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IBD
no contraindication to having children
By Diana Swift
Seattle, WA—
When a pregnant Crohn’s patient asks what chance her child
has of developing the disease, Dr. Daniel Present answers, “nine
per cent,” based on data collected by Yang and colleagues (Gut
1993;34:517-24).
“I reassure her that she would need to have 12 kids before
she was guaranteed one with Crohn’s,” said Dr. Present,
Clinical
Professor of Medicine, Division of Gastroenterology, Mount Sinai
School of Medicine, New York, N.Y.
“One parent with IBD is not a contraindication to having children.
If both parents have IBD, the risk jumps to 40 to 50 per cent, and
there is usually a concordance for the type of disease when it does
develop in a child,” he said.
Studies indicate a tendency to subfertility in women with CD. Male
fertility appears unaffected except for some abnormal sperm forms
in men on sulfasalazine. These can return to normal after six to
eight weeks if patients are taken off this drug.
“Only one study in the literature found fewer children born
to male IBD patients versus age-matched controls, and that may have
been voluntary because sick patients may have been unwilling to
have children,” Dr. Present said. (Burnell et al, Postgraduate
Med J 1986;62:269-72). One analysis of men being treated with azathioprine
found no reduction in semen quality according to World Health Organization
standards, or in male fertility (Dejoco et al, Gastroenterology
2001;121:1048). “In fact, a lot of children were fathered during
the study, so the conclusion was that azathioprine does not affect
male fertility,” he said. In female fertility, most studies
suggest that 90 per cent of women on AZA are fertile-the same proportion
as in the general population.
“But again, people raise the issue of whether women with CD
are afraid to have children.” The female subfertility observed
in CD studies might relate to lack of sexual desire, active disease,
occlusion of the fallopian tubes, perineal fistula, or a physician’s
recommendation not to attempt conception while disease is active.
“We should indeed advise patients not to get pregnant during
active disease.”
One study by Mayberry and colleagues noted a significant reduction
in children among females with CD versus age-matched controls (Gut
1986;27:821-25). It concluded that although it appears to be more
difficult to become pregnant if one has CD, the babies born to women
with this condition are for the most part healthy. A series by Porter
noted that neither CD nor UC affected pregnancy outcomes or increased
the number of congenital abnormalities (Br J Ob Gyn 1986;93:1124-31)
Nor is obstetrical management impacted by IBD, although a few more
premature births and low birth weights have been reported. One study
showed an increased use of C-section in the UC and CD population.
“It may be that these patients are considered high risk and
the physician wants a controlled versus a natural situation,”
Dr. Present said.
Even in the general maternity population perineal rupture occurs
in about five per cent of vaginal deliveries, and subsequent anal
incontinence can occur in four per cent. “About 18 per cent
of women with no prior problem will develop perineal problems later—usually
after episiotomy,” he said. “And in woman with IBD and
severe diarrhea, the last thing you want is a rupture.”
Consequently, he usually makes a recommendation about C-section
based on the size of the baby and mother and the anticipated difficulty
of a vaginal delivery.
While fertility is reduced in CD, in UC it is normal, and in both
conditions the rates of spontaneous abortion and still births are
similar to those in the general maternal population. “Once
the pregnancy is established, obstetrical management is the same
except for the issue of perineal disease,” he said.
Pregnancy and IBD
A study by Miller of 500 patients found an IBD relapse rate in pregnancy
of 25 to 30 per cent, the same as in non-pregnant IBD patients (J
R Soc Med 1986;79:221-25). “But in 45 per cent of women who
became pregnant while their disease was active, their condition
worsened and an additional 26 per cent continued to have difficulty,”
Dr. Patient said. “So 70 per cent will have problems, and the
best advice is to tell a patient not to get pregnant while the disease
is flaring up. Get it under control first.” Fulminant disease
is associated with a fetal mortality rate of 50 per cent.
In both UC and CD, two out of three women will continue to be active
or worsen if they became pregnant during active disease.
“And if CD presents during a pregnancy for the first time,
usually the prognosis is poor because we have difficulty diagnosing
it during pregnancy,” he said. Assessment is impeded because
standard tests such as sed rate, hemoglobin and albumin are skewed.
Sonar evaluation, however, is safe for the fetus and one or two
abdominal films pose little risk, Also, a flexible sigmoidoscopy
can be safely done up to 40 or 50 cm.
Pregnant patients must be strongly encouraged to stop smoking because
this not only reduces fetal growth but also activates CD. On the
other hand, smoking cessation may activate UC. “My strategy
with smokers is to maximize therapy before they conceive- whether
they are on 5-ASAs, 6 MP or AZA,” he said.
Surgery
The indications for surgery are the same as for the nonpregnant
IBD patient, Dr. Present said, but surgery can affect future fertility.
Although patients with an ileal pouch/anal anastomosis sometimes
have trouble getting pregnant, they tend to do well when they do
conceive. Bowel movements can increase somewhat and some pouches
may become dysfunctional.
“Remember that working in the pelvis can markedly reduce fertility-by
20 per cent,” he said. “So if a patient wants children
and has active colitis, we recommend an initial subtotal colectomy,
a standard ileostomy, and then after she’s had her family,
she can have an ileoanal anastomosis.”
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