Variation in Recommendations for Modes of Delivery Post Ileal Pouch-Anal Anastomosis (IPAA) in Women with Ulcerative Colitis

Abstract

Purpose: Fertility may be negatively affected in women with ulcerative colitis (UC) after ileal pouch-anal anastomosis (IPAA). However, it is unclear whether women who do conceive after IPAA should undergo vaginal delivery or cesarean section (CS). There are no formal consensus guidelines in this setting among gastroenterologists (GI), colorectal surgeons (CRS) and obstetricians (OB) who often co-manage these patients. This can lead to variation in care, a marker of poor quality. Furthermore, contrasting recommendations by different specialists may be confusing for the patient. Aim: To determine if there is variation among physicians in their recommendations for mode of delivery post-IPAA in a cohort of female UC patients. Methods: A total of 105 patients of child-bearing age at the time of IPAA (18-44 years old) performed by a single surgeon were surveyed via telephone and/or email using a survey instrument developed with input from GIs (n=2) and CRS (n=1) with expertise in IBD. Survey questions included patient demographics, IBD and surgical history, pregnancy history including any infertility work-up, recommendations regarding modes of delivery and delivery history. Results: A total of 44 (42%) patients (mean age; 38 years) specifically answered the survey question regarding mode of delivery recommended by their physicians (OB, High-risk OB, Midwife, GI, CRS). Half of these patients stated they did not discuss this with their physicians as they had no immediate plans (45%) or future plans (55%) for pregnancy post IPAA. Of the 22 seeking a recommendation, all 17 patients who asked their CRS were recommended to undergo CS. Twelve patients also asked a total of 16 OBs; 10 recommended vaginal delivery, 5 recommended CS, and 1 deferred recommendation until a later date. Four patients asked their GI doctor; 2 recommended CS and 2 were given no recommendation. One patient also asked a midwife, who recommended vaginal delivery. Seven had 13 full-term pregnancies; 6 women had a total of 9 CS, and 1 had a total of 4 vaginal deliveries. Of the 15 women who had not yet conceived, 5 were undergoing infertility work-up and 10 had electively deferred conception. However, at the time of a potential future pregnancy, 8 would elect for CS based on previous CRS recommendation, 1 would elect for vaginal delivery despite a CS recommendation and 6 were undecided. Conclusion: In our cohort, there was disconcordance between CRS and OB recommendations for mode of delivery post-IPAA. Patients tended to follow the recommendation of the CRS more than the OB. A study is underway to further examine variation in recommendations among different specialties managing women with IBD of childbearing age pre- and post-IPAA.