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The Natural History of Inflammatory Bowel Disease and Pregnancy
Most women with IBD who desire to become pregnant can do so Conceive successfully, carry to term, and deliver a healthy
infant
However, management of IBD during pregnancy is challenging Misconceptions Unknowns Some women with CD or UC will have difficulty becoming
pregnant or have increased disease symptoms while pregnant
Control of disease activity before conception and during pregnancy is critical to optimize both maternal and fetal health
IBD and Pregnancy
IBD and Pregnancy Peak age ranges for pregnancy and IBD
coincide Many women develop CD/UC during
reproductive years
Many of the ‘classic’ studies conducted in 1950s: Multiple shortcomings - Before ‘modern era’ of drug therapy Patients treated with steroids were not
always clearly separated from those who were not
Drug therapy was inconsistent No distinctions made on the different
anatomical parts affected Types of complications
Early studies on fertility and CD concluded that fertility is not impaired by CD [Crohn et al, Gastroenterology, 1956]
However, multiple studies since that time refute this Fertility has since been shown to be
decreased in CD [De Dombal et al, BMJ 1972]
Fertility and Pregnancy: CD
Patients with IBD have fewer children than expected for the population
Fertility has been shown to be decreased in CD [De Dombal et al, BMJ 1972] 40/86 women followed became pregnant (subfertility rate 54%
vs. ~8-10% infertility in healthy couples) After surgery, these women became pregnant at same rate as
women in general population Some suggest that women with inactive CD have normal fertility
Control of disease activity appears to restore normal fertility
Fertility is decreased in CD Due to voluntary childlessness?
Question: Is this reduced gravidity voluntary or disease-related?
Large European study [Mayberry et al, Gut 1986] showed the reduced fertility rate is not voluntary b/c contraception was used less in CD patients
Possible etiologies:Medical… Ovary and tube disruption by inflammatory process [R/L] Perirectal, perineal, and rectovaginal abscesses and
fistulas dyspareunia and ⇩libido Overall toxicity from CD (abdominal pain, malnutrition) Men: reduced fertility taking sulfasalazine
Decreased sperm counts in ~60 - 80% men
Others… Relationship difficulties Body image problems Fear of pregnancy Inappropriate medical advice
Fertility and Pregnancy: CD
Fertility and Pregnancy: UC
Several studies [1982 – 1988] showed that infertility rate among women is same as in general population
However, female fertility is impaired by surgery Rectal excision or if pelvic sepsis complicates post-op Caveat: Studies 1980s – different surgical techniques nowadays
Effect of CD or UC on PregnancyPregnancy Outcome is Debatable…
Neither CD nor UC has any unfavorable effect on the outcome of pregnancy Confirmed in several studies over past 3 decades
Incidence of premature births, spontaneous abortions, stillbirths and congenital abnormalities are similar to the general population In review of 748 patients in 1970s, 1980s
<1% congenital abnormalities 12% spontaneous abortions or stillbirth
However, others [Alstead and Nelson-Percy, Gut 2003] believe there’s a significant risk of preterm delivery (<37 wks) and low birth weight (<2500g) in mothers with IBD
Disease Activity
However, in CD there may be a higher rate of fetal abnormalities with active disease at time of conception: Small babies 7% Premature labor 6% Respiratory distress 1%
[Woolfson K et al DCR 1990]
Higher preterm delivery rates in patients with IBD, especially with exacerbation of disease [Fedorkow et al Am J Ob Gyn, 1989]
Effect of CD or UC on Pregnancy
Conception and Disease Activity
In both CD and UC, increased inflammatory activity at the time of conception unfavorably affects the pregnancy and is associated with a significantly higher rate of complications Unknown mechanism(s)
IBD Drug Therapy and Its Effect on Pregnancy
Conflict b/w obstetricians, who often recommend stopping all drugs during pregnancy, and gastroenterologists
Sulfasalazine and its 5-ASA derivative cross the placenta barrier and secreted in milk – but very low levels due to poor absorption from small bowel No increases in prematurity or spontaneous abortion Men: reduced fertility taking sulfasalazine
Decreased sperm counts in ~60 - 80% men Returns after ~ 2 months of discontinuation
Corticosteroids cross the placenta; suppression of HPA axis is rare No evidence of fetal damage but some isolated reports of fetal distress and
stillbirth Concentration in breast milk is low
Conclusions
In general, ~85% of women with IBD (CD, UC) experience normal, uncomplicated pregnancies
Congenital malformations in infants born to women with CD or UC occur ~1%
Risk of miscarriage also does not, in general, appear to be increased
All these rates correspond to those observed in healthy women
Effect of Pregnancy on IBD
Most changes in state of colitis occur in the first trimester Mainly exacerbation
May be partially due to stopping maintenance meds Improvement
It’s not possible to predict the course of IBD during subsequent pregnancies Colitis can behave differently from one pregnancy to another
Effect of Pregnancy on IBD
“Quiescence of disease before conception is likely to be followed by quiescence during pregnancy”
The course of IBD during pregnancy is directly affected by disease activity before conception [Mogadam DM et al Am J Gastro, 1981] Series of 324 patient 75% with quiescent to mild disease remained so 51% active IBD continued with moderate to severe disease
Effect of Pregnancy on IBD
“Quiescence of disease before conception is likely to be followed by quiescence during pregnancy”
Possibly, a rise in serum cortisol during late pregnancy and a rapid fall postpartum may account for the fall and rise in the relapse rate in UC
For active disease at conception, most will continue to have active disease during pregnancy: 25% - 100%
For chronic disease in remission, different studies show varying relapse rates during pregnancy: 10% - 54%
Effect of Pregnancy on IBD Pregnancy in women who have had restorative
proctocolectomy is usually uncomplicated
However, there’s a higher rate of C-sections Due to fear of compromising continence
Uncertainty of how these patients would fare with vaginal deliveries
Pelvic location of the pouch protects it from effect of abdominal wall distention But, makes it more susceptible to pressure exerted on the pelvic
floor during pregnancy and delivery
Effect of Pregnancy on IBD
Many believe that indication for C-section should only be obstetric No good data Small, retrospective studies In some of these, <50% C-sections were performed for
obstetric reasons
Higher complication rates in patients with stoma may be due to abdominal wall distention
Patients with CD do not face any major additional GI risk during pregnancy
Episiotomy and CD?
Effect of Pregnancy on IBD
First IBD Attack During Pregnancy Very few data: Usually thought that the prognosis is generally
poor
Surgery for IBD During Pregnancy
Operate when need for surgery is obvious Fulminant colitis Toxic megacolon Perforation
More typical and difficult situation is patient with severe disease flare who has incomplete response to medical therapy Unfortunately, little literature to guide Pushing medical therapy may not help; may increase the risk to
mother and fetus In the ill, pregnant IBD mother not responding to medical therapy,
greater risk to the fetus is continued maternal illness (rather than surgery)