Colorectal Disorders in Pregnancy

 

Constipation:

Management of constipation during pregnancy and breastfeeding

For the management of constipation during pregnancy:

  1. Advise on sources of information and support, such as the UK Teratology Information Service (UKTIS) patient information leaflet Treating constipation during pregnancy
  2. Advise on lifestyle measures, such as increasing dietary fibre, fluid intake, and activity levels, as appropriate
  3. If these measures are ineffective, or symptoms do not respond adequately, offer short-term treatment with oral laxatives. Adjust the dose, choice, and combination of laxatives used, depending on the woman's symptoms, the desired speed of symptom relief, the response to treatment, and their personal preference
    1. Offer a bulk-forming laxative first-line, such as ispaghula
    2. If stools remain hard, add or switch to an osmotic laxative, such as lactulose
    3. If stools are soft but difficult to pass, or there is a sensation of incomplete emptying, consider a short course of a stimulant such as senna
  4. If the response to treatment is still inadequate, consider prescribing a glycerol suppository
  5. If there is uncertainty about the use or safety of laxatives during pregnancy, contact UKTIS
    1. To discuss with a teratology specialist, telephone 0344 892 0909

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For the management of constipation during breastfeeding:

  1. Advise on sources of information and support, such as the Breastfeeding Network drug factsheet Constipation treatment in breastfeeding mothers
  2. Advise on lifestyle measures, such as increasing dietary fibre, fluid intake, and activity levels, as appropriate
  3. If these measures are ineffective, or symptoms do not respond adequately, offer short-term treatment with oral laxatives. Adjust the dose, choice, and combination of laxatives used, depending on the woman's symptoms, the desired speed of symptom relief, the response to treatment, and their personal preference
    1. Offer a bulk-forming laxative first-line, such as ispaghula
    2. If stools remain hard or difficult to pass, add or switch to an osmotic laxative such as lactulose or a macrogol
    3. If stools are soft but difficult to pass or there is a sensation of inadequate emptying, consider a short course of a stimulant laxative such as bisacodyl or senna
  4. If the response to treatment is still inadequate, consider prescribing a glycerol suppository
  5. If there is uncertainty about the use or safety of laxatives during breastfeeding, contact the UK Drugs in Lactation Advisory Service (UKDILAS) provided by the UK Medicines Information Network:
    1. To discuss with a specialist pharmacist, telephone 0116 2586491 or 0121 4247298
    2. For information on the safety of specific laxatives, contact the Specialist Pharmacy Service (SPS)

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Crohn's Disease:

Fertility, pregnancy and breastfeeding with Crohn's disease

Contraception advice

  • For women with Crohn's disease, the choice of contraceptive method may be influenced by factors such as malabsorption, surgical history, prolonged immobility, extra-intestinal manifestations such as primary sclerosing cholangitis, and associated conditions such as osteoporosis and venous thromboembolism
  • See the guidance document FSRH UKMEC 2016 - Eligibility Criteria on Contraception Use for detailed information on prescribing contraception for women with inflammatory bowel disease

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Fertility advice

  1. Advise women with Crohn's disease that:
    1. Active disease may reduce fertility rates, and inactive disease should not affect fertility
    2. Women who have abdominal or pelvic sepsis, surgery or adhesions may be at increased risk of impaired tubal function
    3. Drug treatment with methotrexate may affect oogenesis and fertility
  2. Advise men with Crohn's disease that:
    1. Fertility is unlikely to be affected for most men with Crohn's disease, but pelvic surgery may lead to erectile dysfunction or ejaculatory problems
    2. Drug treatment with sulfasalazine or methotrexate may affect spermatogenesis, however, the effect should be reversible on stopping treatment. Infliximab may affect semen quality by reducing motility in some men
  3. Offer sources of support and information, such as the information sheet 'Fertility and IBD' booklet (Crohn's and Colitis UK)

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Pregnancy advice

  1. Advise women and men they need to be referred to a gastroenterologist before trying to conceive if they are planning a pregnancy
  2. If a woman has a planned pregnancy, ensure she is managed jointly by a gastroenterologist and obstetrician with appropriate expertise
  3. If a woman has an unplanned pregnancy and is prescribed:
    1. Methotrexate, infliximab, or adalimumab, seek immediate specialist advice from a gastroenterologist and/or a specialist in fetal medicine about stopping and changing treatment and starting folic acid supplementation
    2. Other medication, advise the woman to continue maintenance drug treatment, start folic acid supplementation, and arrange an urgent specialist gastroenterology review appointment to ensure that management of Crohn's disease is optimized
  4. If a woman has had significant pelvic surgery, extensive perianal disease, or active rectal involvement, she may be offered elective Caesarean section to reduce the risk of potential anal sphincter damage
  5. Offer sources of support and information, such as the information sheet 'Pregnancy and IBD' booklet (Crohn's and Colitis UK)

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Breastfeeding advice

  1. If a woman with Crohn's disease wishes to breastfeed, seek specialist gastroenterology advice if there is any uncertainty about the safety of breastfeeding while prescribed specialist medication
    1. NOTE:  Some drug treatments such as methotrexate, adalimumab, loperamide, ciprofloxacin, and high-dose metronidazole may need to be stopped while breastfeeding, and alternative medication started by a specialist if needed

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Ulcerative Colitis:

Contraception

For all women, the choice of contraception is influenced by factors such as age, smoking, family history, and drug treatment

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For women with ulcerative colitis, additional factors to consider include gastrointestinal malabsorption, surgical treatments, immobility, risk of venous thromboembolism, liver conditions (such as primary sclerosing cholangitis), and risk of osteoporosis

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See the UKMEC guidance for contraceptive use in inflammatory bowel disease for reference. Be aware that:

  • Oral contraceptives may be less reliable in women with inflammatory bowel disease who have malabsorption due to severe small bowel disease, surgery, or vomiting for more than 24 hours
  • Barrier methods (such as condoms) are not suitable on their own for women taking potentially teratogenic drugs (such as mercaptopurine and infliximab) as the failure rate is too high
  • Depot medroxyprogesterone acetate (DMPA) may affect bone mineral density. Current advice for DMPA states that:
    • If the woman is younger than 18 years of age, DMPA may be considered after all other methods have been discussed and considered to be unsuitable or unacceptable
    • If the woman wishes to continue using DMPA, the prescriber is required to re-evaluate the risks and benefits of treatment every 2 years
    • If the woman has significant lifestyle or other risk factors for osteoporosis, another method of contraception should be considered

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Pregnancy

Planning a pregnancy:

  1. If the person has questions about fertility, advise that:
    1. Ulcerative colitis does not seem to affect fertility in either men or women; however:
      1. Women who undergo surgery may be at risk of impaired tubal function
      2. Men who undergo ileo-anal pouch surgery may develop retrograde ejaculation and erectile dysfunction
    2. Medication used in the treatment of ulcerative colitis does not appear to affect fertility in women, but some drugs affect fertility in men:
      1. Sulfasalazine may cause a dose-related, reversible decrease in sperm motility and count
      2. Infliximab may reduce sperm motility
  2. For women being treated with infliximab or mercaptopurine, advise that these drugs are contraindicated in pregnancy
    1. For women being treated with infliximab, advise that adequate contraception must be used during treatment and continued for at least 6 months after the last treatment with infliximab
    2. For women being treated with mercaptopurine, advise that adequate contraception must be used during treatment and continued for at least 3 months after the last treatment with mercaptopurine if taken by either partner
  3. Advise both women and men with ulcerative colitis that they should plan to conceive when the disease is well controlled
  4. Prescribe folic acid according to maternal need, and give general pre-conception advice on smoking and alcohol consumption
    1. The standard pre-conception dose of folic acid 400 micrograms a day is usually adequate. However, women who are at risk of malabsorption and women taking drugs such as sulfasalazine should be prescribed folic acid 5 mg a day pre-conceptually and until week 12 of pregnancy

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Unplanned pregnancy:

  1. Seek immediate telephone advice from a gastroenterologist and a specialist in feto-maternal medicine if:
    1. A woman is pregnant and receiving or has received infliximab within the previous 6 months
    2. A woman is pregnant and she or her partner is receiving or has received mercaptopurine within the previous 3 months
  2. For all other women:
    1. Refer to their gastroenterologist to ensure that management is optimized and to plan any additional antenatal monitoring
    2. Encourage the woman to continue with her maintenance drug treatment until she has been seen by a specialist
    3. Prescribe folic acid according to maternal need

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Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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