Women with chronic ulcerative colitis are usually diagnosed in their reproductive years. In the past, women with ulcerative colitis were advised not to become pregnant, but later it became evident that fertility can be normal, and normal pregnancy and delivery is possible if the disease is inactive. It has also been reported that women with active disease can conceive, carry to term and deliver healthy babies, provided their disease is treated appropriately. The incidence of spontaneous abortions is approximately that of the general population, with the exception of those who have severe disease during pregnancy. The risk of fetal death is increased in patients requiring surgery for toxic megacolon or fulminant colitis during pregnancy. Thus, control of disease activity before conception and during pregnancy is critical to optimize both maternal and fetal health. Most medications used to treat ulcerative colitis, including corticosteroids, azathioprine and 5-ASA, are safe during pregnancy.Ileal pouch-anal anastomosis (IPAA pelvic pouch) is the preferred surgical option for most patients requiring surgery for ulcerative colitis. Most patients with the pelvic pouch return to a normal lifestyle and some wish to conceive. Thus, issues related to fertility, pregnancy and the preferred method of delivery are of great concern. There is evidence that women who have had a pelvic pouch have increased difficulty conceiving. This reduced fertility may be due to the pelvic surgery and formation of adhesions, since there is evidence that women having other abdominal surgical procedures may also have increased difficulty conceiving. We sent questionnaires to all women who have had the pelvic pouch procedure performed at the Mount Sinai Hospital between the years 1982-1997 to assess the risk of postoperative infertility. We found that approximately 19% reported difficulty conceiving. However, many of these women were able to conceive and have successful pregnancies, but a third required medication and 13% required surgery for infertility problems. No risk factors were identified that increased difficulty in conceiving.
The first report of a successful pregnancy and delivery after a pelvic pouch procedure was in 1984, and since then other reports have been published. It has been shown that pregnancy is safe after the pelvic pouch procedure. However, there is no consensus regarding the preferred method of delivery, and the long-term effects of delivery on pouch function. The concern is the effect of vaginal delivery on the anal sphincter and the risk of a tear of the sphincter. To date, it does not appear that the risk of a tear is increased. However, if a tear were to occur, it could cause significant problems. Also, it has been shown in normal women, that there may be occult injuries to the sphincter, which do not manifest symptomatically for many years.
We reviewed all women who had pregnancy after the pelvic pouch procedure and examined the effect of pregnancy and the type of delivery on pouch function. Approximately 50 women have given birth since their surgery. The mean length of time taken to conceive was 11 months. Half of the women conceived within 4 months of trying to. The mean number of pregnancies was 1.8 (between 1-4). About half of the deliveries were vaginal deliveries and half were caesarean sections. The reasons for the choice of delivery were primarily patients' preference in the vaginal group and obstetrical reasons or patient's wish to protect the pouch' in the caesarean section group. Most deliveries were full-term (94%). The mean birth weight was 3.2kg (7 pounds). In the caesarean section group, 14% had small bowel obstructions, which resolved without operative intervention. One woman developed uterine prolapse after vaginal delivery, requiring surgical repair.
During the pregnancy, most women had deterioration of their pouch function, including some increase in daytime and nighttime number of bowel movements and worsening of continence. However, most women found this to be only a transient change, and the pouch function promptly returned to the pre-pregnancy status after delivery. These changes are probably related to the pressure exerted by the growing fetus on the pelvic pouch. A small number of patients reported a permanent decrease in their pouch function post partum: 10% of the patients had increased stool frequency, 4% had increased night time stool frequency, 14% had some decrease in their daytime continence, and 10% had some degree of permanent decrease in night time control. These changes were mainly minor and did not differ depending on whether patients had a vaginal delivery or caesarean section.
In summary, most women with the pelvic pouch have uncomplicated pregnancies and are able to carry the baby to term. Many have disturbances in pouch function during the pregnancy, usually during the third trimester, but these are temporary and pouch function returns to pre-pregnancy status after delivery. Vaginal delivery after the pelvic pouch procedure appears to be safe. However, there have been relatively few women who have delivered and follow-up is short. Decisions regarding type of delivery should be discussed with your obstetrician. Your surgeon at the Mount Sinai Hospital would be happy to discuss it with you or your obstetrician.
