Washington state, perinatal outcomes, with two exceptions, were similar to those of 1308 normal pregnancies (Dominitz, 2002). One exception was an inexplicably increased incidence of congenital malformations. These authors and others also compared with that for normal controls (Mahadevan, 2015).
lar outcomes in 187 gravidas with ulcerative colitis compared with normal pregnant controls (Bortoli, 2011).
Crohn Disease and Pregnancy. In general, Crohn disease activity during pregnancy is related to its status around the time of conception. In a cohort study of 279 pregnancies in 186 women whose disease was inactive at conception, a fourth relapsed during pregnancy (Fonager, 1998). In 93 with active disease at conception, however, two thirds either remained active or worsened. Miller (1986) had described similar findings from his earlier review, as did Oron and associates (20a12).
Calcium, vitamin D, and folic acid supplementation mirror that for ulcerative colitis. For maintenance during asymptomatic periods, no regimen is universally efective. Suasalazine is efective for some, but the newer 5-ASA formulations are better tolerated. Prednisone therapy may control moderate to severe lares but is less efective for small-bowel involvement. Immunomodulators such as azathioprine, 6-mercaptopurine, and cyclosporine are used for active disease and for maintenance. These appear relatively safe during pregnancy (Briggs, 2015; Chande, 2015). As discussed in Chapter 12 (pp. 242 and 244), methotrexate, mycophenolate mofetil, and mycophenolic acid are contraindicated in pregnancy (Briggs, 2015; Food and Drug Administration, 2008).
As with ulcerative colitis, treatment with antitumor necrosis factor monoclonal antibodies is often used initially for active Crohn disease and maintenance (Casanova, 2013; Cominelli, 2013; Friedman, 2015). These biological compounds include inliximab, adalimumab, certolizumab (Cimzia), natalizumab (Tysabri), and vedolizumab (Enyvio). As discussed on page 1050, this class of immunomodulators is considered safe in pregnancy (Briggs, 2015; Clowse, 2015). heir discontinuance may be followed by a relapse (Torres, 2015).
Endoscopy or conservative surgery is indicated for complications. Patients with small-bowel involvement are more likely to require surgery for complications that include istulas, strictures, abscesses, and intractable disease. An abdominal surgical procedure was required during 5 percent of pregnancies described by Woolfson (1990). Parenteral hyperalimentation
Stieglitz, 1999). hose with an ileal loop colostomy may have signiicant problems. Women with a perianal istula-unless these are rectovaginal-usually can undergo vaginal delivery without complications (Forsnes, 1999; Takahashi, 2007).
As discussed, the likelihood is greater that Crohn disease is associated with adverse pregnancy outcomes compared with ulcerative colitis (Stephansson, 2010). Outcomes are probably related to disease activities. In a case-control Danish study,
Norgard (2007) reported a twofold risk of preterm births.
preterm delivery, low birthweight, fetal growth restriction, and cesarean delivery in 149 women with Crohn disease. Recall, however, that the prospective ECCO-EpiCom study found outcomes to be similar to those for normal pregnancies.