title: Vaginal delivery after ileal pouch-anal anastomosis: a word of caution.
abstract: OBJECTIVE
  This study was designed to evaluate the impact of childbirth on anal sphincter integrity and function, functional outcome, and quality of life in females with restorative proctocolectomy and ileal pouch-anal anastomosis.
  
  
  METHODS
  The patients who had at least one live birth after ileal pouch-anal anastomosis were asked to return for a comprehensive assessment. They were asked to complete the following questionnaires: the Short Form-36, Cleveland Global Quality of Life scale, American Society of Colorectal Surgeons fecal incontinence severity index, and time trade-off method. Additionally, anal sphincter integrity (endosonography) and manometric pressures were measured by a medical physician blinded to the delivery technique. Anal sphincter physiology also was evaluated with electromyography and pudendal nerve function by nerve terminal motor latency technique.
  
  
  RESULTS
  Of 110 eligible females who had at least one live birth after ileal pouch-anal anastomosis, 57 participated in the study by returning for clinical evaluation to the clinic and 25 others by returning the quality of life and functional outcome questionnaires. Patients were classified into two groups: patients who had only cesarean section delivery after ileal pouch-anal anastomosis (n = 62) and patients who had at least one vaginal delivery after ileal pouch-anal anastomosis (n = 20). The mean follow-up from the date of the most recent delivery was 4.9 years. The vaginal delivery group had significantly higher incidence of an anterior sphincter defect by anal endosonography (50 percent) vs. cesarean section delivery group (13 percent; P = 0.012). The mean squeeze anal pressure was significantly higher in the patients who had only cesarean section delivery (150 mmHg) after restorative proctocolectomy than patients who had at least one vaginal delivery (120 mmHg) after restorative proctocolectomy (P = 0.049). Quality of life evaluated by time trade-off method also was significantly better in the cesarean section delivery group (1) vs. vaginal delivery group (0.9; P < 0.001).
  
  
  CONCLUSIONS
  The risk of the sphincter injury and quality of life measured by time trade-off method are significantly worse after vaginal delivery compared with cesarean section in patients with ileal pouch-anal anastomosis. In the short-term, this does not seem to substantially influence pouch function or quality of life; however, the long-term effects remain unknown, thus obstetric concern may not be the only factor dictating the type of delivery in this group of patients. A planned cesarean section may eliminate these potential and factual concerns in ileal pouch-anal anastomosis patients.
authors.affiliation: Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio 44195, USA. remzif@ccf.org
authors.forename: Feza H
authors.initials: FH
authors.lastname: Remzi
authors.forename: Emre
authors.initials: E
authors.lastname: Gorgun
authors.forename: Jane
authors.initials: J
authors.lastname: Bast
authors.forename: Tom
authors.initials: T
authors.lastname: Schroeder
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Hammel
authors.forename: Elliot
authors.initials: E
authors.lastname: Philipson
authors.forename: Tracy L
authors.initials: TL
authors.lastname: Hull
authors.forename: James M
authors.initials: JM
authors.lastname: Church
authors.forename: Victor W
authors.initials: VW
authors.lastname: Fazio
mesh_terms: D000328:Adult; D001003:Anal Canal / Q000503:physiopathology*; D039021:Colonic Pouches / Q000502:physiology*; D036861:Delivery, Obstetric / Q000379:methods*; D004576:Electromyography; D019160:Endosonography; D005242:Fecal Incontinence / Q000503:physiopathology; D005260:Female; D006801:Humans; D008365:Manometry; D011247:Pregnancy; D011248:Pregnancy Complications / Q000503:physiopathology; D011256:Pregnancy Outcome; D011788:Quality of Life; D011795:Surveys and Questionnaires