Pregnancy and Pregnancy and Pregnancy Outcomes Pregnancy Outcomes

in Women With IBDin Women With IBD

Effects of IBD on Effects of IBD on Pregnancy OutcomesPregnancy Outcomes

Preterm birth Preterm birth risk in both UC and CDrisk in both UC and CD1,2,51,2,5

4 of 5 studies: no major impact on risk of congenital 4 of 5 studies: no major impact on risk of congenital abnormalitiesabnormalities1-51-5

Significant Significant in risk of low birth weight in risk of low birth weight2-52-5

risk of maternal/delivery complicationsrisk of maternal/delivery complications55

11Baird DD, et al. Baird DD, et al. Gastroenterology.Gastroenterology. 1990;99:987-994. 1990;99:987-994. 22Dominitz JA, et al. Dominitz JA, et al. Am J Gastroenterol.Am J Gastroenterol. 2002;97:641- 2002;97:641-648. 648. 33Porter RJ, Stirrat GM. Porter RJ, Stirrat GM. Br J Obstet Gynaecol.Br J Obstet Gynaecol. 1986;93:1124-1131. 1986;93:1124-1131. 44Fonager K, et al. Fonager K, et al. Am J Gastroenterol.Am J Gastroenterol. 1998;93:2426-2430.1998;93:2426-2430.44Mahadevan U, et al. Gastroenterol. 2007;133:1106-1112

Meta-analysisMeta-analysis

12 studies12 studies– N= 3907 (CD 1952, UC 1113) vs. 320, 531N= 3907 (CD 1952, UC 1113) vs. 320, 531

Prematurity OR = 1.87 (1.52-2.31) Prematurity OR = 1.87 (1.52-2.31) p<0.001p<0.001

LBW OR = 2.10 (1.38-3.19) , LBW OR = 2.10 (1.38-3.19) , p<0.001p<0.001

C-section OR = 1.50 (1.26-1.79) C-section OR = 1.50 (1.26-1.79) p <0.001p <0.001

Congen Abnorm. = 2.37 (1.47-3.82) Congen Abnorm. = 2.37 (1.47-3.82) p <0.001p <0.001– 4 studies reported on the incidence IBD vs. controls, no 4 studies reported on the incidence IBD vs. controls, no

differencedifference– UC vs. controls in two studies (Larzilliere 1998, Dominitz)UC vs. controls in two studies (Larzilliere 1998, Dominitz)

Cornish Gut 2006;0:1-8. Cornish Gut 2006;0:1-8.

Effect of Pregnancy on UC: Effect of Pregnancy on UC: Disease Activity at ConceptionDisease Activity at Conception

Miller JP. Miller JP. J R Soc Med.J R Soc Med. 1986;79:221-225. 1986;79:221-225.

InactiveInactive ActiveActive

NoNoRelapseRelapse

RelapseRelapse WorsenedWorsenedActivityActivity

ContinuedContinuedActivityActivity

DecreasedDecreasedActivityActivity

00

n=528n=528 n=227n=2276666

3434

4545

2424 2727

8080

7070

6060

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Effect of Pregnancy on CD: Effect of Pregnancy on CD: Disease Activity at ConceptionDisease Activity at Conception

Miller JP. Miller JP. J R Soc Med.J R Soc Med. 1986;79:221-225. 1986;79:221-225.

InactiveInactive ActiveActive

NoNoRelapseRelapse

RelapseRelapse WorsenedWorsenedActivityActivity

ContinuedContinuedActivityActivity

DecreasedDecreasedActivityActivity

00

n=186n=186 n=93n=937373

27273333 3434

8080

7070

6060

5050

4040

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Perc

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Disease activity during pregnancy in women Disease activity during pregnancy in women with IBDwith IBD

Majority of patients have inactive to mild disease during Majority of patients have inactive to mild disease during pregnancypregnancy

Mahadevan U, et al.Mahadevan U, et al. Gastroenterol. Gastroenterol. 2007;133:1106-1112 2007;133:1106-1112

020406080

100

020406080

100

Concept T1 T2 T3 PP

Inactive

Mild

Moderate

Severe

Trimester

Per

cen

tag

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atie

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Disease activity in Crohn’s disease

Disease activity in ulcerative colitis

Effect of Pregnancy on IBD: Effect of Pregnancy on IBD: Maternal-Fetal HLA DisparityMaternal-Fetal HLA Disparity

Prepartum disease activity significantly predicts Prepartum disease activity significantly predicts disease activity during pregnancy (disease activity during pregnancy (PP=.008)=.008)

In single-locus disparity, no significant difference In single-locus disparity, no significant difference between DR and DQ prepartum, during trimesters 1-3, between DR and DQ prepartum, during trimesters 1-3, or postpartumor postpartum

Disparity at both DR and DQ loci significantly predicts Disparity at both DR and DQ loci significantly predicts disease activity during pregnancy (disease activity during pregnancy (PP=.001)=.001)

Maternal immune response to paternal HLA antigens Maternal immune response to paternal HLA antigens may play role in pregnancy-induced remission of IBDmay play role in pregnancy-induced remission of IBD

Kane S, et al. Kane S, et al. Gastroenterology.Gastroenterology. 1998;114:A1006. Abstract G4121. 1998;114:A1006. Abstract G4121.

Concerns Regarding Concerns Regarding Pregnancy and DeliveryPregnancy and Delivery

What is the effect of pregnancy on pouch What is the effect of pregnancy on pouch function before and after delivery?function before and after delivery?

Should the woman deliver vaginally or have Should the woman deliver vaginally or have cesarean section?cesarean section?

Are there unique concerns if cesarean section Are there unique concerns if cesarean section is performed?is performed?

Delivery Mode and Delivery Mode and Perineal InjuryPerineal Injury

Study indicates that more women with IBD have Study indicates that more women with IBD have cesarean sectionscesarean sections11

Vaginal delivery is usually safe for women with inactive Vaginal delivery is usually safe for women with inactive perianal symptomsperianal symptoms11

11Ilnyckyji A, et al. Ilnyckyji A, et al. Am J Gastroenterol.Am J Gastroenterol. 1999;94:3274-3278. 1999;94:3274-3278.

Pouch Function During and After Pouch Function During and After PregnancyPregnancy

10 vaginal deliveries, 6 cesarean sections10 vaginal deliveries, 6 cesarean sections– No pouch complicationsNo pouch complications

8.1 bowel movements/day during pregnancy 8.1 bowel movements/day during pregnancy vs 6.5/day postpartumvs 6.5/day postpartum

3 women had incontinence during pregnancy, 3 women had incontinence during pregnancy, 1 frequent and 2 mild1 frequent and 2 mild

1 woman had nighttime incontinence1 woman had nighttime incontinencepostpartumpostpartum

Scott HJ, et al. Scott HJ, et al. Int J Colorectal Dis.Int J Colorectal Dis. 1996;11:84-87. 1996;11:84-87.

Pregnancy, Delivery, Pregnancy, Delivery, and Pouch Function and Pouch Function

After IPAA in UCAfter IPAA in UC Questionnaires sent to women with IPAA for UCQuestionnaires sent to women with IPAA for UC

ResultsResults

– 49 deliveries for 29 women (25 vaginal, 24 c-sections)49 deliveries for 29 women (25 vaginal, 24 c-sections)

– 6 pouch-related complications (2 during pregnancy; 6 pouch-related complications (2 during pregnancy; 4 postpartum)4 postpartum)

stool frequency and incontinence during pregnancystool frequency and incontinence during pregnancy

– 83% regained prepregnancy function; 17% had some 83% regained prepregnancy function; 17% had some permanent pouch function deterioration not related to permanent pouch function deterioration not related to delivery methoddelivery method

– Delivery method did not affect incontinence, Delivery method did not affect incontinence, stool frequencystool frequency

Conclusion: Pregnancy is safe for women with IPAAConclusion: Pregnancy is safe for women with IPAA

Ravid A, et al. Ravid A, et al. Dis Colon Rectum.Dis Colon Rectum. 2002;45:1283-1288. 2002;45:1283-1288.

IBD in Pregnancy: IBD in Pregnancy: SummarySummary

Pregnancy outcomes best if patient in remission at time of Pregnancy outcomes best if patient in remission at time of conception, though even patients in remission can have conception, though even patients in remission can have higher rates of adverse outcomes compared to the general higher rates of adverse outcomes compared to the general populationpopulation

IBD increases the risk of preterm birth and low birth weight IBD increases the risk of preterm birth and low birth weight and maternal complicationsand maternal complications

No significant increase in risk of congenital abnormalitiesNo significant increase in risk of congenital abnormalities

Women with IBD have a higher rate of cesarean sectionsWomen with IBD have a higher rate of cesarean sections

Pregnancy may not increase the risk of relapse or Pregnancy may not increase the risk of relapse or significantly increase disease activitsignificantly increase disease activit