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Background Women with inflammatory bowel disease [IBD] have an increased risk for caesarean section [CS], but perineal obstetric outcomes, which may have significant consequences for women with IBD, have not been previously studied. Method Maternal outcomes in singleton pregnancies of IBD and non-IBD patients [2014–2018] in a single centre were studied. Results In 31 528 non-IBD and 179 IBD patients delivery by CS was more likely in IBD patients (p = 0.0021, relative risk [RR] 1.45, confidence interval [CI] 1.16–1.81). Elective CS in IBD patients occurred in 40% for IBD indications, all in accordance with current international guidelines. Perineal trauma, including tears involving the anal sphincter, were equally uncommon in IBD [2.23%] and non-IBD patients [3.40%; p = 0.35, RR 0.64, CI 0.24–1.68]. Of the four IBD patients with clinically significant tears, none had pelvic floor dysfunction or incontinence at follow-up in a specialist postnatal perineal trauma clinic. One IBD patient who had a clinically non-significant second-degree perineal tear reported incontinence a year after giving birth. Previous perianal disease was not associated with significant perineal trauma. Conclusion The low rate of perineal trauma is reassuring for promotion of vaginal delivery in most IBD patients. In those who experienced tears involving the anal sphincter no continence issues occurred. Women with IBD having a greater incidence of delivery by CS was only partially explained by IBD indications.

IntroductionSuboptimal control of inflammatory bowel disease (IBD) can result in increased rates of adverse pregnancy-related outcomes. We aimed to describe the current landscape of provision of antenatal care for women with IBD in the UK.MethodsThis cross-sectional survey collected data on service setup; principles of care pre-conception, during pregnancy and post partum; and on perceived roles and responsibilities of relevant clinicians.ResultsData were provided for 97 IBD units. Prepregnancy counselling was offered mostly on request only (54%) and in an ad hoc manner. In 86% of units, IBD antenatal care was provided by the patient’s usual gastroenterologist, rather than a gastroenterologist with expertise in pregnancy (14%). Combined clinics with obstetricians and gastroenterologists were offered in 14% of units (24% academic vs 7% district hospitals; p=0.043). Communication with obstetrics was ‘as and when required’ in 51% and 30% of IBD units reviewed pregnant women with IBD ‘only when required’. The majority of respondents thought gastroenterologists should be involved in decisions regarding routine vaccinations (70%), breast feeding (80%), folic acid dosage (61%) and venous thromboembolism (VTE) prophylaxis (53%). Sixty-five per cent of respondents thought that gastroenterologists should be involved in decisions around mode of delivery and 30% recommended caesarean sections for previous but healed perianal disease.ConclusionsThis nationwide survey found considerable variation in IBD antenatal services. We identified deficiencies in service setup, care provided by IBD units and clinician knowledge. A basic framework to inform service setup, and better education on the available clinical guidance, is required to ensure consistent high-quality multidisciplinary care.

Background Studies indicate there is a need to improve the delivery of unexpected news via obstetric ultrasound, but there have been few advances in this area. One factor preventing improvement has been a lack of consensus regarding the appropriate phrases and behaviours which sonographers and ultrasound practitioners should use in these situations. Aims To develop consensus guidelines for unexpected news delivery in Early Pregnancy Unit and Fetal Anomaly Screening Programme NHS settings. Methods A workshop was conducted to identify priorities and reach consensus on areas of contention. Contributors included interdisciplinary healthcare professionals, policy experts, representatives from third-sector organisations, lay experts and academic researchers ( n = 28). Written and verbal feedback was used to draft initial guidance which was then circulated amongst the wider writing group ( n = 39). Revisions were undertaken until consensus was reached. Results Consensus guidelines were developed outlining the behaviours and phrases which should be used during scans where unexpected findings are identified. Specific recommendations included that: honest and clear communication should be prioritised, even with uncertain findings; technical terms should be used, but these should be written down together with their lay interpretations; unless expectant parents use other terminology (e.g. ‘foetus’), the term ‘baby’ should be used as a default, even in early pregnancy; at the initial news disclosure, communication should focus on information provision. Expectant parents should not be asked to make decisions during the scan. Conclusions These recommendations can be used to develop and improve news delivery interventions in obstetric ultrasound settings. The full guidelines can be accessed online as supplemental material and at https://doi.org/10.5518/100/24 .

BackgroundPregnant women with inflammatory bowel disease (IBD) are at increased risk of adverse pregnancy outcomes. Comprehensive guidelines on medical management have been published; yet, there is limited guidance on service set-up and minimum standards of care for pregnant women with IBD.AimTo develop a position statement on service set-up and minimum standards of care in the UK.MethodsA working group consisting of 16 gastroenterologists, obstetricians, obstetric physician, IBD specialist nurses and midwives was assembled. Initial draft statements were produced and a modified Delphi process with two rounds of voting applied. Statements were modified according to voters’ feedback after each round. Statements with ≥80% agreement were accepted.ResultsAll 15 statements met criteria for inclusion. To facilitate optimal care, regular and effective communication between IBD and obstetric teams is required. There should be nominated link clinicians for IBD in obstetric units and for pregnancy in IBD units. Preconception counselling should be available for all women with IBD. All pregnant women should be advised on the safety of IBD medication during pregnancy and breast feeding, the optimal mode of delivery, the management of biologics (where applicable) and safety of childhood vaccinations. Regular audit of pregnancy outcomes and documentation of advice given is recommended.ConclusionPosition statements have been developed that advise on the importance of joined-up multidisciplinary care, proactive decision-making with clear documentation and communication to the woman and other healthcare practitioners.

Background: Patients with inflammatory bowel disease (IBD) are at increased risk of adverse outcomes from pregnancy. It is unclear whether IBD indications account for the higher rate of Caesarean section (CS) in IBD patients. Methods: A retrospective cohort study of 179 IBD patients cared for in a dedicated combined IBD antenatal clinic and 31,528 non-IBD patients was performed. The outcomes were method of delivery, preterm birth, birthweight, admission to neonatal intensive care unit (NICU), and stillbirth. We analysed the associations between disease activity, medication with method of delivery, and neonatal outcomes. Results: Delivery by CS was more common in IBD patients (RR 1.45, CI 1.16–1.81, p = 0.0021); emergency CS delivery was equally likely (RR 1.26, CI 0.78–2.07, p = 0.3). Forty percent of elective CS were performed for IBD indications. Stillbirth was five-fold higher in IBD patients (RR 5.14, CI 1.92–13.75, p < 0.001). Preterm delivery, low birthweight, and admission to NICU were not more common in patients with IBD, and IBD medications did not increase these risks. Active disease during pregnancy was not associated with adverse outcomes. Conclusions: Delivery by CS was more frequent in the IBD cohort, and most elective CSs were obstetrically indicated. A dedicated IBD antenatal clinic providing closer monitoring and early detection of potential issues may help improve outcomes.

Background Pregnant women with IBD face important but complex choices on medication, delivery and breast feeding. While foetal and maternal IBD outcomes have been well studied there is less evidence regarding maternal obstetric outcomes. Women with IBD have higher rates of Caesarean section (CS) but the reasons for this remain largely unknown. Perineal birth trauma in IBD can potentially negatively affect long-term quality of life but is so far unstudied. Method In this prospective cohort study we compared maternal and foetal outcomes in singleton pregnancies of IBD and non-IBD patients in a tertiary centre. IBD patients from the Combined IBD Antenatal Clinic delivering between 2014 and April 2018 were included. All non-IBD patients delivering between 2015 and April 2018 were comparators. Routinely collected maternal and foetal data were analysed with sub-analysis of primiparous patients. We recorded indications for CS as IBD/obstetric and absolute/relative. Results Of 31,707 births analysed 179 occurred in mothers with IBD. Incidence of CS was higher in IBD patients overall (30% vs 21%, RR 1.6, p=0.02, CI 1.2–2.6) and in primiparous analysis of 12639 (33% vs 21%, RR 1.9, p=0.03, CI 1.2–2.9). CS rates between IBD subtypes in multiparous and primiparous women were similar. In IBD patients, obstetric rather than IBD indication was more common for elective CS (60% vs 40%). IBD indications were all absolute indications (active perianal disease, ileo-anal pouch, extensive previous surgery, emergency surgery for ileal perforation). Emergency CS constituted 35% of IBD and 40% of non-IBD CS deliveries with no significant difference across all patients (p=0.08, CI 0.9–3.8) or primiparous patients (p=0.3, CI 0.4–1.4). There was no increased risk of perineal tears involving at least the internal anal sphincter in IBD patients compared to non-IBD (RR 0.7, p=0.5, CI 0.3–1.9). Four IBD patients with significant perineal trauma were followed in a specialist obstetric injury clinic: None had pelvic floor dysfunction or incontinence at follow-up. Previous perianal disease was not associated with an increased risk of significant tears. Conclusion Data on Caesarean delivery and perineal trauma are reassuring for IBD patients. Whilst CS is more frequent in IBD patients, we found that all IBD indications were absolute. Emergency CS incidence is no greater in IBD patients than non-IBD, implying that Caesarean is recommended appropriately in the Combined IBD Antenatal Clinic. Perineal tears are a theoretical risk for poor future IBD outcomes. As significant perineal tears are not more common in IBD patients and healed well in our series, the promotion of normal vaginal delivery (barring other indication for CS) is advisable.

Background inflammatory bowel disease (IBD) results in increased rates of negative pregnancy outcomes; particularly in poorly controlled disease. We aimed to describe the current landscape of provision of antenatal care for women with IBD in the UK. Methods This cross-sectional study collected data on service set-up, on principles of care pre, during, and after pregnancy and on perceived responsibilities of clinicians. An online survey was distributed to all gastroenterology units in the UK. Results Data were provided for 97 of 273 IBD units. Pre-pregnancy counselling was not available in 7%, offered routinely (39%), or on request (54%) but predominantly (91%) in an ad-hoc fashion rather than in a dedicated set-up. Ninety-two per cent of units provided a nominated gastroenterology consultant during pregnancy. In 86% of this was the patient’s usual consultant rather than a consultant with expertise in pregnancy (14%). Combined clinics with obstetricians and gastroenterologists were offered in 14% of units only, but more often in academic rather than district hospitals (24% vs. 7%; p = 0.043) Otherwise, communication with obstetrics was ‘as and when required’ in 51% of cases. Patients were reviewed either every trimester (55%), monthly (15%) or ‘only when required’ (30%). The majority of respondents thought gastroenterologists should be involved in decisions regarding routine vaccinations (70%), breastfeeding (80%), folic acid dosage (61%), and VTE prophylaxis (53%). Sixty-five per cent of participants thought that gastroenterologists should be involved in decision-making regarding the delivery method. Regarding IBD indications for elective caesarean section, 94% of participants recommended these for active peri-anal disease, 30% for previous but healed peri-anal disease, 56% for ileo-anal pouch and 20% for previous abdominal and/or pelvic surgery. Conclusion In a nationwide survey on the provision of antenatal IBD care we found considerable variation in all aspects of service provision, particularly the availability of expertise and specialist services. We have detected areas of poor care (review only when required, communication ad-hoc only, poor provision of dedicated pre-pregnancy counselling). A significant minority of IBD units also felt that they do not need to provide input into areas such as VTE prophylaxis, delivery method and folic acid dosing. IBD indications for caesarean section seem to be poorly understood by a sizable minority. A basic framework to inform service set-up, and better education on the available clinical guidance for clinicians, is required to ensure consistent identification and review of patients and high-quality care.

Folate, a key periconceptional nutrient, is ultraviolet light (UV-R) sensitive. We therefore hypothesise that a relationship exists between sunspot activity, a proxy for total solar irradiance (particularly UV-R) reaching Earth, and the occurrence of folate-sensitive, epigenomic-related neonatal genotypes during the first trimester of pregnancy. Limited data is provided to support the hypothesis that the solar cycle predicts folate-related human embryo loss: 379 neonates born at latitude 54°N between 1998 and 2000 were examined for three folate-sensitive, epigenome-related polymorphisms, with solar activity for trimester one accessed via the Royal Greenwich Observatory-US Air force/National Oceanic and Atmospheric Administration Sunspot Database (34,110 total observation days). Logistic regression showed solar activity predicts C677T-methylenetetrahydrofolate reductase (C677T-MTHFR) and A66G-methionine synthase reductase (A66G-MSR) genotype at discrete phases of trimester one. Total and maximal sunspot activity predicts C677T-MTHFR genotype for days 31–60 of trimester one (p = 0.0181 and 0.0366, respectively) and A66G-MSR genotype for days 61–90 of trimester one (p = 0.0072 and 0.0105, respectively). Loss of UV-R sensitive folate associated with the sunspot cycle might therefore interact with variant folate genes to perturb DNA methylation and/or elaboration of the primary base sequence (thymidylate synthesis), as well as increase embryo-toxic homocysteine. We hypothesise that this may influence embryo viability leading to 677CC-MTHFR and 66GG-MSR embryo loss at times of increased solar activity. This provides an interesting and plausible link between well recognised ‘folate gene originated developmental disorders’ and ‘solar activity/seasonality modulated developmental disorders’.

Data is presented, which suggest that the day length a woman experiences during the periconceptional period predicts the C677T-MTHFR genotype of her child. Logistic regression analysis involving 375 neonates born in the same geographical location within a three year period demonstrated that photoperiod (minutes) at conception predicts both genotype (P = 0.0139) and mutant allele carriage (P = 0.0161); the trend clearly showing that the 677T-MTHFR allele frequency increases as photoperiod increases. We propose a number of explanations, including a hypothesis in which a long photoperiod around conception decreases maternal systemic folate because of UVA induced dermal oxidative degradation of 5-methyl-H4folate, leading to a lower cellular 5,10-methylene-H4folate status. In this scenario, 5,10-methylene-H4folate would be more efficiently used for dTMP and DNA synthesis by 677T-MTHFR embryos than wildtype embryos giving the 677T-MTHFR embryos increased viability, and hence increasing mutant T-allele frequency. Alternate hypotheses include: increased seasonal availability of folate rich foods that genetically buffer any negative effect of 677T-MTHFR in embryos; seasonal oxidative stress lowering embryo-toxic homocysteine; an undefined hormonal effect of photoperiod on the neuroendocrine axis, which mediates genotype/embryo selection. The effect of photoperiod on genotype seems clear, but the speculative molecular mechanism underpinning the effect needs careful examination. Am. J. Hum. Biol., 2010. © 2010 Wiley-Liss, Inc.

The aim of this study was to determine if fetal C677T methylenetetrahydrofolate reductase (MTHFR) genotype contributes to low birth weight. The study group consisted of 243 term babies with a birth weight10th centile for gestational age, with subgroup analyses for those1st centile. The control group consisted of 132 term babies with a birth weight 3.3-3.8 kg. Odds ratio analyses with 95% confidence intervals (CI) were calculated for carriage of the t allele and overall genotype frequencies. There was no significant difference in carriage of the t allele between study and control groups, odds ratio (OR) 0.79 (95% CI, 0.57-1.09). No differences were observed for frequencies of heterozygote and recessive homozygote genotypes for the two populations. In the subgroup analyses, no statistical differences were observed in the t allele frequency, frequency of the heterozygote or homozygote genotype. Trends were seen and the study suggests that fetal C677T MTHFR genotype may be a factor contributing to birth weight. The potential may exist to influence clinical outcome by maternal folate supplementation.

Several molecular mechanisms that underpin genomic integrity and function are sensitive to B-vitamin status, and in particular, are responsive to the interaction between folate nutrition and folate dependent enzyme polymorphisms. Mechanisms that may be affected include maintenance of genomic CpG methylation patterns for regulated gene expression, and proficient synthesis of nucleotides to prevent DNA strand breakage. We review some of these important molecular mechanisms that underpin the role of folate and other B-vitamins in disease processes, and discuss how they explain why this vitamin may be an important factor in human evolution. We look at three particular phenomena that link folate status/genes to evolutionary pressures: 1) The evolution of pigmentation to avert the impact of UV light on labile folates needed for developmental processes. 2) The effect of C677T-MTHFR on foetal survival, and 3) the ability of folate to mask harmful developmental mutations.

Introduction Care for pregnant women with IBD requires complex decision making weighing the risks and benefits of medication. Patients are often exposed to conflicting information from different health care professionals. This novel IBD antenatal clinic provides multidisciplinary care with an IBD clinician, an IBD nurse and an obstetrician all present during the consultation. Methods Prospective data collection for all patients attending the clinic from March 2014 to September 2015 included IBD diagnosis, treatment, adherence (MARS self report scale), disease & pregnancy related patient knowledge (CCPKnow), course of pregnancy, mode of delivery and breast feeding. Patient satisfaction (1 not to 5 very satisfied) was ascertained by formal feedback weeks after delivery. Results Of 48 women (mean age 32 years; range 21–43) 27 had Crohn’s disease, 17 ulcerative colitis and 4 IBD-unclassified. Medication exposure during pregnancy included 5 ASA in 19, Thiopurines in 22 and anti-TNF in 11 cases (3 ongoing, 1 continued to birth, 7 stopped at mean week 25). Disease severity during pregnancy was remission in 62%, mild in 18%, moderate in 16% and severe in 4%. Poor medication adherence occurred in 5 of 27 patients providing adherence data. IBD investigations during pregnancy included 2 bowel ultrasound scans, 1 MRI and 2 sigmoidoscopies. Mean CCPKnow scores were 8.9 at 1 st consultation and 10.1 after birth. Two patients attended for pre-pregnancy counselling and 15 are currently pregnant. There were 27 (17 female) live births, 2 miscarriages, 1 intra-uterine death and 1 medically indicated termination for cardiac abnormalities. Delivery occurred on average at week 39 (range 29–41) with only 2 births before 35 weeks gestation. 19 (70%) patients had a vaginal delivery (5 assisted), 3 underwent elective and 5 emergency caesarean section. Average birth weight was 3099 gram (4 weighed less than 2500 g) and only 3 babies were on the 5 th percentile on personalised growth charts. 18 (66.6%) of mothers breastfed the infant. The average patient satisfaction score was 4.6. Conclusion This novel clinic model offers unique care for pregnant women with IBD. We have demonstrated very good IBD, obstetric and neonatal outcomes. Medication adherence was at least equivalent to non-pregnant patients. In contrast to previous studies showing high caesarean section and poor breast feeding rates in women with IBD our results were close to the national average for healthy women. As patient satisfaction was also high a wider adoption of the model should be considered. Disclosure of Interest C. Selinger Grant/research support from: Abbvie, Warner Chilcott, Consultant for: Abbvie, Warner Chilcott, MSD, Takeda, Speaker bureau with: Abbvie, Warner Chilcott, Dr Falk, Takeda, N. Carey: None Declared, G. Ulivi: None Declared, L. Walker: None Declared, F. Shaikh: None Declared, T. Glanville: None Declared