Our Paper of the Month for April looks at the largest study of pregnancy outcomes after stoma surgery for inflammatory bowel disease.
Pregnancy outcomes after stoma surgery for inflammatory bowel disease: The results of a retrospective multicentre audit
The PAPooSE Study Group
Journal: Colorectal Disease 2022;00:1-7
What is known about this subject?
Inflammatory bowel disease (IBD) affects up to 500,000 people in the UK. The diagnosis of IBD can frequently occur at a young age and those undergoing surgery can often require stoma formation – either temporary or permanent. There are data relating to the impact of IBD and stoma formation on fertility, but little information exists on the perinatal outcomes of women with a stoma. Potential problems cited in case reports include parastomal hernias, difficulties in attaching stoma appliances and obstructive symptoms. This study by the PAPooSE Group aims to capture data related to the obstetric, neonatal and stoma outcomes of pregnant women with an IBD related stoma.
Retrospective audit conducted across 15 UK centres.
Female patients with confirmed IBD who had a pregnancy with an existing stoma from 2014 -2020. Those with non IBD related stomas and previous stoma reversal were excluded.
- Co-primary: Stoma complications and obstetric mode of delivery.
- Secondary: Week of gestation, birth weight, and congenital abnormalities, IBD flare (change in medical therapy or high output stoma), incidence of intestinal obstruction, stoma prolapse, stoma herniation, and need for further stoma surgery.
- 82 pregnancies in 77 women were analysed of which 61% had Crohn’s and 35% had ulcerative colitis with 4% unclassified IBD.
- Stoma types included Ileostomy in 72 (88%) and colostomy in 10 (12%) pregnancies.
- Biologics were stopped in 20 of 29 cases at a mean of 25 weeks’ gestation. In 45 patients no medical therapy for IBD was required during pregnancy.
- The overall cesarean section (CS) rate was 73% (n=58, 44 elective and 14 emergency). For reference, the population CS rate is 30.9% in the general IBD population and 29% in all national deliveries. In 19 elective CS, an IBD indication for CS was documented.
- In 20 (24%) pregnancies, serious stoma-related complications occurred – all in ileostomies. Complications included stoma prolapse (11%, n=9), new parastomal hernia (4%, n=3), small bowel obstruction (9%, n=7).
- Mean gestation was 37 weeks. 19% delivered before 37 weeks and 17% had a birth weight <2500g. Postpartum haemorrhage occurred in six (7.5%) cases, of which one required surgical intervention. Bladder injuries during CS occurred in three patients.
- Complications relating to IBD occurred in 11 cases (13%) – IBD flare, perianal sepsis, high output stoma.
Implications for colorectal practice?
This audit is the largest study of pregnancy outcomes after stoma surgery for IBD. It has found that cesarean section rates are significantly higher than the general population and the non-stoma IBD population. However, the rate of emergency CS was similar to the general population. Interestingly, IBD was only documented as the reason in 19 of 44 elective CS. It would be interesting to understand the reason for the remainder. Complications of bladder injury at CS (5%) were also much higher than the population rate (0.1% to 0.3%). Stoma complication rates were also high in the perinatal period with an overall rate for 24%. The quantification of these risks has not previously reported and will provide important information for this patient group. The study is limited by its retrospective nature and its reliance on the accuracy of existing hospital records. However, the information provided will not only assist colorectal surgeons but also obstetric teams and specialist stoma care nurses during consultations with women at an early stage of their pregnancy. Ultimately this should lead improved patient-clinician decision-making around methods of delivery and perinatal care in this patient group.