1. IBD & Pregnancy Christian Selinger Consultant Gastroenterologist

2. Talk outline

3. 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? Many men and women of childbearing age Crohn’s diseaseUlcerative coltis

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. 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?