IBD & Pregnancy

1. IBD & Pregnancy Christian Selinger Consultant Gastroenterologist

2. Talk outline

3. Talk outline • 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

4. Who is affected by IBD? Crohn’s disease Ulcerative coltis Many men and women of childbearing age

5. Can I have children? • YES • Why talk about it then? • Not everyone knows this • Patients • Doctors • Friends & relatives • It should involve careful planning

6. Can I pass IBD on to my child? • Developing IBD is complex • Family history / Inherited part / Genes • Environmental effects • Smoking • “Dirt exposure” • Antibiotics in childhood • Many unknown as yet

7. Who gave birth after being diagnosed with IBD?

8. 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

9. Fertility • In men • Normal • Sulphasalazine can temporarily disturb it • In women • Generally good • Better chance of falling pregnant • When well • Good disease control

10. 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

11. Anyone experienced fertility problems?

12. 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

13. 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

14. 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

15. 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

16. Medication and Pregnancy Who would you want to be?

17. Who stopped medication?Who continued?

18. 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)

19. Medication and Pregnancy • Mesalazine • Asacol, Mesren, Mezavant, Octasa, Pentasa, Salofalk • All extremely safe • Thiopurines • Azathioprine, 6-Mercaptopurine • Safe in IBD • Better than steroids

20. 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

21. 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

22. 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

23. Worst case scenario • Symptoms • Diarrhoea 15* day, heavy bleeding • Dehydrated • Tired • Anaemia • Problems • Needs steroids for 8 weeks and higher doses of Asacol • Risk to pregnancy

24. 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

25. 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

26. 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

27. Breast feeding

28. 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

29. Our aim

30. The Leeds plans • Combined IBD clinics with obstetrician • 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

31. Thank you Questions?