Ulcerative colitis and pregnancy

Ulcerative colitis and pregnancy Inheritance Not a genetic disorder in a true Mendelian fashion If one affected parent – risk is 1.6% If both parents have the disease – risk is 37% Risk is higher in Jewish than non Jewish families Am J Gastroenterol 1999 Ulcerative colitis and pregnancy Fertility Females Fertility is same as that of general population if voluntary childlessness because of fear is taken into account None of the medications routinely used to treat ulcerative colitis adversely affect female fertility Fertility may be reduced after surgery Males Reproductive capacity of men with IBD is not markedly diminished Sulphasalzine therapy reduces sperm motility and count Effects are dose related and reversible after stopping therapy 5-ASA and AZT are safe Narendranthan , J Clin Gastro 1989, Alstead,Gastro 1990 Ulcerative colitis and pregnancy Effect of ulcerative colitis on pregnancy Inactive Disease: No increase in risk of spontaneous abortion still birth congenital abnormality Active Disease : A greater risk of premature birth preterm birth small gestational size Presence of disease does not increase complications like eclampsia, hypertension Significant favorable factor : quiescent disease before planned conception Recommended quiescent interval is three months Discussion between patient and physician promotes a successful pregnancy outcome If active disease is present it is likely to continue through pregnancy and will increase the risk of a pregnancy complication Risks higher in Crohn’s disease than in Ulcerative Colitis Kane et al ,GCNA 2003 Ulcerative colitis and pregnancy Effect of pregnancy on ulcerative colitis • • • • • • • • Inactive disease at conception: rate of relapse is same as in non pregnant patients Active disease at conception: 70% have continued or worsening disease during pregnancy Occasionally, pregnancy induces an improvement in disease activity Course of previous pregnancy does not predict outcome in subsequent pregnancy Psychologic factors may affect disease course : In unwanted pregnancies : 38% had increased disease activity In planned pregnancies : 12% had disease activity Ulerative colitis does not significantly affect the method of delivery, and is not an indication for cesarian section Miller JP JR Soc Med 1986, Mogaddam, AJG 1981, Levy Dis Colon Rectum 1981 Ulcerative colitis and pregnancy Management of ulcerative colitis during pregnancy Principles Establish and maintain remission before conception Active disease rather than therapy poses the greatest risk to pregnancy Key Issues Outcome of pregnancy when the mother is on drug therapy Medication safety Pitfalls in assessing disease activity Disease assessment during pregnancy relies more on clinical symptoms than on lab parameters as there may be physiological changes in Hb,ESR Sigmoidoscopy induces premature labour : No evidence Sachar D, Gut 1998 Ulcerative colitis and pregnancy Medication safety during pregnancy Safe to use Oral, topical mesalamine Sulfasalazine Steroids TPN Loperamide* Limited data Olsalazine Azathioprine 6 MP Cyclosporine* Metronidazole* Ciprofloxacin* Contraindicated Methotrexate* Thalidomide* Diphenoxylate* Infliximab *avoid these during breastfeeding Ulcerative colitis and pregnancy Drug treatment The Norgard Study (N=148 pregnancies): No significant increase in risk of congenital abnormalities, conception failures, abortions, neoplasms with 5ASA, sulphasalazine, 6 MP Confirms an association between the use of steroids and stillbirth Infliximab in CD and rheumatoid arthritis : No increase in adverse events Female and male patients starting methotrexate must use contraception and should avoid conceiving for 6 months after stopping the drug 155/458 patients who had conceived at least one pregnancy after developing IBD Comparison of pregnancy outcomes in IBD patients on 6 MP and those not on 6 MP Discontinuation of the drug before and during pregnancy is not indicated Gut 2003, Gastroenterology 2001, Francella A, Gastroenterol 2003 Ulcerative colitis and pregnancy Surgery for ulcerative colitis in pregnancy Indications for surgery are identical to those in non pregnant patients In the ill pregnant patient , continued maternal illness poses a greater risk to the foetus than the surgical intervention A temporary ileostomy is preferred Female fertility significantly decreases after Ileal pouch – anal anastomosis ( IPAA) Subhani JM, Alimen Pharmacol Ther 1998, Wolf JL, Gastroenterology 2002 Ulcerative colitis and pregnancy Summary Fertility is not affected in ulcerative colitis. May be reduced after surgery. Adverse fetal outcomes are not increased when ulcerative colitis is quiescent Active disease at conception increases the risk of adverse foetal outcomes Open discussions between the patient and the physician promote a successful pregnancy outcome Most medications for Ulcerative colitis are safe during pregnancy and breast feeding Active disease is usually more deleterious than maintaining medical therapy Endoscopy is safe. Medication is component of risk Ulcerative colitis does not alter mode of delivery Indications for surgery remain the same Ulcerative colitis in children Diagnosis Delay in diagnosis Under-recognized condition Especially in under 5 Incidence low but not zero Proctitis – constipation with bleeding Referral system non-existent Difficulty in diagnosis Colonoscopy difficult in 1 year Equipment issues Children refuse to drink barium!! Ulcerative colitis in children Disease in children 1. Genetic anticipation 2. EIM may be the main problem for years Liver transplant for PSC Arthritis/perianal abscess 3. Change in disease pattern Proctitis to left sided or pan-colitis 4. Increased risk of malignancy Ulcerative colitis in children Growth and development in children 1. Growth and development: malnutrition, zinc deficiency, rickets, osteoporosis Short Stature Disease itself/nutrition/medication Delayed puberty 2. School days lost Disease activity Running to bathroom- ridiculed, Cushingoid Infectivity to others – all chronic disease is HIV!! Ulcerative colitis in children Treatment of ulcerative colitis in children 1. Medications – Same as in adults Liquid preparations, granules 2. Steroids - growth failure/immunosuppression 6 MP - infections/malignancy 5 ASA – 3-5% pancreatitis rate 3. Effects of long term use of newer agents? 4. When to stop therapy/surgery in chronic disease 5. Nutrition Ulcerative colitis in children Quality of life • Poor quality of life Multiple hospitalizations and surgeries Colectomy and ileostomy Psychological problems including depression Fish oils High cost of chronic illness Money, physical and mental cost Neglect of other children Divorce! 2.