Ulcerative colitis and Crohn’s disease, collectively referred to as inflammatory bowel disease, are diagnosed most commonly in patients in their childbearing years. The incidence of Crohn’s disease in young adults is increasing, whereas the incidence of Ulcerative colitis affecting patients in their reproductive years has remained stable.
The etiology of IBDs is unknown, but clearly genetic factors and tobacco use have been implicated. Women routinely express concern about sexual intimacy, self-esteem, marriage, fertility, offspring inheritance of inflammatory bowel disease, role of disease activity during pregnancy, safety of medications, and, finally, outcome or general health of the fetus. The most important issues for the patient are education and optimal timing of the pregnancy.
Fertility and Disease Activity
Most studies support normal fertility rates in females with Ulcerative colitis. However, Swedish physicians report a markedly reduced potential of reproductive capacity of women after restorative proctocolectomy. It has been noted that women with inflammatory bowel disease have fewer children than unaffected individuals. This may reflect decreased libido, dyspareunia, abdominal pain, diarrhea, or a conscious decision not to procreate.
Active Crohn’s disease does impair fertility. Heal inflammation can involve the ovaries and fallopian tubes resulting in scarring and obstruction. In addition, recto-vaginal and perianal fistulizing disease may contribute to fear of intimacy, and dyspareunia, and vaginal candidiasis may follow medical therapy. In general, patients with Ulcerative colitis and Crohn’s disease should have a quiescent disease interval of at least 3 months prior to conception. The course of inflammatory bowel disease during pregnancy usually correlates with disease activity at time of conception. Patients with active disease may continue with symptoms one-third of the time and may actually have worsening of disease. Women with disease quiescence typically remain in remission during the pregnancy. Additionally, the gastroenterologist should be vigilant for possible disease recurrence in the puerperium.
Studies suggest that smoking supports active Crohn’s disease, affecting fertility and reducing fetal growth. Most patients are aware of tobacco’s ill effects and consider cessation prior to conception. Alternatively, the Ulcerative colitis patient risks disease flare with smoking cessation. The physician should prescribe adequate medical maintenance therapy to avoid reactivation of symptoms and disease during tobacco withdrawal, pregnancy, and postpartum.
In male patients with inflammatory bowel disease, impotence from proctocolectomy maybe an unspoken issue regarding fertility. Compassionate inquiry may be helpful; some patients respond to Viagra therapy. It is known that sulfasalazine may cause reversible oligospermia and impair sperm morphology and motility.
Because of the well-described concept of genetic predisposition to Crohn’s disease, and less commonly Ulcerative colitis, patients inquire about disease transmission to their offspring. The risk of inheriting Crohn’s disease is four times greater in Ashkanazae Jewish families. A positive family history, greater risk when a first degree relative, coupled with location, extent and behavior of Crohn’s disease influence risks. These phenotypes may provide future basis for molecular classification of inflammatory bowel disease.
Recent data suggests that when the affected non-Jewish parent has Crohn’s disease the child has a 5% lifetime risk. The offspring has a 1.6% risk when the affected parent has Ulcerative colitis. Another study reports that with Jewish parents, lifetime risk to child for Crohn’s disease is 7.8%; if both parents have inflammatory bowel disease, the risk to offspring may exceed 35%. The risk to the child for Ulcerative colitis is lower in all scenarios.
Medications During Pregnancy
Disease Activity Assessment
Pregnant women by nature may have intermittent abdominal discomfort from the enlarging gravid uterus, preexisting fibroids, changing bowel habits particularly constipation, bladder compression and gastroesophageal reflux. Other more serious causes of accelerating abdominal pain include cholelithiasis or choledocholithiasis, sphincter of oddi dysfunction, intra-abdominal or retroperitoneal abscess, and toxemia of pregnancy.
Because anemia and erythrocyte sedimentation rate (ESR) elevations occur in pregnancy, basic laboratory parameters (complete blood count, ESR, and albumin) are usually of little value unless there is a dramatic fall of hemoglobin or albumin or a rise of two to three fold of the erythrocyte sedimentation rate.
Diagnostic imaging by either transabdominal ultrasound or magnetic resonance are considered safe in the pregnant patient. If concern for an acute complication such as perforation exists, the suprapubic area can be shielded with a lead apron, and an obstruction series to rule out pneumoperitoneum can be performed. Risk to the fetus from the radiograph is considered minimal when clinical necessity is paramount.
Upper endoscopy may be indicated in the patient with intractable nausea and vomiting in the setting of hematemesis. Note that intravenous propofol (diprovan) for sedation is pregnancy category B, demerol (meperidine) category C, and versed (midazolam) category D. Flexible sig-moidoscopy may be safely performed in the patient with Ulcerative colitis. Colonoscopy is rarely necessary in pregnancy though some clinicians feel that it can be performed safely.
Perforation, hemodynamically significant or transfusion dependent gastrointestinal bleeding and severe medication refractory disease are absolute indications for surgery. If invasive intervention is necessary, the “safest” opportunity, according to surgeons and obstetricians, is the second trimester though fetal demise can approach 50%.
Women with ileo-anal anastomotic pouches and conventional Brooke ileostomies are often concerned about abnormal bowel function during pregnancy. Several of my patients have developed parastomal hernias requiring revision of the ileostomy at cesarean delivery. One patient developed distal small bowel obstruction postpartum as the boggy uterus compressed the ileal pouch. This resolved in time with nasogastric suction and pharmacologic assistance to the uterus.
Outcome of Pregnancy
In quiescent inflammatory bowel disease epidemiologic and case controlled studies suggest that birth weight, prematurity, spontaneous abortion and congenital anomalies are no different from the general population. Importantly, active Crohn’s disease prior to conception and/or during the pregnancy may account for adverse events of pre-term delivery or fetal loss. Thus, both delaying pregnancy when the inflammatory bowel disease is active and using maintenance therapy during pregnancy are good pieces of advice. However, a Swedish prospective population-based study reports increases in pre-term birth and small gestational size of babies with inflammatory bowel disease mothers. Steroid use could be one factor in decreased birth weights.
Mode of Delivery
Population-based cohort studies reveal an increased rate of cesarean section for both patients with Ulcerative colitis and Crohn’s disease versus the general population, 26% versus 13% respectively. Cesarean section is not necessary if there is no perineal disease or if the perianal disease is inactive. Mediolateral episiotomy is recommended to avoid rectal sphincter damage. However, Brandt and others report vaginal delivery and episiotomy may lead to perineal involvement in women with no prior perianal disease.
Pregnancy and inflammatory bowel disease requires education and planning with the patient and physician. Folic acid supplementation prior to conception is essential. Disease activity should be managed expediently. I personally see my pregnant patients in each trimester and 6 to 8 weeks postpartum.