95% CI); 44.6-47.9] in 9639 women with IBD and 49.3 (95% CI 49.2-49.5) in 2 131 864 without (AFRR: 0.93; 95% CI: 0.89-0.96). Excluding periods of contraception use, the AFRR was 0.99 (95% CI: 0.95-1.03). Before diagnosis, the AFRR for women with ulcerative colitis (UC) was 1.07 (95% CI: 0.99-1.16) and was 0.88 (95% CI: 0.81-0.97) for women with CD. After diagnosis, AFRRs were 0.87 (95% CI: 0.82-0.94) for CD and 0.92 (95% CI: 0.86-1.00) for UC. The fertility rate was lower following flares (AFRR: 0.70; 95% CI: 0.59-0.82) or surgery (AFRR: 0.84; 95% CI: 0.77-0.92). Women with pouch and non-pouch surgery had similar overall fertility though the reduction after surgery was greater for pouches (AFRR: 0.48; 95% CI: 0.23-0.99).

CONCLUSIONS

Women with Crohn's disease have marginally lower fertility rates. These rates decreased following flares and surgical interventions. Fertility rates returned almost to normal when women were not prescribed contraception but the reduction following surgical intervention remained. As the lifetime effect of pouch vs. nonpouch surgery on fertility is small, the reduction post-pouch surgery should be interpreted with caution.

First-in-Human Case Study: Pregnancy in Women With Crohn's Perianal Fistula Treated With Adipose-Derived Stem Cells: A Safety Study

The aim of this study was to determine whether treatment with adipose-derived stem cells (ASCs) had any influence on fertility, course of pregnancy, newborn weight, or physical condition of newborns. We performed a retrospective study of patients with a desire to become pregnant after having received intralesional injection of autologous ASCs for the treatment of perianal or rectovaginal fistula associated with Crohn's disease. We collected data on the resulting pregnancies, deliveries, and newborns of these patients. ASCs were expanded in vitro and characterized according to the international guidelines for cell surface markers (clusters of differentiation) and differentiated to adipocytes, chondrocytes, and osteocytes prior to implantation (except first implant in 2002). We analyzed five young women with Crohn's disease treated with ASCs: one for rectovaginal and perianal fistula, two for rectovaginal fistula only, and two for perianal fistula only. All patients received 2 doses of 20 million and 40 million cells at an interval of 3-4 months. Another patient received 2 doses of 6.6 million and 20 million ASCs with 9 months between each dose. Fertility and pregnancy outcomes were not affected by cell therapy treatment. No signs of treatment-related malformations were observed in the neonates by their respective pediatricians. In the patients studied, cell therapy with ASCs did not affect the course of pregnancy or newborn development.

SIGNIFICANCE

Local treatment with mesenchymal stem cells derived from adipose tissue seems not to affect the ability to conceive, the course of pregnancy, pregnancy outcomes, or newborns' health in female patients. This is the first publication about pregnancy outcome in women with perianal fistula and Crohn's disease treated with stem cell therapy, and could be of interest for doctors working in cell therapy. This is a very important question for patients, and there was no answer for them until now.

IBD: reproductive health, pregnancy and lactation

The peak incidence of inflammatory bowel diseases (IBD) occurs during the child-bearing years, and so questions about fertility, pregnancy and breast feeding are often asked by patients. It is known that patients with IBD receive twice as much information about pregnancy-related issues from gastroenterologists as from any other source (including the internet). Therefore, the role of the gastroenterologist in correctly educating patients to avoid misconceptions is paramount, and this should be done proactively prior to planning pregnancy so that the patient's health and medications can be optimised. A clear understanding of medication safety during pregnancy and lactation will improve clinical management.

Magnetic resonance enterography in pregnant women with Crohn's disease: case series and literature review

BACKGROUND

Evaluation of pregnant women with known or suspected Crohn's disease (CD) remains a challenge. Magnetic Resonance Enterography (MRE) is a promising diagnostic tool in these patients; however, the clinical data on MRE utilization in pregnancy is scarce. The aim of the study was to describe the experience with MRE in pregnant CD patients in a tertiary referral center.

METHODS

We retrospectively reviewed MRE studies performed in pregnant women with known or suspected CD that were performed between January 2007 and November 2012. Imaging findings, clinical management and outcome were extracted from patient's file and electronic records. Image quality was evaluated.

RESULTS

Ten studies of 9 patients were included. MRE protocol was modified to maximize maternal and fetal safety, and intravenous gadolinium was not used. In 7 patients, CD diagnosis was previously established; six were admitted with clinical symptoms consistent with CD exacerbation, and an additional patient with a recurrent groin abscess without apparent luminal symptoms. In all seven patients, imaging features consistent with active CD were detected; new penetrating complications were detected in 4 patients. Two patients underwent MRE for suspected CD which was not comforted by study results. The clinical management was significantly impacted by MRE results in all positive cases. The image quality of the fast MRE sequences obtained without gadolinium was satisfactory and allowed meaningful interpretation.

CONCLUSION

MRE with an adapted protocol for pregnancy is a reliable imaging modality to manage in pregnant women with known or suspected CD.

Pregnancy-specific glycoprotein 1 (PSG1) activates TGF-β and prevents dextran sodium sulfate (DSS)-induced colitis in mice

Transforming growth factor-βs (TGF-βs) are secreted from cells as latent complexes and the activity of TGF-βs is controlled predominantly through activation of these complexes. Tolerance to the fetal allograft is essential for pregnancy success; TGF-β1 and TGF-β2 play important roles in regulating these processes. Pregnancy-specific β-glycoproteins (PSGs) are present in the maternal circulation at a high concentration throughout pregnancy and have been proposed to have anti-inflammatory functions. We found that recombinant and native PSG1 activate TGF-β1 and TGF-β2 in vitro. Consistent with these findings, administration of PSG1 protected mice from dextran sodium sulfate (DSS)-induced colitis, reduced the secretion of pro-inflammatory cytokines, and increased the number of T regulatory cells. The PSG1-mediated protection was greatly inhibited by the coadministration of neutralizing anti-TGF-β antibody. Our results indicate that proteins secreted by the placenta directly contribute to the generation of active TGF-β and identify PSG1 as one of the few known biological activators of TGF-β2.

Crohn's disease in women

This article provides an overview of the obstetric and gynecological manifestations of Crohn’s disease (CD). High incidence of the new onset of the disease in young women in their reproductive years demands special concern from physicians involved in their treatment. Pregnant women with CD are considered high-risk patients, regardless of disease activity index, due to associated complications. Predominately described complications are premature birth, low birth weight, and congenital anomalies. To minimize the risk for adverse pregnancy/birth outcomes, it is recommended that remission be achieved before conception. Treatment of CD in pregnant women is similar to that among the nonpregnant population, and there is no valid reason to terminate it, since most of the drugs are proven to be safe. Women with CD who wish to conceive or are already pregnant need to be properly advised according to the newest guidelines on the subject, given by the European Crohn’s and Colitis Organization. Gynecological manifestations are another special feature of CD. They are important in that they may facilitate early recognition of the underlying disease, which usually stays unrecognized for years before intestinal manifestation; in this way, the underlying manifestations are often mistreated.

Systematic review: fertility in non-surgically treated inflammatory bowel disease

BACKGROUND

Inflammatory bowel diseases (IBD) typically affect young patients during the reproductive years, and reproductive issues are of key concern to them.

AIM

To evaluate the impact of IBD on fertility in both women and men with IBD who had no history of surgical treatment for IBD.

METHODS

We searched MEDLINE, Cochrane Library, EMBASE and international conference abstracts and included all controlled observational studies that evaluated fertility in Crohn's disease (CD) and/or ulcerative colitis (UC) in women and/or men.

RESULTS

Eleven studies matching our criteria were included. In women with CD, there was a 17-44% reduction in fertility as compared with controls. Reduction in fertility was linked to voluntary childlessness, while there was no evidence of physiological causes of infertility. Most studies did not find any reduction in fertility in women with UC as compared with controls. In men with CD, there was an 18-50% reduction in fertility as compared with controls with no difference in reproductive capacity. There was no evidence of reduced fertility in men with UC.

CONCLUSIONS

The infertility observed in both women and men with CD is due to voluntary childlessness as opposed to involuntary infertility. This voluntary childlessness is often based on incorrect beliefs about the impact of the disease on fertility and pregnancy outcomes. Our results reinforce the need to increase awareness among male and female patients that IBD does not itself lead to reduced fertility.

Meta-analysis: the impact of disease activity at conception on disease activity during pregnancy in patients with inflammatory bowel disease

BACKGROUND

The rate of exacerbation of inflammatory bowel disease (IBD) during pregnancy varies in the published literature.

AIM

We sought to perform a systematic review and meta-analysis of the effects of disease activity at conception on disease course during pregnancy in women with IBD.

METHODS

Published studies and abstracts from standard sources were screened for appropriate studies. Data were pooled and analysed using funnel and forest plots. Quality assessment scores were given using GRADE criteria.

RESULTS

Fourteen studies were eligible for inclusion; ten studies contained patients with UC (N = 1130), and six studies contained patients with CD (N = 590). In patients with UC there was a significantly higher risk ratio of active disease during pregnancy in patients who commenced pregnancy with active disease (55%), when compared with those in remission at conception (36%) (RR 2.0, 95% CI: 1.5-3, P < 0.001). This risk was also higher in patients with CD (RR 2.0, 95% CI: 1.2-3.4, P = 0.006). Thirteen of the studies rated 'low' in all domains of a quality assessment, and there was significant statistical heterogeneity.

CONCLUSIONS

Patients with IBD who conceive when their disease is active are more likely to have active disease during pregnancy than those who conceive when in remission. All studies used in this analysis had a high risk of bias therefore further studies are required.

Lethal fetal stroke in utero

OBJECTIVE

Fetal intracranial hemorrhage (ICH) in utero is a rare complication of pregnancy associated with subsequent neurological sequelae or fetal death.

CASE REPORT

A 34-year-old woman with Crohn's disease presented at 36 weeks' gestation due to decreased fetal movement. Fetal heart-rate tracing indicated poor beat-to-beat variability. In addition, a Doppler ultrasonography suggested a prenatal stroke with evidences of ICH, reverse-end diastolic velocity of the middle cerebral artery, and a persistent distended bladder. A nonaggressive treatment option was chosen after counseling about the unfavorable prognosis. However, 22 hours after her admission, intrauterine fetal death occurred.

CONCLUSION

Fetal ICH in utero might be a rare yet lethal complication of Crohn's disease in pregnancy.

Therapeutic infliximab drug level in a child born to a woman with ulcerative colitis treated until gestation week 31

A 26 year old woman with ulcerative colitis was treated with regular infliximab (IFX) infusions until gestation week 31, and gave birth to a healthy child at gestation week 37. Maternal IFX trough level was relatively high during the course of pregnancy. In the infant, therapeutic level of IFX was detectable at week 16 after birth, but not at reassessment at week 28. Anti-IFX antibodies were consistently below the detection limit in the patient and in the child. This case illustrates that IFX is transferred through the placenta to the embryo, and may result in therapeutic drug levels in the newborn child despite IFX discontinuation in third trimester 6 weeks prior to delivery. The half life of IFX appeared markedly longer in infants as compared to adults. The safety of IFX beyond the first trimester is unknown, and this case highlights the need for further investigations of maternal transfer of IFX as well as the risks associated with IFX administrations in the second and third trimester.