IBD & Pregnancy
Christian Selinger
Consultant Gastroenterologist
Talk outline
Talk outline
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Can I have children?
Can I pass on IBD to my child?
Fertility issues
How to plan for pregnancy
– When to conceive
– Medication before and during
– Who to speak to
• Breast feeding
Who is affected by IBD?
Crohn’s disease
Ulcerative coltis
Many men and women of childbearing age
Can I have children?
• YES
• Why talk about it then?
– Not everyone knows this
• Patients
• Doctors
• Friends & relatives
– It should involve careful planning
Can I pass IBD on to my
child?
• Developing IBD is complex
– Family history / Inherited part / Genes
– Environmental effects
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Smoking
“Dirt exposure”
Antibiotics in childhood
Many unknown as yet
Who gave birth after being
diagnosed with IBD?
Can I pass IBD on to my
child?
• Chance of passing on IBD
– If one parent affected: 4-10%
– If both parents affected: 30%
• Very good chance child will not get IBD
• Whether you child will get IBD depends on
many other factors
Fertility
• In men
– Normal
– Sulphasalazine can temporarily disturb it
• In women
– Generally good
– Better chance of falling pregnant
• When well
• Good disease control
Fertility
• Vast majority should experience little
problems (other than the general public)
• Problem areas
– Crohn’s disease with complex inflammation in
pelvis / “deep” pelvic surgery
– Pouch surgery
• IVF works in these cases
Anyone experienced fertility
problems?
Fertility
• Unable to have children
– “involuntary infertility”
– Overall not more common than general public
• Decided not to have children
– “voluntary infertility”
– Much more common in IBD
– 18% versus 6% in general public
Decided not to have children
• Why?
– Might not be aware that they can
• Poor knowledge
• Anxiety about pregnancy, inheritance
– Bad advice
• “Google”…
• Friends
• Some doctors not well informed
• We need to get the message out
When to have a baby?
• When well / in remission
– Better chance of falling pregnant
– Better chance of good course of pregnancy
• In some cases this might mean
– Increased medication
– Decisions around surgery
• If
• What operation
• when
Medication and Pregnancy
• Worth talking about
• Active disease (ongoing symptoms)
– Less chance of conceiving
– Worse outcomes for the baby
• Premature birth
• Small baby
• Loss of pregnancy
– Hence need to keep disease under control
Medication and Pregnancy
Who would you want to be?
Who stopped medication?
Who continued?
Medication and Pregnancy
• Generally benefits outweigh risks
– Being well more important
• For baby and mum
– Risk to baby small
• All IBD drugs can be used
– Except Methotrexate
– Very poisonous (men and women)
Medication and Pregnancy
• Mesalazine
– Asacol, Mesren, Mezavant, Octasa, Pentasa,
Salofalk
– All extremely safe
• Thiopurines
– Azathioprine, 6-Mercaptopurine
– Safe in IBD
– Better than steroids
Medication and Pregnancy
• Biologics
– Infliximab (Remicade), Adalimumab (Humira)
– Safe when needed
– Generally used in severe disease
• Can I stop my medicines before falling
pregnant?
– For most better not
– If been well a long time
• see specialist: ? well off drug
Medication and Pregnancy
• Your IBD nurse and Gastroenterologist
• GP, midwife, obstetrician
– Often little knowledge of IBD drugs
– Very specialist area
• BNF (drug bible), internet, pharmacist
– Don’t bother
– Officially all meds not licensed for pregnancy
and carry warnings
Worst case scenario
• 26 year old woman
– Ulcerative colitis for 5 years
– Usually on Asacol and well
• Falls pregnant unexpectedly
• Sees GP -> advised to stop meds
• Comes to clinic 10 weeks
Worst case scenario
• Symptoms
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Diarrhoea 15* day, heavy bleeding
Dehydrated
Tired
Anaemia
• Problems
– Needs steroids for 8 weeks and higher doses of
Asacol
– Risk to pregnancy
Our advice
• Ideally plan pregnancy with us
• When questions over medications or
symptoms (not only during pregnancy)
contact
– IBD nurse
– Your specialist
• Don’t stop / change meds without
speaking to us
Pregnancy course / outcomes
• Chance of flare
– Same during pregnancy
– Some women get much better
– Very few get significantly worse
• Babies
– Can be on the smaller side
– Sometimes premature but few weeks only
Giving birth
• Vaginal delivery for most
– Episiotomy safe unless (see below)
• Caesarean section preferred for
– Woman with active peri-anal Crohn’s disease
• Fistula, seton, abscess
• Well healed: can consider vaginal delivery
– Woman after pouch surgery
– Too avoid tears, incontinence, worse fistulae
• Plan ahead
Breast feeding
Breast feeding
• Best possible nutrition for baby
• May protect the child from developing IBD
• All drugs (except Methotrexate) are
considered safe for breast feeding
• However greater choice here
– Bottle feeding and staying on drug
• Discuss with IBD nurse / specialist
Our aim
The Leeds plans
• Combined IBD clinics with obstetrician
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Starts January 2014
For women during pregnancy
Also for women planning pregnancy
Aim: Joint up care throughout trying, pregnancy and
breast feeding
• Personalised information for all women (?how)
– Soon after diagnosis
– Well before planning pregnancy
Questions?
Thank you