In general, therapy of intestinal stenosis, abscess or ileus in pregnancy is based on the same principles as in nonpregnant IBD patients and operation is indicated in most patients. Patients with a strong indication for abdominal surgery, like intraperitoneal sepsis, should undergo operation urgently, as severe illness seems be the greater risk for mother and foetus. This approach has been adopted from data on acute appendicitis. The mode of delivery should generally be chosen according to obstetric recommendations. However, in some situations in IBD Caesarean section should be considered.
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After restorative proctocolectomy with IPAA, patients are highly dependent on intact anal sphincter, consequently Caesarean section is advised, as the risk of sphincter injury seems to be increased after vaginal delivery. In summary, there are few gastroenterological indications for Caesarean section, but decision about delivery mode should be taken by obstetrician, gastroenterologist and colorectal surgeon together.
In IBD patients, threshold for Caesarean section should be set to a low level in cases of obstetric concerns. However, performing Caesarean section only on patient's wish in absence of medical indication has to been seen critical, as birth by Caesarean section is associated with moderately higher rates of IBD onset in childhood. Breastfeeding is generally considered to be the ideal form of nutrition with positive effects on various aspects of health of mother and child. Indeed, the proportion of breastfeeding mothers among IBD patients is smaller than in the general population.
While most of the drugs used in the therapy of IBD can be detected in breast milk, standard medications are safe for the use during breastfeeding. Generally, the health status of the nursing infant should be attended carefully even if the maternal medication was considered to be safe. The concentrations of mesalazine and sulfasalazine in breast milk of patients receiving therapeutic doses of this medication are low and the use is generally considered safe during breastfeeding, - although anecdotal reports described bloody diarrhoea in infants induced by mesalazine via breast milk.
Prednisolone and prednisone levels in breast milk depend directly from the serum concentrations.
Data on budesonide in breastfeeding women only exist for inhaled budesonide in asthmatic mothers, negligible systemic exposure to budesonide was reported for breastfed children. Studies dealing with orally taken budesonide in breastfeeding are missing. Thus, systemic plasma levels in mothers as well as systemic exposure to breastfed infants are assumed very low. Since the concentration of thiopurines and their metabolites are very low in human breast milk and in the serum of breastfed infants, the use of these medications in standard doses is not contraindicated during breastfeeding.
While most studies could not find any detrimental effect of the maternal use of thiopurines during breastfeeding, genetical changes impairing the metabolism of thiopurines e. TPMT genotypes may pose a potential risk for adverse effects.
Methotrexate is a folate antagonist, has teratogenic effects, and is excreted into human breast milk. In contrast to earlier studies, recent analyses could detect infliximab in the human breast milk in very low concentrations. One case report could not find ADA in the serum of the infant while the mother received scheduled therapy. None of the infants in the available studies exhibited signs of adverse reactions to the maternal medication. Although no adverse effects have been observed in small case series, the biological effects of these agents in the neonate remain unclear.
Ciclosporin and tacrolimus can be detected in breast milk of nursing mothers receiving standard doses of this medication.
Text / Travis Diehl
Ciclosporin levels are varying considerably. Case reports from renal and liver transplantation programs indicate that the medication levels in the breast milk and the absorption by the neonate are very low. The authors concluded that both medications could be compatible with breastfeeding. Ciprofloxacin and metronidazole are not generally incompatible with breastfeeding. The development of a pseudomembranous colitis after maternal ciprofloxacin use has been described.
The indication for a systemic therapy with both agents has to be critically evaluated. Probiotics e. Furthermore, specific probiotics have been shown to be effective in reducing the risk of eczema in breastfed children. Metoclopramide has been used as galactogogue, because it increases maternal prolactin levels. The bioavailability after oral ingestion of loperamide is very low but in can be detected in breast milk in low concentration.
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Nevertheless, the use of loperamide over a short period of time during lactation seems to be safe. Simethicone is not absorbable and often used in neonates to treat abdominal discomfort. The use of simethicone during breastfeeding is safe. All bile acid sequestrants cholestyramine, colestipol, colesevelam may impair the absorption of medications and vitamins. As they are generally not absorbed from the gastrointestinal tract, the use during lactation appears safe under medical observation.
Safety data from controlled studies are missing. In contrast to UC, active CD is reported to have a negative influence on fertility rates.
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Female IBD patients wishing to become pregnant should be advised to plan pregnancy in a phase of stable remission, if possible. The ultrasound examination of the abdomen is the diagnostic method of choice in pregnant women.
Gastroscopy, sigmoidoscopy and colonoscopy with propofol sedation are assumed safe, especially in the second trimester. In case of active perianal or rectal disease Caesarean section is recommended. Breastfeeding is not associated with a worsening of the course of disease or the development of acute flares in IBD. Author contributions : All authors were searching for references, contributed to the preparation of the manuscript and reviewed the manuscript.
All authors have approved the final version of this manuscript. Declaration of personal and funding interests : H. Volume 40 , Issue 9. The full text of this article hosted at iucr. If you do not receive an email within 10 minutes, your email address may not be registered, and you may need to create a new Wiley Online Library account. If the address matches an existing account you will receive an email with instructions to retrieve your username.
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Share Give access Share full text access. Share full text access. Please review our Terms and Conditions of Use and check box below to share full-text version of article. Summary Background Inflammatory bowel diseases IBD commonly affect young patients in the reproductive phase of their lives. Results Male and female fertility are not impaired in the majority of IBD patients. Conclusions The overall outcome of pregnancies in IBD patients is favourable and not different to healthy controls, thus patients with IBD should not be discouraged from having children.
Acknowledgements Declaration of personal and funding interests : H. Fear and fertility in inflammatory bowel disease: a mismatch of perception and reality affects family planning decisions. Inflamm Bowel Dis ; 15 : — 5. Google Scholar. PubMed Google Scholar. Crossref PubMed Google Scholar. You are expected to study at least four topics. There will be revision teaching in ET.