Ulcerative colitis in pregnancy and lactation

Points of note about ulcerative colitis for pregnancy and lactation:

• male and female fertility is usually normal in ulcerative colitis. Note though in 80% of men, sulphasalazine does induce sperm abnormalities which may induce a temporary reversible state of infertility (1,2,3).
• women with UC are able to conceive as long as there is not severe disease at the time of conception
• pregnancy has a variable effect on the patient's UC:
  • 1/3 - clinical improvement
  • 1/3 - clinical worsening
  • 1/3 - flare-up in the postpartum period
• standard treatments - steroids and aminosalicylates - have not been associated with human birth defects or complications during parturition
• in some women immunosuppressives have been continued throughout pregnancy without apparent teratogenicity

A meta-analysis revealed a higher incidence of adverse pregnancy outcomes in patients with inflammatory bowel disease (4).

There has been FSRH guidance regarding Inflammatory bowel disease (IBD) and Pregnancy (5)

• women with IBD should be advised to plan to conceive when the disease is well controlled
  
  
• appropriate referral for pre-pregnancy counselling should be available for men and women in order to optimise their IBD management prior to conception
  
  
• there is controversy regarding the most appropriate mode of delivery (caesarean section or vaginal) following ileal pouch-anal anastomosis surgery. Women should be guided in their decision by the advice of the obstetric and gastrointestinal specialists in charge of their care
  
  
• if either partner is taking methotrexate, pregnancy should be prevented by use of effective contraception during and for at least 3 months after treatment
  
  
• if either partner is taking mycophenolate mofetil, pregnancy should be prevented by use of effective contraception during and for at least 6 weeks (women) or 3 months (men) after treatment has ended
  
  
• the British National Formulary advises that pregnancy should be prevented by use of effective contraception for women treated with tumour necrosis factor alpha (TNF-alpha) inhibitors (e.g. infliximab, adalimumab) and for 6 months after treatment has ended. Consideration for use during pregnancy requires specialist advice
  
  
• health professionals should check current National Institute for Health and Care Excellence, British Society for Gastroenterology, and European Crohn's and Colitis Organisation guidelines and the Summary of Product Characteristics for each medication for specific advice on use while trying to conceive and while pregnant or breastfeeding. The decision to discontinue any treatment requires expert clinical judgement, balancing the risks of stopping the drug against the risks associated with continuing
  
  
• health professionals should consider ectopic pregnancy in their differential diagnosis of abdominal pain and gastrointestinal symptoms in sexually active women with IBD
  
  

Reference:

• (1) Birnie, G.G. et al. Incidence of sulphasalazine induced infertility. Gut 1982; 22: 452-55.
• (2) Cann, P.A. et al.. Reversal of male infertility on changing treatment from sulfasalazine to 5-aminosalicylic acid. Lancet 1984; 1: 1119.
• (3) Alstead, E.M. et al. Safety of azathioprine in pregnancy in inflammatory bowel disease. Gastroenterology 1990; 443-6.
• (4) Cornish J et al. A meta-analysis on the influence of inflammatory bowel disease on pregnancy.Gut. 2007 Jun;56(6):830-7
• (5) FSRH (2016).Sexual and Reproductive Health for Individuals with Inflammatory Bowel Disease