Not Too Late to Make Cutting-Edge Decisions: Editorial Response to ‘Predictors of Cesarean Delivery in Pregnant Women with Inflammatory Bowel Disease’

Not Too Late to Make Cutting-Edge Decisions: Editorial Response to ‘Predictors of Cesarean... Journal of the Canadian Association of Gastroenterology, 2018, 1(2), 53 doi: 10.1093/jcag/gwy011 Editorial Advance Access publication 7 April 2018 Editorial Not Too Late to Make Cutting-Edge Decisions: Editorial Response to ‘Predictors of Cesarean Delivery in Pregnant Women with Inflammatory Bowel Disease’ In this issue of JCAG, Sharaf and Nguyen report on the predictors also be considered is in women with IBD who have undergone of Cesarean delivery in pregnant women with inflammatory bowel an ileal pouch anal anastomosis (IPAA), in order to reduce the disease (IBD) (1). This retrospective study reviewed all deliveries risk of anal sphincter injury which may lead to fecal incontinence. over an 8-year period at a tertiary referral institution. Consistent Sharaf et al. report that within the UC population, prior colectomy with existing literature, which have demonstrated up to a two-fold increased the odds five-fold of requiring a Cesarean delivery; how - risk of Cesarean delivery in the IBD population over the general ever, the proportion of these women who had a ileostomy versus population (2), Sharaf et al. reported 52% of those with Crohn’s dis- an IPAA at time of pregnancy was not reported (1). ease and 48% with ulcerative colitis underwent Cesarean delivery. Overall, Sharaf and Nguyen’s study contributes to the grow- The Toronto Consensus Statements for the Management of IBD ing body of evidence that women with IBD undergo Cesarean in Pregnancy (which includes three statements addressing mode of delivery at a rate exceeding the general population and per- delivery) was published in Gastroenterology in 2016 (3), postdating haps contrary to the defined indications outlined by the 2016 the study period (2006–2014) of Sharaf ’s paper (1). The panel, Toronto Consensus Statements for the Management of IBD. which included expertise in IBD, obstetricians and maternofetal Future studies could take into account factors including the medicine, provided a strong recommendation that the decision publication of the guidelines, geographical variation and insti- regarding Cesarean delivery should be based on obstetric consider- tution (academic versus community). Accordingly, more tar- ations and not the diagnosis of IBD alone (statement 21) (3). geted education can be provided with the hope that outcomes However, exceptions may be made in two specific scenarios: such as mode of delivery for pregnant women with IBD can the presence of active perianal disease and patients who have more closely approximate that of the general public. undergone an ileal pouch anal anastomosis (statements 21 and Cynthia H. Seow MBBS (Hons) MSc FCP RA 22). Sharaf et al. observed that a history of perianal disease was University of Calgary, 3280 Hospital Drive NW, Calgary, AB, the strongest predictor of Cesarean delivery in women with Canada T2N 4Z6 CD, with an adjusted odds ratio of 13.6 (95% CI, 3.87–47.5). However, it should be noted that the guidelines specif y that this References strong recommendation is reserved for women with active peri- anal disease, as disease activity may be a risk factor for worsen- 1. Sharaf AA, Nguyen GC. Predictors of cesarean delivery in preg- nant women with inflammatory bowel disease. Canadian Journal ing symptoms (4) and perineal lacerations (5). In Sharaf et al.’s of Gastroenterology 2018;1:76–81. cohort, only 42% of women with perianal disease had active 2. Ananthakrishnan AN, Cheng A, Cagan A, et al. Mode of childbirth symptoms during pregnancy, suggesting the presence of other and long-term outcomes in women with inflammatory bowel dis - risk factors for Cesarean delivery. ease. Dig Dis Sci 2015;60:471–7. Overall, prior Cesarean delivery was the strongest predictor 3. Nguyen GC, Seow CH, Maxwell C, et  al. The Toronto consensus of Cesarean delivery in women with CD (aOR 22.2; 95% CI, statements for the management of inflammatory bowel disease in 6.16–80.2), highlighting the importance of initial judicious deci- pregnancy. Gastroenterology 2016;150(3):734–57. sion-making by obstetrics, other medical care providers and 4. Foulon A, Dupas JL, Sabbagh C, et  al. Defining the most appro - patients regarding mode of delivery. While there are emergency, priate delivery mode in women with inflammatory bowel disease: elective, obstetric, and gastroenterologic indications, and not A systematic review. Inflamm Bowel Dis 2017;23:712–20. withstanding personal preference for Cesarean delivery, elective 5. Hatch Q, Champagne BJ, Maykel JA, et  al. Crohn’s disease and gastroenterologic indications should constitute the minority of pregnancy: the impact of perianal disease on delivery methods and complications. Dis Colon Rectum 2014;57:174–8. procedures. The other scenario in which Cesarean delivery should © The Author(s) 2018. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology. 53 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/53/4964009 by guest on 20 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the Canadian Association of Gastroenterology Oxford University Press

Not Too Late to Make Cutting-Edge Decisions: Editorial Response to ‘Predictors of Cesarean Delivery in Pregnant Women with Inflammatory Bowel Disease’

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology.
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2515-2084
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2515-2092
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Abstract

Journal of the Canadian Association of Gastroenterology, 2018, 1(2), 53 doi: 10.1093/jcag/gwy011 Editorial Advance Access publication 7 April 2018 Editorial Not Too Late to Make Cutting-Edge Decisions: Editorial Response to ‘Predictors of Cesarean Delivery in Pregnant Women with Inflammatory Bowel Disease’ In this issue of JCAG, Sharaf and Nguyen report on the predictors also be considered is in women with IBD who have undergone of Cesarean delivery in pregnant women with inflammatory bowel an ileal pouch anal anastomosis (IPAA), in order to reduce the disease (IBD) (1). This retrospective study reviewed all deliveries risk of anal sphincter injury which may lead to fecal incontinence. over an 8-year period at a tertiary referral institution. Consistent Sharaf et al. report that within the UC population, prior colectomy with existing literature, which have demonstrated up to a two-fold increased the odds five-fold of requiring a Cesarean delivery; how - risk of Cesarean delivery in the IBD population over the general ever, the proportion of these women who had a ileostomy versus population (2), Sharaf et al. reported 52% of those with Crohn’s dis- an IPAA at time of pregnancy was not reported (1). ease and 48% with ulcerative colitis underwent Cesarean delivery. Overall, Sharaf and Nguyen’s study contributes to the grow- The Toronto Consensus Statements for the Management of IBD ing body of evidence that women with IBD undergo Cesarean in Pregnancy (which includes three statements addressing mode of delivery at a rate exceeding the general population and per- delivery) was published in Gastroenterology in 2016 (3), postdating haps contrary to the defined indications outlined by the 2016 the study period (2006–2014) of Sharaf ’s paper (1). The panel, Toronto Consensus Statements for the Management of IBD. which included expertise in IBD, obstetricians and maternofetal Future studies could take into account factors including the medicine, provided a strong recommendation that the decision publication of the guidelines, geographical variation and insti- regarding Cesarean delivery should be based on obstetric consider- tution (academic versus community). Accordingly, more tar- ations and not the diagnosis of IBD alone (statement 21) (3). geted education can be provided with the hope that outcomes However, exceptions may be made in two specific scenarios: such as mode of delivery for pregnant women with IBD can the presence of active perianal disease and patients who have more closely approximate that of the general public. undergone an ileal pouch anal anastomosis (statements 21 and Cynthia H. Seow MBBS (Hons) MSc FCP RA 22). Sharaf et al. observed that a history of perianal disease was University of Calgary, 3280 Hospital Drive NW, Calgary, AB, the strongest predictor of Cesarean delivery in women with Canada T2N 4Z6 CD, with an adjusted odds ratio of 13.6 (95% CI, 3.87–47.5). However, it should be noted that the guidelines specif y that this References strong recommendation is reserved for women with active peri- anal disease, as disease activity may be a risk factor for worsen- 1. Sharaf AA, Nguyen GC. Predictors of cesarean delivery in preg- nant women with inflammatory bowel disease. Canadian Journal ing symptoms (4) and perineal lacerations (5). In Sharaf et al.’s of Gastroenterology 2018;1:76–81. cohort, only 42% of women with perianal disease had active 2. Ananthakrishnan AN, Cheng A, Cagan A, et al. Mode of childbirth symptoms during pregnancy, suggesting the presence of other and long-term outcomes in women with inflammatory bowel dis - risk factors for Cesarean delivery. ease. Dig Dis Sci 2015;60:471–7. Overall, prior Cesarean delivery was the strongest predictor 3. Nguyen GC, Seow CH, Maxwell C, et  al. The Toronto consensus of Cesarean delivery in women with CD (aOR 22.2; 95% CI, statements for the management of inflammatory bowel disease in 6.16–80.2), highlighting the importance of initial judicious deci- pregnancy. Gastroenterology 2016;150(3):734–57. sion-making by obstetrics, other medical care providers and 4. Foulon A, Dupas JL, Sabbagh C, et  al. Defining the most appro - patients regarding mode of delivery. While there are emergency, priate delivery mode in women with inflammatory bowel disease: elective, obstetric, and gastroenterologic indications, and not A systematic review. Inflamm Bowel Dis 2017;23:712–20. withstanding personal preference for Cesarean delivery, elective 5. Hatch Q, Champagne BJ, Maykel JA, et  al. Crohn’s disease and gastroenterologic indications should constitute the minority of pregnancy: the impact of perianal disease on delivery methods and complications. Dis Colon Rectum 2014;57:174–8. procedures. The other scenario in which Cesarean delivery should © The Author(s) 2018. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology. 53 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/53/4964009 by guest on 20 June 2018

Journal

Journal of the Canadian Association of GastroenterologyOxford University Press

Published: Apr 7, 2018

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