The effects of inflammatory bowel disease on pregnancy: a case-controlled retrospective analysis

Retrospective analysis of 82 pregnancies in women with either ulcerative colitis or Crohn's disease suggested that, in general, neither disease had a major effect on pregnancy outcome. The birth-weights of babies born to women with inflammatory bowel disease were marginally lower than those born to women in a control group matched for age and parity, but the difference was statistically significant only in women with Crohn's disease. In both disease groups there was a higher frequency of low haemoglobin levels in pregnancy than in the matched control groups. There were no statistically significant effects of ulcerative colitis or Crohn's disease on duration of pregnancy, mode of delivery or raised blood pressure and/or proteinuria. In the absence of a relapse, a diagnosis of inflammatory bowel disease should not influence obstetric management.     

The effects of inflammatory bowel disease on pregnancy: a case-controlled retrospective analysis

Summary. Retrospective analysis of 82 pregnancies in women with either ulcerative colitis or Crohn's disease suggested that, in general, neither disease had a major effect on pregnancy outcome. The birthweights of babies born to women with inflammatory bowel disease were marginally lower than those born to women in a control group matched. for age and parity, but the difference was statistically significant only in women with Crohn's disease. In both disease groups there was a higher frequency of low haemoglobin levels in pregnancy than in the matched control groups. There were no statistically significant effects of ulcerative colitis or Crohn's disease on duration of pregnancy, mode of delivery or raised blood pressure and/or proteinuria. In the absence of a relapse, a diagnosis of inflammatory bowel disease should not influence obstetric management.     

Pregnancy and inflammatory bowel disease: a review of the literature

This review encompasses fertility with inflammatory bowel disease, risk of inheritance, effects of inflammatory bowel disease on pregnancy, effects of pregnancy on inflammatory bowel disease, effects of treatment on the mother and child, and pregnancy after proctocolectomy with ileostomy. Fertility is minimally, if at all, compromised. The fetus is likely to survive despite disease activity. Inactive disease favors a normal pregnancy. Active disease may worsen during the first trimester or the puerperium. Close medical supervision allows therapy to be instituted promptly. Patients with Crohn's disease who have medically induced remissions may fare less well than those who have undergone a successful operation. Previous surgery does not preclude vaginal delivery. Sulfasalazine and corticosteroids may be used. Patients with extensive fistulas may require cesarean section. There are few reasons to consider therapeutic abortion.     

Obstetric triage: management of acute nonobstetric abdominal pain in pregnancy

Acute, nonobstetric abdominal pain is a common complaint during pregnancy. Both anatomic and physiologic variations in pregnancy cloud the clinical picture when attempts at clinical decision-making and triage are made. Abdominal disorders such as appendicitis, gallbladder disease, pancreatitis, bowel obstruction, liver disease, pyelonephritis, and inflammatory bowel disease are explored from an obstetric triage perspective. Key triage points are noted to augment clinical assessment by the practitioner.     

Inflammatory bowel disease: a controlled study of late pregnancy outcome

A retrospective controlled study of 98 pregnancies complicated by inflammatory bowel disease was conducted with control pregnancies matched for parity, sex of offspring, year of delivery, and maternal age. Two control pregnancies were paired with each study case. There was no significant difference in weight gain or hemoglobin levels between the two groups. However, patients with inflammatory bowel disease had a statistically significantly higher preterm delivery rate (p less than 0.01) than the rate of the control group. The risk of these two disorders was further increased when exacerbation of the bowel disease occurred during pregnancy.     

Hyperemesis gravidarum,gastrointestinal and liver disease in pregnancy

Women of childbearing age may be affected by diseases of the gastrointestinal tract or liver; some have no effect on obstetric outcome, some are improved in pregnancy and some deteriorate. Gastrointestinal or liver disease may be caused by pregnancy and resolve following delivery e.g. hyperemesis gravidarum, pre-eclampsia, acute fatty liver of pregnancy, HELLP syndrome and obstetric cholestasis, or may present for the first time in pregnancy e.g. inflammatory bowel disease, cholelithiasis and hepatitis. These examples and other common gastrointestinal and liver disorders will be discussed giving details of diagnosis, management and effects on pregnancy outcome and also background information on normal liver physiology in pregnancy.     

Isotretinoin: Update on Controversial Issues

Acne vulgaris is a commonly seen dermatologic condition that plagues millions and can be very psychosocially disabling. Severe and recalcitrant acne is typically treated with isotretinoin. Isotretinoin is a synthetic vitamin A derivative that has been available since 1982. This therapeutic option has been the most effective at putting severe and recalcitrant acne vulgaris into remission. Despite its effectiveness, it has been associated with inflammatory bowel disease, depression, suicidality, and teratogenicity. We review the current literature on isotretinoin's role in inflammatory bowel disease, depression, and suicidality. In addition, we review whether or not the iPledge program has been successful at reducing pregnancy rates while on isotretinoin.     

Care of Women with Chronic Inflammatory Bowel Disease (Chronic IBD) During Pregnancy: Recommendations of the Obstetrics and Prenatal Medicine Working Group of the DGGG

The incidence of chronic inflammatory bowel disease (chronic IBD) in persons of reproductive age is high. Chronic IBD does not typically lead to impaired fertility. Nevertheless, the percentage of women suffering from chronic IBD who have children is lower than that of the general population, due to self-imposed childlessness. Providing women with open, unbiased information and, if necessary, helping them to overcome baseless fears should therefore be an essential part of preconception counseling. With the exception of methotrexate, most standard drugs can and should be continued during pregnancy. If the pregnancy occurs during an inactive phase of disease, the rate of complications in pregnancy should, in principle, not be higher than normal. Nevertheless, pregnant women with chronic IBD are classed as high-risk pregnancies. Organ screening in accordance with DEGUM II criteria should be carried out in every case, and women must be monitored for the potential development of placental insufficiency. Any flare-ups which occur during pregnancy should be treated in full. Vaginal delivery can be considered if there is no perianal manifestation of disease; however, the individual risk must be carefully weighed up.Key words: chronic inflammatory bowel disease, Crohnʼs disease, ulcerative colitis, pregnancy     

Inflammatory bowel diseases: gynecological and obstetrical considerations

Inflammatory bowel diseases (IBD), including Crohn's disease and ulcerative colitis, are invalidating inflammatory affections, which evolve by relapse interrupted with clinical remission. Crohn's disease commonly affects young women in their reproductive years with a peak of incidence between 20 and 30. Infertility and sexual dysfunction are equivalent to that of the general population while they are increasing in patients with active IBD or after colorectal surgery. IBD are well controlled by medical treatments and the frequency of relapse during the pregnancy is similar to that of the non-pregnant IBD patients. The data concerning the risk of congenital malformations in IBD are contradictory. The risk of preterm delivery and low birth weight is significantly increased and correlated to the disease activity. When a medical treatment insures a quiescent disease before the pregnancy, it is advisable to continue it during the pregnancy because the benefits of controlled disease outweigh the risks of medication. IBD, possible perianal lesions and colorectal surgical interventions influence the mode of delivery, but the indication of caesarean section should primarily be governed by obstetric necessity. Preconceptional counseling seems desirable because of the risks during pregnancy, according to the disease activity, the surgical histories and the therapeutic agents.     

Gastrointestinal disease

Gastrointestinal diseases in pregnancy can be divided into diseases specific to pregnancy, for example, hyperemesis gravidarum, obstetric cholestasis, HELLP syndrome and acute fatty liver of pregnancy, and diseases incidental to pregnancy, for example, inflammatory bowel disease, dyspepsia, peptic ulcer disease and viral hepatitis. Disorders in the second category may present for the first time in pregnancy. This chapter considers the drug management of each of these conditions, with the exception of HELLP syndrome and acute fatty liver. The preferred drug treatment and the known complications associated with their use in pregnancy are also described. Where possible, studies relating to the safety of different therapeutic options are discussed.     

Drugs in pregnancy. Gastrointestinal disease.

Gastrointestinal diseases in pregnancy can be divided into diseases specific to pregnancy, for example, hyperemesis gravidarum, obstetric cholestasis, HELLP syndrome and acute fatty liver of pregnancy, and diseases incidental to pregnancy, for example, inflammatory bowel disease, dyspepsia, peptic ulcer disease and viral hepatitis. Disorders in the second category may present for the first time in pregnancy. This chapter considers the drug management of each of these conditions, with the exception of HELLP syndrome and acute fatty liver. The preferred drug treatment and the known complications associated with their use in pregnancy are also described. Where possible, studies relating to the safety of different therapeutic options are discussed.     

Subfertility and gastrointestinal disease: 'unexplained' is often undiagnosed

Subfertility can be more reliably explained and effectively treated with an improved understanding of the contribution of chronic medical disease to reproductive dysfunction. This review addresses several common gastrointestinal disorders which are increasingly implicated in infertility and early pregnancy loss: celiac disease, inflammatory bowel disease (ulcerative colitis and Crohn's disease), and hemochromatosis. Appreciating the reproductive impact of these comorbidities and their treatments enables clinicians to accurately counsel patients and to modify medical and fertility treatments based on etiology. Because unexplained infertility can represent the initial presentation of undiagnosed medical disease, considering these often-subclinical gastrointestinal disorders in the differential diagnosis of subfertility provides an opportunity not only to increase the probability of conception and uncomplicated pregnancy, but also to improve overall maternal health.     

Reproduction and ulcerative colitis: a review

Ulcerative colitis is a chronic inflammatory bowel disease. The onset peaks at age 15-30 years and coincides with the reproductive period. We screened and summarized the relevant English-language publications (Entrez-PubMed) on ulcerative colitis, fertility and pregnancy. The presence of ulcerative colitis per se does not seem to significantly alterfertility in young women. However, associated conditions, such as active disease, surgical interventions and medication, may interfere with reproduction. It is difficult to draw conclusions regarding the effect of ulcerative colitis on pregnancy outcome in terms of pregnancy loss, intrauterine growth restriction, low birth weight, preterm labor, stillbirth and perinatal mortality. Nevertheless, it appears that major complications do not occur in ulcerative colitis patients more frequently than in healthy women. The rate of exacerbation is probably the same for pregnant and nonpregnant women. Disease control during pregnancy is of the utmost importance. Fortunately, most drugs can by used safely during pregnancy.     

Inflammatory Bowel Disease Presenting in Pregnancy

A case of inflammatory bowel disease (IBD) presenting in pregnancy is described. Despite previous reports of severe fulminating disease in this type of patient, this woman did well with an uncomplicated course; she responded to standard medical therapy and there were no fetal complications. IBD should not be a contraindication to pregnancy unless the disease is poorly controlled. Pregnancy does not increase the risk of relapse of IBD, but should this occur it is more likely in the first trimester or in the postpartum period. Treatment of IBD in pregnancy should be much the same as in the nonpregnant woman. Corticosteroids and sulphasalazine are safe in pregnancy and are the mainstays of medical treatment. Surgery should proceed for the usual indications of toxic megacolon and perforation. In the group requiring surgery fetal mortality is considerable but the maternal outcome is improving. Patients presenting with IBD in pregnancy may have more severe disease but recent reports suggest that the outcome for mother and infant in this group is improving.     

Chronisch-entzündliche Darmerkrankungen in der Schwangerschaft

Crohn’s disease and ulcerative colitis are the most frequent forms of chronic inflammatory bowel disease. Peak frequency of this disease coincides with the time of fertility. Thus, preconception counseling and medical management to reduce activity indices during the periconception period are important. As a basic principle, medicinal treatment should be adapted to disease activity, distinguishing between first-line and second-line therapy. Intensive antenatal and dietary counseling continue to be significant for prognosis of the disease during pregnancy. The incidence of complications—spontaneous abortions, preterm deliveries, retarded fetal growth and malformations—is elevated. Surgical intervention should be reserved for exceptional circumstances.     

Tubo-ovarian abscess mimicking ovarian tumor in a sexually inactive girl

Tubo-ovarian abscess is a serious complication of pelvic inflammatory disease rarely seen in sexually inactive girls. Early diagnosis and treatment are essential to prevent further sequela including infertility, ectopic pregnancy, and chronic pelvic pain. We present a case of 19-year-old sexually inactive girl who presented with abdominal pain and pelvic mass resembling ovarian tumor. Unilateral tubo-ovarian abscess with extensive bowel adhesions was determined at laparotomy. Drainage of the abscess and postoperative antibiotic therapy cured the patient.     

Epidemiology of extrauterine pregnancy

An epidemiological study of ectopic pregnancy shows an increased frequency, a diminution of mortality by ectopic pregnancy. This review of the literature points out the influence of several factors implicated in the increased incidence of ectopic pregnancy: pelvis inflammatory disease (PID), intrauterine device and other contraceptive methods tubal ligation, induced abortions, tubal microsurgery, proximal tubal disease, ovulation induction and in vitro fertilization, diethylstilboestrol (DES) syndrome.     

Crohn's disease: "its gynecologic aspect"

An analysis of the medical records of 103 women with Crohn's disease points up the following observations. There is a slight increase in spontaneous abortions and a substantial degree of subfertility. The obstetric experience is the same as in the normal obstetric population and the effects of the disease on pregnancy and of pregnancy on the disease are minimal. Features seemingly unrelated to Crohn's disease and of a gynecologic nature may be present months before the onset of the main bowel inflammation. These features consist of abscesses, fistulas, ulcers, fissures, and infections involving not only the internal pelvic organs but also the vulvovagina, perineum, labia, rectovaginal septum, rectum, and anus. The onset of Crohn's disease may be acute and present the picture of an abdomen requiring surgical treatment. A tender, low abdominal, adnexal, or pelvic mass may incorrectly be diagnosed as acute appendicitis, pelvic inflammatory disease, or ovarian cyst, and lead to surgery. In 23 instances the diagnosis of Crohn's disease was established only after laparotomy. A total of 27 appendectomies were performed and none of these patients had acute appendicitis. Four pelvic abscesses developed after the appendectomies. To avoid the pitfalls of misdiagnosis and mismanagement, the nature of Crohn's disease should be understood and the gynecologic aspects of the disease recognized.     

Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial

OBJECTIVE: Pelvic inflammatory disease (PID) is a common and morbid intraperitoneal infection. Although most women with pelvic inflammatory disease are treated as outpatients, the effectiveness of this strategy remains unproven. STUDY DESIGN: We enrolled 831 women with clinical signs and symptoms of mild-to-moderate pelvic inflammatory disease into a multicenter randomized clinical trial of inpatient treatment initiated by intravenous cefoxitin and doxycycline versus outpatient treatment that consisted of a single intramuscular injection of cefoxitin and oral doxycycline. Long-term outcomes were pregnancy rate, time to pregnancy, recurrence of pelvic inflammatory disease, chronic pelvic pain, and ectopic pregnancy. RESULTS: Short-term clinical and microbiologic improvement were similar between women randomized to the inpatient and outpatient groups. After a mean follow-up period of 35 months, pregnancy rates were nearly equal (42.0% for outpatients and 41.7% for inpatients). There were also no statistically significant differences between outpatient and inpatient groups in the outcome of time to pregnancy or in the proportion of women with pelvic inflammatory disease recurrence, chronic pelvic pain, or ectopic pregnancy. CONCLUSION: Among women with mild-to-moderate pelvic inflammatory disease, there was no difference in reproductive outcomes between women randomized to inpatient treatment and those randomized to outpatient treatment.     

Gender issues in the management of inflammatory bowel disease and irritable bowel syndrome

Crohn's disease and ulcerative colitis are two chronic inflammatory diseases involving the gastrointestinal tract. While many aspects of the management of these diseases are identical for all patients, there are some issues that are specific to women that are not necessarily part of routine care. Such gender-specific issues as menses, fertility, pregnancy and menopause are often overlooked and mismanaged. Women have different psychological concerns as compared with men with regard to their self-image and impact of disease. Health care providers, regardless of their primary focus, should be aware of these differences and be familiar with general information. Irritable bowel syndrome is a prevalent condition that affects more women than men. Theories as to its underlying pathophysiology are still evolving, but what does appear clear is that women pose specific challenges to the management of this condition.