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CASE SERIES
Year : 2022  |  Volume : 20  |  Issue : 2  |  Page : 95-98

Inflammatory bowel disease in pregnancy: case series with review of literature


1 Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Obstetrics, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission16-Nov-2021
Date of Decision18-Dec-2021
Date of Acceptance23-Dec-2021
Date of Web Publication07-May-2022

Correspondence Address:
Dr. Audrin Lenin
Department of Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_102_21

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  Abstract 


Inflammatory bowel disease (IBD) affects women in their reproductive years with severe disease associated with maternal morbidity and adverse fetal outcome. A retrospective chart review was conducted for all patients admitted under the departments of Medicine and Obstetrics from 2012 to 2018. The patients with IBD in pregnancy were identified. The inpatient and outpatient charts of these patients were reviewed for the clinical profile, treatment received, and outcomes. We report our experience of managing pregnant women with IBD in South India. Of the five patients, two presented with the active severe disease during pregnancy and were treated with steroids and azathioprine of whom, one developed chorioamnionitis and the other metabolic complications. All except one pregnancy required operative delivery. Pregnancy outcomes in IBD are dependent on the disease activity status at conception. Diagnosis of IBD in pregnancy is a challenge, as full-length colonoscopy and computed tomography imaging is not feasible. Chorioamnionitis is a complication associated with IBD, probably due to immunosuppressive drugs.

Keywords: Crohn's disease, inflammatory bowel disease, pregnancy, ulcerative colitis


How to cite this article:
Lenin A, Ninan GA, Vijayaselvi R, Rathore S, Rajan SJ. Inflammatory bowel disease in pregnancy: case series with review of literature. Curr Med Issues 2022;20:95-8

How to cite this URL:
Lenin A, Ninan GA, Vijayaselvi R, Rathore S, Rajan SJ. Inflammatory bowel disease in pregnancy: case series with review of literature. Curr Med Issues [serial online] 2022 [cited 2022 May 25];20:95-8. Available from: https://www.cmijournal.org/text.asp?2022/20/2/95/344922




  Introduction Top


Inflammatory bowel disease (IBD) is an emerging disease in the tropics with improving socioeconomic status and changes in dietary practices and worsening economic disparity. Infective diarrhea is the most common reason for an acute episode of altered bowel symptoms in India. However, some of these infections can persist for >2 weeks, and given the high burden of infections in the tropical regions delay the diagnosis of inflammatory disorders. In European countries, the incidence rates of ulcerative colitis (UC) and Crohn's disease (CD), are 10.4/100,000 and 5.6/100,000/year, respectively.[1] Epidemiological studies from India have reported a prevalence rate of 42.8–44.3/100,000, and a crude incidence rate of 6.02/100,000 population. Access to clean drinking water was an independent risk factor for developing CD.[2],[3],[4]

Both CD and UC affect women in the reproductive age group. Around one in four women diagnosed to have IBD become pregnant.[5] Hence, it is important to understand the effects of IBD on pregnancy and vice versa for the treatment of pregnant women with IBD, especially in a tropical country with high diarrhea burden. Women with IBD may choose to avoid pregnancy or discontinue their medications during pregnancy. Pregnant women are less likely to be subjected to invasive investigations like colonoscopy to diagnose CD. Noninvasive tests like fecal calprotectin can be falsely positive in gastrointestinal tuberculosis.[6] Diagnostic delay in IBD is associated with poorer outcomes and an increased risk of requiring surgery.[7] Maintaining remission before pregnancy with appropriate medications offsets the risks of disease flares.[8],[9] These effects in a tropical country have not been studied.


  Methodology Top


Study setting

This study was done in a high-risk obstetric care center in South India with 15,000 deliveries conducted from 2012 to 2018.

Study design

This was a retrospective chart review of patients admitted under the departments of medicine and obstetrics from 2012 to 2018.

Participants

The patients with the diagnosis of IBD in pregnancy were identified. The inpatient and outpatient charts of the patients with IBD in pregnancy were reviewed. The data regarding the type of IBD, clinical profile, diagnostic evaluation, surgical intervention, and treatment given were collected. A descriptive analysis of the clinical profile and the treatment given was done. The maternal, neonatal, and medical outcomes of the patients were described.

Ethical considerations

The institutional review board (IRB) clearance was obtained prior to initiation of the study (IRB 12107, 26/06/2019). Permission for waiver of consent was obtained before commencement of the study.


  Results Top


The retrospective database search identified five patients with IBD during pregnancy. There were eight pregnancies as three of these patients became pregnant twice. The clinical details, endoscopy findings, histopathology findings, therapy given, and pregnancy maternal and fetal outcomes are summarized in [Table 1], [Table 2], [Table 3]. Four patients had UC and one had CD. The mean age at the time of first childbirth in these women with IBD was 30.4 (range: 28–34) years. Three of the patients were diagnosed to have IBD before pregnancy.
Table 1: Baseline characteristics

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Table 2: Pregnancy outcomes

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Table 3: Neonatal outcomes

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Two patients had active severe disease requiring steroids, azathioprine, and aminosalicylates. One patient had flare of disease during pregnancy when she stopped her medications in the first trimester. All of the patients were on aminosalicylates. The patient with CD had a history of small bowel resection and anastomosis before pregnancy; but none required surgical intervention for IBD during pregnancy.

The mean gestational age at delivery was 38 (range: 37–40) weeks. Seven pregnancies required operative delivery by lower section cesarean section (LSCS) or instrumental delivery. Two patients developed chorioamnionitis, one was on immunosuppressive therapy with azathioprine and steroids, and the other had preterm premature rupture of membrane (PPROM). One patient developed infective gastroenteritis postpartum. All the infants had normal Apgar with a mean birth weight of 2.93 (range: 2.32––3.62) kg.


  Discussion Top


In our series of patients, UC was more common than CD. Disease activity at the time of diagnosis has a strong association with maternal morbidity. Patients on treatment for IBD at the time of being pregnant should be advised to continue the medications unless strongly contraindicated. Studies show that if IBD remains in remission during the duration of pregnancy, the risks of adverse maternal and fetal outcomes are similar to the general population. They need to be monitored for infective complications in tropical countries with a high burden of infectious disease.

Diagnosis during pregnancy is challenging as computed tomography scan is contraindicated and a complete colonoscopy is associated with increased risk. Magnetic resonance imaging of the abdomen, limited colonoscopy, or flexible sigmoidoscopy can be used to in patients with high suspicion of IBD.

In a tropical country with a high prevalence of intestinal tuberculosis, enteric fever with ileal involvement and amoebiasis, the diagnosis of IBD require a more thorough workup as CD commonly involves the ileum and presents with granulomas. The diagnosis of IBD in pregnancy is a challenge and there can be a delay in diagnosis. Delay in diagnosis and delay in time to initiate immunosuppression is frequent. The diagnosis of IBD should be considered in any patient with chronic diarrhea, prolonged blood-stained stools, and negative workup for infections. Early diagnosis and disease remission is essential to ensure good pregnancy outcomes.

Two of the patients had developed chorioamnionitis in this series. Of the patients with chorioamnionitis, one was on azathioprine and steroids and the other had PPROM. Chorioamnionitis is not common in patients with IBD in pregnancy.[10] Helpman et al. reported chorioamnionitis in an IBD patient on treatment with azathioprine, but there are no large studies showing this correlation.[11] However, in tropical countries with a higher infectious disease burden, the risk may be higher. The risk of chorioamnionitis with IBD, especially among women on immunosuppression, needs to be explored in further studies.


  Conclusion Top


The pregnancy outcome with IBD is associated with the disease activity status at the time of pregnancy. Aminosalicylates are the mainstay of therapy and are relatively safe in pregnancy. Stopping of aminosalicylates during pregnancy can precipitate a flare and may lead to adverse outcomes. With quiescent disease, the maternal and fetal outcomes are comparable to a normal population. Active disease may be associated with a higher incidence of maternal morbidity related to the disease, immunosuppression, and higher LSCS rates.

Acknowledgment

The authors would like to thank Department of Medicine and Department of Obstetrics, CMC Vellore.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Binder V. Epidemiology of IBD during the twentieth century: An integrated view. Best Pract Res Clin Gastroenterol 2004;18:463-79.  Back to cited text no. 1
    
2.
Khosla R, Willoughby CP, Jewell DP. Crohn's disease and pregnancy. Gut 1984;25:52-6.  Back to cited text no. 2
    
3.
Sood A, Midha V, Sood N, Bhatia AS, Avasthi G. Incidence and prevalence of ulcerative colitis in Punjab, North India. Gut 2003;52:1587-90.  Back to cited text no. 3
    
4.
Pugazhendhi S, Sahu MK, Subramanian V, Pulimood A, Ramakrishna BS. Environmental factors associated with Crohn's disease in India. Indian J Gastroenterol 2011;30:264-9.  Back to cited text no. 4
    
5.
Heetun ZS, Byrnes C, Neary P, O'Morain C. Review article: Reproduction in the patient with inflammatory bowel disease. Aliment Pharmacol Ther 2007;26:513-33.  Back to cited text no. 5
    
6.
Larsson G, Shenoy KT, Ramasubramanian R, Thayumanavan L, Balakumaran LK, Bjune GA, et al. Faecal calprotectin levels differentiate intestinal from pulmonary tuberculosis: An observational study from Southern India. United European Gastroenterol J 2014;2:397-405.  Back to cited text no. 6
    
7.
Lee DW, Koo JS, Choe JW, Suh SJ, Kim SY, Hyun JJ, et al. Diagnostic delay in inflammatory bowel disease increases the risk of intestinal surgery. World J Gastroenterol 2017;23:6474-81.  Back to cited text no. 7
    
8.
Lindhagen T, Bohe M, Ekelund G, Valentin L. Fertility and outcome of pregnancy in patients operated on for Crohn's disease. Int J Colorectal Dis 1986;1:25-7.  Back to cited text no. 8
    
9.
Mountifield RE, Prosser R, Bampton P, Muller K, Andrews JM. Pregnancy and IBD treatment: This challenging interplay from a patients' perspective. J Crohns Colitis 2010;4:176-82.  Back to cited text no. 9
    
10.
Taleban S, Gundogan F, Chien EK, Degli-Esposti S, Saha S. Placental inflammation is not increased in inflammatory bowel disease. Ann Gastroenterol 2015;28:457-63.  Back to cited text no. 10
    
11.
Helpman L, Pauzner D, Lessing JB, Kupferminc MJ, Gutman G. Chorioamnionitis associated with Crohn's disease and azathioprine treatment: A case report. J Med Microbiol 2005;54:803-4.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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