Inheritance

1
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
2
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
3
Ulcerative colitis and pregnancy
Effect of ulcerative colitis on pregnancy

• Inactive Disease
• No increase in risk of
• spontaneous abortion
• still birth
• congenital abnormality

• Active Disease
• A greater risk of
• premature birth
• preterm birth
• small gestational size

Presence of disease does not increase
complications like eclampsia, hypertension Signifi
cant 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 Crohns disease than in Ulcerative
Colitis Kane et al ,GCNA 2003
4
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
5
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
6
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 M
etronidazole Ciprofloxacin Infliximab
avoid these during breastfeeding
7
Ulcerative colitis and pregnancy

• Drug treatment
• The Norgard Study (N148 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
8
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
9
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

10
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 Diffic
ulty in diagnosis Colonoscopy difficult in 1
year Equipment issues Children refuse to
drink barium!!
11
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
12
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!!
13
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
14
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!