IBD & PregnancyIBD & Pregnancy

Christian SelingerChristian Selinger

Consultant GastroenterologistConsultant Gastroenterologist

Talk outline

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

Who is affected by IBD?

Many men and women of childbearing age

Crohn’s disease Ulcerative coltis

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

• 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– 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– 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

Thank youThank you

Questions?Questions?