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Pregnancy After Total Colectomy

5th October 2020

There is no reason why you shouldn’t go ahead with any exciting plans to start or extend your family whilst you have a stoma. Most ostomates do very well during their pregnancy and do not always experience complications before or after the birth.

However, it would be wise to discuss any wishes to start a family and potential pregnancy with your surgeon prior to your planned total colectomy surgery, where possible. You may be taking medication which could impact on your ability to conceive and therefore you may need guidance from your Doctor. The surgeon may also need to know your pregnancy plans, as this will help guide him/her to help you make the correct decision as to which type of surgery would benefit you the most.

There are also a few important factors to consider straight after total colectomy surgery. After surgery there is a period of recovery, whilst your body needs to heal to its new state. Total colectomy is a major surgery and therefore rest and recovery for the first 8 weeks are important. Recovery time is very dependent on your health prior to surgery. Discussing your pregnancy plans with your surgeon following your surgery, will help you decide when you are fit to go ahead and start trying to conceive. The discussion of any reconstructive surgery is an important factor when you are considering pregnancy and the possibility of this can be delayed until after you have completed your family.

What is a total colectomy and when is it required?

This type of surgery treats inflammatory bowel conditions (IBD) such as Crohn’s Disease and Ulcerative Colitis, familial adenomatous polyposis (an inherited, hereditary condition) in which multiple polyps form throughout the entire large bowel, colon cancer, trauma to the intestine and severe chronic constipation.

Colectomy is bowel resection of the large bowel (colon). It consists of the surgical removal of any extent of the colon, usually segmental resection (partial colectomy). In extreme cases where the entire large intestine is removed, it is called total colectomy and proctocolectomy denotes that the rectum and anus are included.

Once the entire colon has been removed the surgeon creates an ileostomy from the end of the ileum (small intestine) which diverts faeces into a stoma appliance attached to your abdomen. This is known as a total colectomy with ileostomy formation.

Ileal pouch-anal anastomosis (IPAA) surgery follows total colectomy surgery. It is also known as an ileo-anal pouch (IAP), restorative proctocolectomy and ileal-anal pull-through or sometimes is referred to J pouch or internal pouch which is an anastomosis of the ileum to the anus, bypassing the former site of the colon in cases where the colon has been removed. Its purpose is to restore the function of the anus, serving as an alternative to the ileostomy. The pouch component is a surgically constructed internal reservoir attached to the anus where the rectum would normally be. This surgery is not offered to patients with crohn’s disease.

IAP surgery can be performed as a two or three stage procedure:

  • Two stage: The colon is removed and the ileoanal pouch is formed. A loop ileostomy diverts stool away from the pouch to allow it to heal. The second stage is to reverse the ileostomy and allow the pouch to function. This surgery is performed when the risk of any surgical complications is very low or when follow up treatment (such as chemotherapy) is not required.
  • Three stage: The colon is removed and the end of the small bowel is brought up onto the surface of the abdomen. The redundant rectum is closed internally and the patient is allowed to recover fully from the operation until the next stage. This is usually the preferred method should the patient have been very unwell leading up to their surgery (e.g. lost a lot of weight, been taking high dose steroids or biologics). Once well enough for the second stage, the ileoanal pouch is formed and a new loop ileostomy is fashioned to divert the faeces away from the pouch and allow it time to heal. The third and final stage is to close the ileostomy and allow the pouch to function.

Some women prefer to postpone starting a family until after their final stage of surgery, whilst others are keen to go ahead as soon as they are recovered from their first stage.

Focus on recovery after surgery:

Immediately after major abdominal surgery you are bound to feel exhausted. Listen to your body and rest when you can, as you will often feel tired, but each week will get better. It can take about 6 weeks before you get back to your usual level of activity and 12 weeks before full recovery. During this recovery phase you may also feel a mix of emotions, as you learn to live with a stoma, these are perfectly normal.

At the 12 week stage you will be returning to full activities and it may be worth talking to your surgeon whether this is a time when you can start trying to conceive. Make sure you are emotionally strong enough for the additional excitement that pregnancy brings. Consider if this is the right time for you, as reconstructive surgery might be a discussion for the near future.

Fertility:

Women with IBD appear to have the same fertility as the general population. Although, any reduction in women with IBD may be due to the chronic inflammation from bowel disease, surgery in the pelvis, pelvic scarring, consequent adhesions and potential damage to reproductive organs. Medications are another factor to consider. These factors will be discussed in depth, if you let your surgeon know your plans.

Medications:

Before you start trying to conceive it is important that you check which medications you are taking. Depending on your situation, you may still take some painkillers, these must be reviewed before you put yourself at risk of being pregnant.

For those who suffer with inflammatory bowel conditions (IBD) check whether you are still taking any anti-inflammatory or biologic medicines which may affect the baby, if you or your partner were to become pregnant. For men, some of the medications can reduce fertility e.g. Sulphasalazine, yet it does not affect women’s fertility. Methotrexate is another medicine which should not be taken by either party whilst trying to conceive, due to the links with birth defects or miscarriages and it may affect the formation of sperm. Talk through some alternative options with your surgeon or GP.

Your surgeon or gastroenterologist may also advise waiting a little longer after surgery, to check you do not have a flare up of inflammatory bowel symptoms, before trying to conceive. You may be advised to wait until you are in remission or only have mild disease, as you will be likely to have a more normal and uncomplicated pregnancy.

Pregnancy:

As your abdomen gets larger with your pregnancy, you may find your stoma changes shape slightly. It’s important to get the size (aperture) checked and measured regularly, to make sure your appliance is fitting correctly. It becomes a little tricky to change your appliance when the stoma is slightly below your baby bump, so try using a mirror whilst standing up as this may be a little easier, or hopefully a partner could help you when needed. You may even want to consider a larger pouch to hold a little more than usual, if you are struggling to bend and empty it. Try using a jug to save you bending over the toilet.

Labour and delivery:

You may want to discuss the mode of delivery of your baby with your surgeon or obstetrician. You will be guided by your obstetrician as to whether a vaginal delivery or caesarean is safer for both you and your baby, depending on the type of bowel surgery you have had. The last thing you would want to happen is aggravating any peri-anal disease with a vaginal delivery and a possible episiotomy. Or any damage to the anal sphincter or ileoanal pouch may not be immediate, but could be a longer term issue.

We hope that has cleared up any issues or worries you may have had. Remember, if you have any concerns at all, you can always speak to your HCP or stoma nurse.

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