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Prentice R, Flanagan E, Wright E, Prideaux L, Connell W, Sparrow M, De Cruz P, Lust M, Hardikar W, Goldberg R, Vogrin S, Palmer K, Ross A, Burns M, Greeve T, Bell S. Thiopurine Metabolite Shunting in Late Pregnancy Increases the Risk of Intrahepatic Cholestasis of Pregnancy in Women With Inflammatory Bowel Disease, and Can be Managed With Split Dosing. J Crohns Colitis 2024; 18:1081-1090. [PMID: 38366352 DOI: 10.1093/ecco-jcc/jjae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/12/2023] [Accepted: 02/09/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND AND AIMS The risk of intrahepatic cholestasis of pregnancy [ICP] is increased in thiopurine-exposed pregnancies. Thiopurine 'shunting', with a 6-methylmercaptopurine [MMP] to 6-thioguanine [TGN] ratio of >11, progresses over pregnancy, and may promote ICP development. We aimed to explore the association between thiopurine exposure and ICP, including the hypothesised impact of thiopurine shunting, and identify risk minimisation strategies. METHODS This prospective multicentre cohort study compared thiopurine and biologic monotherapy-exposed pregnant participants. Disease activity and obstetric outcome data, thiopurine metabolites, bile acids, and transaminases were obtained before conception, in each trimester, at delivery, and postpartum. Thiopurine dose management was at the discretion of the treating physician. RESULTS Included were 131 thiopurine and 147 biologic monotherapy-exposed pregnancies. MMP/TGN ratio increased from preconception to third trimester [p <0.01], with approximately 25% of participants shunting in pregnancy. Second trimester split dosing led to a decrease in the median MMP/TGN ratio from 18 (interquartile range [IQR] 6-57) to 3 [IQR 2-3.5] at delivery [p = 0.04]. The risk of ICP was increased in thiopurine-exposed pregnancies (6.7% [7/105] vs 0% [0/112], p <0.001), with all ICP cases occurring in the setting of antenatal thiopurine shunting. Thiopurine dose increases (risk ratio [RR] 8.10, 95% confidence interval [CI] 1.88-34.85, p = 0.005) and shunting in third trimester [6.20, 1.21-30.73, p = 0.028] and at delivery [14.18, 1.62-123.9, p = 0.016] were associated with an increased risk of ICP. CONCLUSIONS Thiopurine exposure is associated with an increased risk of ICP, particularly following dose increases antenatally and with shunting in late pregnancy. The latter may be effectively managed with split dosing, although further studies are warranted.
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Affiliation(s)
- Ralley Prentice
- Monash Health, Gastroenterology Department, Melbourne, VIC, Australia
- St Vincent's Hospital Melbourne, Gastroenterology Department, Melbourne, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Emma Flanagan
- St Vincent's Hospital Melbourne, Gastroenterology Department, Melbourne, VIC, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Emily Wright
- St Vincent's Hospital Melbourne, Gastroenterology Department, Melbourne, VIC, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Lani Prideaux
- Monash Health, Gastroenterology Department, Melbourne, VIC, Australia
| | - William Connell
- St Vincent's Hospital Melbourne, Gastroenterology Department, Melbourne, VIC, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Miles Sparrow
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Alfred Health, Gastroenterology Department, Melbourne, VIC, Australia
| | - Peter De Cruz
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Austin Health, Gastroenterology Department, Melbourne, VIC, Australia
| | - Mark Lust
- St Vincent's Hospital Melbourne, Gastroenterology Department, Melbourne, VIC, Australia
| | - Winita Hardikar
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Royal Children's Hospital, Gastroenterology Department, Melbourne, VIC, Australia
| | - Rimma Goldberg
- Monash Health, Gastroenterology Department, Melbourne, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Sara Vogrin
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Kirsten Palmer
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Monash Health, Maternofoetal Medicine Department, Melbourne, VIC, Australia
- Monash Health, Obstetrics and Gynaecology Department, Melbourne, VIC, Australia
| | - Alyson Ross
- St Vincent's Hospital Melbourne, Gastroenterology Department, Melbourne, VIC, Australia
| | - Megan Burns
- Monash Health, Gastroenterology Department, Melbourne, VIC, Australia
| | - Tessa Greeve
- Monash Health, Gastroenterology Department, Melbourne, VIC, Australia
| | - Sally Bell
- Monash Health, Gastroenterology Department, Melbourne, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
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Boughton RS, Brophy C, Corbett G, Murphy S, Clifford J, Hanly A, Fitzpatrick M, O'Brien L. Haemorrhoids and Anal Fissures in Pregnancy: Predictive Factors and Effective Treatments. Cureus 2024; 16:e53773. [PMID: 38327723 PMCID: PMC10849161 DOI: 10.7759/cureus.53773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 02/09/2024] Open
Abstract
Introduction Haemorrhoids and anal fissures (HAF) are common in pregnancy and can severely affect the quality of life of those suffering from them. Despite the condition being common, there is limited evidence, formal guidelines or recommendations on treatment, and little is known about the natural course during pregnancy. Methods This was a prospective, observational cohort study conducted at a tertiary-referral university maternity hospital (The National Maternity Hospital, Dublin), conducted over a nine-month period. The first part of the study was a case-control study of antenatal patients over 34 weeks' gestation. The second part of the study involved a cohort of postnatal patients. Anonymous patient surveys were performed and analysed. Results Two hundred and fifty-eight patients were recruited into the study from the outpatient clinics and wards of one maternity hospital from April to December 2021. Of the antenatal patients, 82/184 (45%) of these patients had symptoms of HAF and 102/184 (55%) antenatal patients were unaffected, acting as controls. In addition, 74 affected postnatal patients were also included. In the affected antenatal group, 36/82 (44%) of patients had self-reported HAF (symptoms or signs of HAF); 50/82 (61%) of patients diagnosed with HAF on their own. 12/82 (15%) noticed symptoms in the first trimester, 25/82 (30%) in the second and 45/82 (55%) in the third. 142/184 (77%) of antenatal patients used conservative methods to manage their symptoms, including an increase in dietary fibre. 144/184 (78%) used medical treatments including suppositories. Only one patient had surgery. 70/156 (45%) of postnatal patients' symptoms resolved within days, 42/156 (27%) in weeks and 44/156 (28%) within months. Conclusion HAF affect almost half of the pregnancies. Age over 35 was significantly associated with antenatal haemorrhoids or anal fissures. Concerningly, the majority of patients (64%) self-diagnose and manage the condition without either seeking or receiving guidance from medical professionals. In terms of the natural course of the disease, it was encouraging that 45% of patients' symptoms resolved within a few days. This will help when counselling patients with distressing symptoms. Conservative measures such as increased dietary fibre, increased fluid intake and bath salts were effective in relieving symptoms for the majority of patients.
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Affiliation(s)
- Rebecca S Boughton
- Obstetrics and Gynaecology, The National Maternity Hospital, Dublin, IRL
| | - Caroline Brophy
- Obstetrics and Gynaecology, The National Maternity Hospital, Dublin, IRL
| | - Gillian Corbett
- Obstetrics and Gynaecology, The National Maternity Hospital, Dublin, IRL
| | - Sophie Murphy
- Obstetrics and Gynaecology, The National Maternity Hospital, Dublin, IRL
| | - Jacqui Clifford
- Obstetrics and Gynaecology, The National Maternity Hospital, Dublin, IRL
| | - Ann Hanly
- Obstetrics and Gynaecology, The National Maternity Hospital, Dublin, IRL
| | - Myra Fitzpatrick
- Obstetrics and Gynaecology, The National Maternity Hospital, Dublin, IRL
| | - Laoise O'Brien
- Obstetrics and Gynaecology, The National Maternity Hospital, Dublin, IRL
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