Review article

Inflammatory bowel disease in pregnancy

Onset and diagnosis during pregnancy

An early clinical series suggested that women with ulcerative colitis diagnosed during pregnancy had a poor prognosis [3]. Since that time, epidemiologic data have failed to show a worse disease course during pregnancy [4]. The clinical course of the de novo diagnosis of Crohn's disease during pregnancy is unstudied. Hence, disease severity during this circumstance is unknown.

Contraception

The management of contraception in women with IBD differs from that in other women. The most important goal still remains selection of the most reliable method of birth control. Barrier methods of contraception are acceptable but are less effective than alternatives. Although not absolutely contraindicated, use of intrauterine devices is often discouraged because complaints of abdominal pain could potentially delay the diagnosis of active IBD versus pelvic inflammatory disease.

The data

Fertility

The fertility of women with ulcerative colitis is essentially the same as that of the general population [17]. Early studies suggesting lower fertility had not taken into account an increased rate of voluntary childlessness in women with IBD.

Active Crohn's disease, however, reduces fertility by several mechanisms, depending upon the location of inflammation. Active inflammation in the colon [18] and terminal ileal disease [19] decrease fertility. Active ileal inflammation can cause inflammation

Inheritance

Some women remain childless for fear of disease transmission to their offspring. Inflammatory bowel disease, however, is not a genetic disorder in a true Mendelian fashion. Despite genetic predisposition, other factors are necessary for disease expression. Current data suggest that a child of an affected parent has a 5% risk when the proband has Crohn's disease and a 1.6% risk when the proband has ulcerative colitis [26]. The risk of IBD increases up to 37%, however, if both parents have the

Effect of inflammatory bowel disease on pregnancy

Open discussions between patient and physician promote a successful pregnancy outcome. If a woman is doing well and is in remission, the pregnancy should proceed smoothly. Although there is no minimum required time period for quiescent disease before planned conception, a quiescent interval of at least 3 months is recommended. If active disease is present, it is likely to continue through pregnancy and will increase the risk of a pregnancy complication [28]. This risk seems to be higher in

Effect of pregnancy on inflammatory bowel disease

For women with quiescent ulcerative colitis at conception, the rate of relapse is approximately the same in pregnant as in nonpregnant patients [28]. In contrast, about 70% of women with active ulcerative colitis at the time of conception have continued or worsening disease activity during pregnancy. The same effects occur in Crohn's disease [35]. The older literature suggested disease tended to flare during the first trimester, but this effect was observed before the currently accepted

Surgery and pregnancy

Elective surgery is uncommon in the pregnant IBD patient. Surgery performed in the second trimester does not seem to entail a significant increase in perinatal morality compared with women without IBD [99].

The indications for surgery for IBD during pregnancy are identical to those in nonpregnant patients. Indications include obstruction, perforation, abscess, and hemorrhage. In the ill pregnant IBD patient, continued maternal illness poses a greater risk to the fetus than surgical intervention

Summary

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  Fertility is affected in ulcerative colitis after surgery and in active Crohn's disease.

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  Adverse fetal outcomes are not increased when IBD is quiescent.

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  Active disease at conception increases the risk of adverse fetal outcomes.

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  Most medications for IBD are safe during pregnancy and breastfeeding, with notable exceptions. Active disease is usually more deleterious than maintaining medical therapy.