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Significant Variation in Recommendation of Care for Women of Reproductive Age with Ulcerative Colitis Postileal Pouch–Anal Anastomosis

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Abstract

Background and Aim

Ileal pouch–anal anastomosis (IPAA) is the preferred surgical option for treatment refractory ulcerative colitis. Infertility risk post IPAA and sphincter injury concerns with vaginal delivery has led to a lack of consensus regarding timing and recommended mode of delivery (MOD) post-IPAA. To better understand these issues, we surveyed gastroenterologists (GI), colorectal surgeons (CRS), and obstetricians (OB) to assess practice variation in recommendations for delivery post IPAA.

Methods

Clinical vignettes were developed to assess knowledge, attitudes, and beliefs surrounding (1) the impact of IPAA on fertility, (2) IPAA timing around pregnancy, (3) recommended MOD after IPAA and (4) which specialist should advise on MOD. These were emailed to providers using specialty society address lists. Univariate analyses tested differences among groups.

Results

A total of 244 GI, 158 CRS and 39 OBs responded to the survey. The majority of GI (67 %) and CRS (60 %) quoted fertility reduction of >20 % post-IPAA versus 11 % OB (p < 0.001). More GI than CRS (67 vs. 45 %) recommended delaying IPAA until after pregnancy (p < 0.001), and this was more commonly suggested by CRS in practice <10 years (p = 0.01) and <45 years old (p = 0.003). Vaginal delivery was recommended post-IPAA in 43, 20 and 57 % for GI, CRS and OB, respectively (p < 0.001). Only 28 % CRS versus 59 % OB thought OB should primarily advise on MOD (p < 0.001).

Conclusions

There is significant intra- and inter-group variation in management of women post-IPAA. There is need for consensus among subspecialists involved in managing women with this complex condition.

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Conflict of interest

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Author information

Authors and Affiliations

  1. Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA

    Kara Bradford & Gil Y. Melmed

  2. Division of Colorectal Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA

    Phillip Fleshner

  3. Department of Obstetrics and Gynecology, UCLA Medical Center, Los Angeles, CA, USA

    Neil Silverman

  4. Department of Pediatrics, Cedars Sinai Medical Center, 8635 West 3rd Street, Suite 1165 W, Los Angeles, CA, 90048, USA

    Marla C. Dubinsky

Authors
  1. Kara Bradford
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  2. Gil Y. Melmed
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  3. Phillip Fleshner
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  4. Neil Silverman
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  5. Marla C. Dubinsky
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Corresponding author

Correspondence to Marla C. Dubinsky.

Appendix: Survey Vignette

Appendix: Survey Vignette

Clinical Vignette

  1. 1.

    A 31-year-old female with extensive ulcerative colitis is hospitalized for medically refractory disease. She has been maintained on 4.8 g of mesalamine and infliximab 5 mg/kg every 8 weeks, but began to “flare” 3 weeks ago. Stool studies and sigmoidoscopy show no infection, and she has not improved on oral corticosteroids. In the hospital, she has minimal response to IV corticosteroids and the decision is made to undergo colectomy.

What do you tell her about fertility after IPAA as compared to the general population?

  1. (i)

    No different

  2. (ii)

    Reduced by <20 %

  3. (iii)

    Reduced by 20–50 %

  4. (iv)

    Reduced by 50–80 %

  5. (v)

    Reduced by >80 %

  1. 2.

    Regarding the recommended timing and type of colectomy in this patient. Surgeons were given the options of:

  1. (i)

    Subtotal colectomy with end-ileostomy and defer the IPAA until after successful pregnancy (or multiple), or

  2. (ii)

    IPAA now (done in either 1, 2 or 3 stages) and attempt conception after the IPAA

  3. (iii)

    Don’t know; defer to other specialist(s)

*This question was asked only of the GI and CRS

  1. 3.

    This 31-year-old woman undergoes a subtotal colectomy with end ileostomy followed by the ileal pouch–anal anastomosis (“J-Pouch”) 3 months after the initial surgery. She presents 11 months after reversal of her loop ileostomy feeling well and reports that she is 14 weeks pregnant. She wants to discuss options for mode of delivery.

What mode of delivery do you recommend?

  1. (i)

    Vaginal delivery

  2. (ii)

    C-Section

  3. (iii)

    Allow the patient to decide

  4. (iv)

    Don’t know; defer to other specialist(s)

  1. 4.

    Which specialist do you think should be the PRIMARY specialist to advise a woman on the optimal mode of delivery in the setting of pregnancy after IPAA?

  1. (i)

    Gastroenterologist

  2. (ii)

    Colorectal surgeon

  3. (iii)

    Obstetrics and gynecology

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Bradford, K., Melmed, G.Y., Fleshner, P. et al. Significant Variation in Recommendation of Care for Women of Reproductive Age with Ulcerative Colitis Postileal Pouch–Anal Anastomosis. Dig Dis Sci 59, 1115–1120 (2014). https://doi.org/10.1007/s10620-014-3043-4

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  • DOI: https://doi.org/10.1007/s10620-014-3043-4

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