Crohn Disease and William P.
Pregnancy
Homan, MD, Bjorn Thorbjarnarson, MD
\s=b\ Seventy-eight women with Crohn disease, each having the physical capability and opportunity to bear children, were admitted to the New York Hospital-Cornell Medical Center during a 20-year period. Forty-two pregnancies occurred. Results are suggestive of overall decreased fertility with no significant difference according to site of disease. The outcome of the pregnancies was not unlike that of the general population. Pregnancy did not exert an adverse effect on the disease itself, but termination of pregnancy was associated with relapse of
Crohn disease 24% of the time.
(Arch Surg 111:545-547, 1976)
disease, a disabling and idiopathic bowel disorder, is characteristically a disease of young people. As its incidence has increased during the past years, more and more women with childbearing potential have become afflicted, causing uncertainty regarding the effect of pregnancy on Crohn disease and vice versa.' Reports on the coexistence of the other idiopathic inflammatory bowel disease, ulcerative colitis, and pregnancy have been frequent, yet relatively little notice has been paid to Crohn disease.- This is particularly true of Crohn colitis, which has only recently been clearly defined as a separate entity.3 In reviewing our experience with Crohn disease during the past 20 years, the quandary surrounding its relationship to fertility and pregnancy was intriguing, and it prompted this report.
Crohn
SUBJECTS AND METHODS Between Jan 1, 1955, and Dec 31, 1974, three hundred fifteen patients were treated at the New York Hospital-Cornell Medical Center with a diagnosis of Crohn disease. In each patient the clinical impression was confirmed pathologically, radiologically, or at exploratory surgery. A combination of these confirmations was
Accepted for publication Nov 25, 1975. From the Department of Surgery, the
New York Hospital-Cornell Center, New York. Reprint requests to Department of Surgery, New York Hospital-Cornell Medical Center, 525 E 68th St, New York, NY 10021 (Dr Thorbjarnarson). Medical
usually
obtained. All other patients were excluded. Of these patients, 140 were women and were therefore theoret¬ ically available for study. However, 22 in this group developed Crohn disease after age 44 and were excluded from the study in keeping with the policy of the National Center for Health Statistics on natality.' An additional 34 women were unmarried at the time of the development of their disease and remained so during the period of study. Two patients were divorced before the onset of the disease; four patients received no follow-up after their diagnosis and were therefore not suitable for study. The remaining 78 patients were included in this report. The age range was between 15 and 44 years and was taken as the span over which a patient might probably bear children'-no children were born outside this range. Follow-up was therefore complete when a woman's history was available from the time of diagnosis to age 45. By this definition, follow-up was complete in 70 (90%) of the patients. Information was obtained from hospital and physician's records, personal interviews, and questionnaires to patients and their doctors. Of the 78 patients analyzed, 35 had borne 50 children before the onset of their disease. There were 42 pregnancies following the diagnosis of Crohn disease.
RESULTS Site of Crohn Disease
Eighteen patients had involvement primarily of the colon; in most cases,.it was right-sided, in keeping with previous findings.'1 Twelve of the patients in the study had enterocolitis and 48 patients had disease primarily or exclusively of the small bowel (Figure). Effect of Crohn Disease
on
Pregnancy
Five of the 18 patients with Crohn colitis became pregnant a total of nine times. In the 12 patients with large and small bowel involved equally, there were nine pregnan¬ cies in five patients. Sixteen of the 48 patients with small bowel involvement conceived 24 times (Table 1). Thus, 67% of the patients could be termed as "subfertile" or "infer¬ tile," as proposed by others."·7 The differences in fertility among the sites of primary disease are not statistically
significant.
Table 2 indicates fertility rates by site of disease with the fertility rate of the United States in
compared
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/01/2015
Table 1.—Patients
Conceiving, According to Site of Disease No.
Site of Disease Colon Colon and small intestine Small intestine Total
Conceived
Did Not Conceive
Total
5(28)
13(72)
18(100)
5(42) (33) (33)
32 52
7(58) (67) (67)
12(100) 48(100) 78(100)
16 26
Colon all bowel nd colon
Table
(%) of Patients
2.—Fertility
Rate
to Site of Disease''
According
Fertility Rate,
Pregnancy/Woman/yr
Site of Disease Colon Colon and small intestine Small intestine All sites US population (1970)
0.079 0.083 0.053 0.063 0.088
Table 3.—Outcome of Pregnancies In Patients With Crohn Disease by Site of Involvement
Sites of Crohn disease in 78 women studied. Colon, 18 patients; small bowel and colon, 12 patients; small bowel, 48 patients.
Site
1970.' The fertility rates for women with colonie disease do not differ remarkably from the United States as a whole, but the low fertility rate for women with small bowel disease suggests a problem in fertility. The outcome of the 42 pregnancies encompassed by this study is summarized in Table 3. One abortion was performed "therapeutically" in a woman with extensive small bowel involvement for fear she would have an exacerbation of her disease, although at the time she was having only mild symptoms. Two abortions were perform¬ ed for personal reasons. With the exception of these two unwanted pregnancies, 31 of 40 pregnancies (78%) resulted in a live child. Spontaneous abortion occurred in seven (17%) pregnancies, and is not out of line with estimates of 15% occurring in all pregnancies." Two deliveries were accomplished by cesarean section for fetal distress. These represent 6.2% of pregnancies not ending in abortion and this rate is closely comparable to the estimated incidence of cesarean section in the United States." The only congenital
defect was
a case
of
polydactylism.
Outcome of Delivery Full-term vaginal
Colon
Group
28
Effect of
Pregnancy
No
on
Crohn Disease
In analyzing the effects of pregnancy on Crohn disease, results have been classified as follows, as suggested by Abramson et al." Group i.—Group 1 consists of patients in whom preg¬ nancy occurs in the quiescent stage of disease. Group ¿.—Group 2 includes patients in whom pregnancy occurs during the active phase of the disease. Group 3— Group 3 comprises patients in whom the onset of disease occurs during pregnancy.
on
Crohn Disease
No.
(%) of Patients Severity of Disease
Group
1
Total
(N-42)
delivery
Exacerbation?
Yes
Small Intestine
Premature (
Pregnancy
Homan, MD, Bjorn Thorbjarnarson, MD
\s=b\ Seventy-eight women with Crohn disease, each having the physical capability and opportunity to bear children, were admitted to the New York Hospital-Cornell Medical Center during a 20-year period. Forty-two pregnancies occurred. Results are suggestive of overall decreased fertility with no significant difference according to site of disease. The outcome of the pregnancies was not unlike that of the general population. Pregnancy did not exert an adverse effect on the disease itself, but termination of pregnancy was associated with relapse of
Crohn disease 24% of the time.
(Arch Surg 111:545-547, 1976)
disease, a disabling and idiopathic bowel disorder, is characteristically a disease of young people. As its incidence has increased during the past years, more and more women with childbearing potential have become afflicted, causing uncertainty regarding the effect of pregnancy on Crohn disease and vice versa.' Reports on the coexistence of the other idiopathic inflammatory bowel disease, ulcerative colitis, and pregnancy have been frequent, yet relatively little notice has been paid to Crohn disease.- This is particularly true of Crohn colitis, which has only recently been clearly defined as a separate entity.3 In reviewing our experience with Crohn disease during the past 20 years, the quandary surrounding its relationship to fertility and pregnancy was intriguing, and it prompted this report.
Crohn
SUBJECTS AND METHODS Between Jan 1, 1955, and Dec 31, 1974, three hundred fifteen patients were treated at the New York Hospital-Cornell Medical Center with a diagnosis of Crohn disease. In each patient the clinical impression was confirmed pathologically, radiologically, or at exploratory surgery. A combination of these confirmations was
Accepted for publication Nov 25, 1975. From the Department of Surgery, the
New York Hospital-Cornell Center, New York. Reprint requests to Department of Surgery, New York Hospital-Cornell Medical Center, 525 E 68th St, New York, NY 10021 (Dr Thorbjarnarson). Medical
usually
obtained. All other patients were excluded. Of these patients, 140 were women and were therefore theoret¬ ically available for study. However, 22 in this group developed Crohn disease after age 44 and were excluded from the study in keeping with the policy of the National Center for Health Statistics on natality.' An additional 34 women were unmarried at the time of the development of their disease and remained so during the period of study. Two patients were divorced before the onset of the disease; four patients received no follow-up after their diagnosis and were therefore not suitable for study. The remaining 78 patients were included in this report. The age range was between 15 and 44 years and was taken as the span over which a patient might probably bear children'-no children were born outside this range. Follow-up was therefore complete when a woman's history was available from the time of diagnosis to age 45. By this definition, follow-up was complete in 70 (90%) of the patients. Information was obtained from hospital and physician's records, personal interviews, and questionnaires to patients and their doctors. Of the 78 patients analyzed, 35 had borne 50 children before the onset of their disease. There were 42 pregnancies following the diagnosis of Crohn disease.
RESULTS Site of Crohn Disease
Eighteen patients had involvement primarily of the colon; in most cases,.it was right-sided, in keeping with previous findings.'1 Twelve of the patients in the study had enterocolitis and 48 patients had disease primarily or exclusively of the small bowel (Figure). Effect of Crohn Disease
on
Pregnancy
Five of the 18 patients with Crohn colitis became pregnant a total of nine times. In the 12 patients with large and small bowel involved equally, there were nine pregnan¬ cies in five patients. Sixteen of the 48 patients with small bowel involvement conceived 24 times (Table 1). Thus, 67% of the patients could be termed as "subfertile" or "infer¬ tile," as proposed by others."·7 The differences in fertility among the sites of primary disease are not statistically
significant.
Table 2 indicates fertility rates by site of disease with the fertility rate of the United States in
compared
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/01/2015
Table 1.—Patients
Conceiving, According to Site of Disease No.
Site of Disease Colon Colon and small intestine Small intestine Total
Conceived
Did Not Conceive
Total
5(28)
13(72)
18(100)
5(42) (33) (33)
32 52
7(58) (67) (67)
12(100) 48(100) 78(100)
16 26
Colon all bowel nd colon
Table
(%) of Patients
2.—Fertility
Rate
to Site of Disease''
According
Fertility Rate,
Pregnancy/Woman/yr
Site of Disease Colon Colon and small intestine Small intestine All sites US population (1970)
0.079 0.083 0.053 0.063 0.088
Table 3.—Outcome of Pregnancies In Patients With Crohn Disease by Site of Involvement
Sites of Crohn disease in 78 women studied. Colon, 18 patients; small bowel and colon, 12 patients; small bowel, 48 patients.
Site
1970.' The fertility rates for women with colonie disease do not differ remarkably from the United States as a whole, but the low fertility rate for women with small bowel disease suggests a problem in fertility. The outcome of the 42 pregnancies encompassed by this study is summarized in Table 3. One abortion was performed "therapeutically" in a woman with extensive small bowel involvement for fear she would have an exacerbation of her disease, although at the time she was having only mild symptoms. Two abortions were perform¬ ed for personal reasons. With the exception of these two unwanted pregnancies, 31 of 40 pregnancies (78%) resulted in a live child. Spontaneous abortion occurred in seven (17%) pregnancies, and is not out of line with estimates of 15% occurring in all pregnancies." Two deliveries were accomplished by cesarean section for fetal distress. These represent 6.2% of pregnancies not ending in abortion and this rate is closely comparable to the estimated incidence of cesarean section in the United States." The only congenital
defect was
a case
of
polydactylism.
Outcome of Delivery Full-term vaginal
Colon
Group
28
Effect of
Pregnancy
No
on
Crohn Disease
In analyzing the effects of pregnancy on Crohn disease, results have been classified as follows, as suggested by Abramson et al." Group i.—Group 1 consists of patients in whom preg¬ nancy occurs in the quiescent stage of disease. Group ¿.—Group 2 includes patients in whom pregnancy occurs during the active phase of the disease. Group 3— Group 3 comprises patients in whom the onset of disease occurs during pregnancy.
on
Crohn Disease
No.
(%) of Patients Severity of Disease
Group
1
Total
(N-42)
delivery
Exacerbation?
Yes
Small Intestine
Premature (
