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: Active Disease :
No increase in risk of A greater risk of
spontaneous abortion premature birth
still birth preterm birth
congenital abnormality 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 Limited data Contraindicated
Oral, topical mesalamine Olsalazine Methotrexate*
Sulfasalazine Azathioprine Thalidomide*
Steroids 6 MP Diphenoxylate*
TPN Cyclosporine*
Loperamide* Metronidazole*
Ciprofloxacin*
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
2. High cost of chronic illness
Money, physical and mental cost
Neglect of other children
Divorce!