103 Ulcerative Colitis 123

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Pregnancy Issues

As UC often occurs in young adults, managing the disease in pregnancy is not unusual. The risks of infertility are no different to those for a woman who does not suffer from UC6,8, and 25% of women with UC will conceive following diagnosis3.

Control during pregnancy is crucial for fetal and maternal health. Women may need to remain on medication to remain in remission, rather than risk an acute flare-up, which could hold more dangers for feto-maternal well being.3

Risks to pregnancy

• No significant increase in the rate of spontaneous miscarriage when compared with the normal population8

• An increased risk of pre-term birth, IUGR and caesarean section with active disease9

• If the woman has an ileostomy, there is a significant risk of a hernia or stomal prolapse developing, due to the increased strain on the weak abdominal walls

• Vomiting in pregnancy can also cause herniation of the small bowel

Medical Management and Care

In the event of acute flare-up:

• IV access with fluid and electrolyte replacement to prevent any dehydration or electrolyte imbalance

• FBC, ESR or CRP, serum electrolytes and liver function tests should be measured every 24-48 hours to monitor the severity of flare

• Flexible sigmoidoscopy can be used safely in pregnancy6

• Do not manage acute UC any differently than in non-pregnancy

• Azathioprine and corticosteroids to be continued as risks to fetus from disease outweigh risks from the continued therapy

• Emergency colectomy is not encouraged during pregnancy

• An intrapartum care plan to be agreed between the woman and the multi-disciplinary team (MDT) and documented in the notes

Midwifery Management and Care

• Involve the Inflammatory Bowel Disease nurse specialist (if available) as teamwork is fundamental to effective care

• Be aware that severe disease will require hospital admission, mild or moderate disease can be managed as an outpatient

• If hospital admission occurs, monitor the following:

- stool frequency and condition

- blood, mucous and consistency

- four-hourly vital signs3

- levels of abdominal pain and tenderness

• Due to the degree of 'urgency' UC women experience, it is essential that they have easy access to toilet facilities

• These women are prone to malnutrition, and may need referral to a dietician during pregnancy

• Regular weighing is essential

Labour Issues

Mode of delivery should be carefully planned and options discussed with the woman. This discussion will incorporate the multi-disciplinary team (MDT), so the woman can make an informed decision. Aim for vaginal delivery in most cases, unless severe or chronic disease is present. In these instances, a caesarean section may be offered in order to protect the anal sphincter from damage.

If the woman has already undergone gastrointestinal surgery, e.g. ileoanal pouch for-mation3, or has an ileostomy, an elective LSCS may be offered, as an emergency LSCS would be very complex due to the scar tissue from previous surgery.

Medical Management and Care

• Aim for vaginal delivery unless disease is active

• Active disease - consider LSCS to protect the anal sphincter

• Prolonged second stage and difficult instrumental deliveries should be avoided to prevent anal sphincter damage, particularly if future surgery for ileoanal pouch is contemplated

• A senior obstetrician should perform caesarean if there is a history of previous gastrointestinal surgery, as there is a higher risk of bowel damage from previous adhesions

Midwifery Management and Care

• Quiescent disease - normal midwifery management of labour

• Keep woman well hydrated in labour

• Easy access to toilets, or alternative, is essential in labour

• There is no need for the midwife to have any concerns over bag management, if a woman with an ileostomy is labouring normally; assistance may be needed in emptying the appliance if the woman has an epidural and cannot get to the toilet

Postpartum Issues

• Anaemia may result from rectal bleeding, which is a symptom of active disease

• With haemoglobin already compromised, even the 'normal' bleeding at delivery may be detrimental to the woman's health

• If the disease remains quiescent, there are no significant postpartum issues

• With active disease, the mother may suffer from extreme tiredness; giving birth is a demanding experience, even without a chronic condition causing exhaustion

• Immunosuppressant drugs may be either contraindicated with breast-feeding, or used on a risk-benefit assessment basis, especially azathioprine (see Appendix 11)

Medical Management and Care

• Treat any anaemia

• If breast-feeding while taking azathioprine or 6-MP it is advisable for the baby to be monitored for clinical signs of immunosuppression and regular complete blood counts should be taken10,11

• A four-hour delay in breast-feeding following oral corticosteroid use is recommended by most manufacturers; this has practical implications and, after observation, steroids appear to be safe6

Midwifery Management and Care

• Support the mother in her choice of infant feeding, and deflect any guilt she may feel if she is not breast-feeding

• Be aware of the extreme tiredness and assist as needed

• Ascertain if the woman has any help at home

• Ensure that the mother and her relatives understand the need for rest

- that housework is not essential

- to rest when the baby rests

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