Inflammatory Colorectal Disease and Pregnancy: R e p o r t of a Case* MANDELL I. GANCHROW,

M.D.,t

HOWARD BENJAMIN, M . D .

From the Department of Colon-Rectal Surgery, Ferguson Clinic, Grand Rapids, Michigan

TABLE 1. Operations Performed

INFLAMMATORY DISEASE of the bowel affects primarily young people. Its occurrence in relationship to pregnancy is an area of much relevance. The purpose of this paper is to analyze this relationship.

Chronic Ulcerative Colitis

(34)

Colectomy and ileostomy Right hemicolectomy Small-bowel resection Colostomy Laparotomy for "appendicitis" Appendectomy

Material and Methods One hundred women, between the ages of 18 and 50 years, consecutively hospitalized at the Ferguson Clinic with the diagnosis of inflammatory disease of the bowel, were sent questionnaires regarding various facets of their obstetrical and intestinal histories. Where applicable, pathology was reviewed by the Department of Pathologyl

7

Crohn's Disease

(17) 5* 4 1 2 I

1 8

13

* Two cases were diagnosed clinically as chronic ulcerative colitis.

Crohn's disease had undergone surgery. Two of the five patients who had transmural colitis and had undergone colectomy and ileostomy had originally been diagnosed both clinically and pathologically as having nmcosal colitis.

Results Sixty replies were received. After discarding those who were unmarried and those whose disease had occurred after their last pregnancy, 51 patients were accepted for this study. Thirty-four were classified as having mucosal disease (ulcerative colitis) and 17 as having transmural disease (granulomatous or Crohn's).

Difficulty in Conception Four of 3'4 patients (11.7 per cent) who had mucosal colitis reported subjective difficulty with conception, while one of 17 (5.8 per cent) with transmural disease reported such difficulty.

Prior Surgery Seven of the 34 patients who had mucosal colitis had undergone colectomy and ileostomy (Table 1), while 18 of 17 who had

Number of Pregnancies The 34 patients with mucosal disease had 138 pregnancies, with a live birth rate of 81.8 per cent, while the 17 with transmural disease had 51 pregnancies and a live birth rate of 78.2 per cent (Table 2).

* Received for publication January 27, 1975. J-Current address: Chief, Section of Colon-Rectal Surgery, Department of Surgery, Good Samaritan Hospital, Suffern, New York. Address reprint requests to: Ferguson Clinic, 72 Sheldon S.E., Grand Rapids, Michigan 49502.

706 Nov.-Dec. 1975 Dis. CoL & Rect.

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COLITIS AND PREGNANCY TABLE 2.

Rates of Success[ul Pregnancies

Number of Patients

Number of Pregnancies

Pregnancies/Pt.

Number of Live Births

Per Cent Live Births

Chronic ulcerative colitis

34

138

4

113

81.8

Crohn's disease

17

51

3

41

78.2

TABLE 3. Subjective Condition of Bowel Disease during Pregnancy Improved

Same

Worse

Number

Per Cent

Number

Per Cent

Number

Per Cent

5

16,5

10

29,7

19

62.7

13

75,8

4

24.2

0

Chronic ulcerative colitis Crohn's disease

Subjective Condition of Bowel During Pregnancy W h e n asked how they would categorize their bowel condition during pregnancy, five with mucosal disease and 13 with transmural disease felt improved. T e n with mucosal and four with transmural disease felt the same, and 19 with mucosal disease felt worse (Table 3). No patient with transmural disease felt worse during her pregnancy. T h e times of increased severity of disease in the 19 patients are listed in Table 4. T h r e e patients with Crohn's disease did feel worse in the immediate postpartum period.

Complications T a b l e 5 outlines a list of complications. Both patients with rectovaginal fistulas were post-episiotomy. One patient had had a temporary colostomy elsewhere. Our initial interest in this subject was brought about by the second patient.

Report of a Case A 35-year-old white woman was first seen at the Ferguson Clinic in 1967, with crampy abdominal pain and arthritis. Examination revealed tenderness of the right lower quadrant, an anal fistula, and slgmoidoscopic findings of diffuse granularity with skip areas and x-rays suggestive of transmural ileo-

colitis. The patient was treated with prednisone, azulfidine, tranquilizers, and diet, but was lost t o follow.up. She returned in December 1969, two months postpartum, Delivery and baby had been "normal." Her complaint now was exacerbation of her disease. She also had two rectovaginal fistulas in the episiotomy incision. Her steroid dosage was increased. The fistulas failed to heal with conservative treatment despite subsidence of the intestinal symptoms. The patient has refused all suggestions of surgery.

Discussion Various authors 1, 2, 12 reported the incidences of pregnancy in women less than 45 years old who have ulcerative colitis as ranging from 40 to 50 per cent. Crohn et al. 4 found that of 133 married women with Crohn's disease, ~t8 had had pregnancies before the onset of the disease, 53 had 85 Time of increased Severity of Intestinal Symptoms

TASLE 4.

Chronic ulcerative colitis First trimester Second trimester Third trimester Immediately postpartum Not stated TOTAL

4 1 3 4 7 19

Crohn's disease During pregnancy Immediately postpartum

0 3

708

GANCHRO~V AND BENJAMIN

p r e g n a n c i e s after onset, a n d 32 m i g h t have been infertile. F i e l d i n g a n d Cooke 7 f o u n d t h a t 25 of 77 p a t i e n t s w i t h C r o h n ' s disease were sterile, a n d felt t h a t this was attribu t a b l e to the effects of the disease. I n our study 100 p e r cent of w o m e n w i t h b o t h diseases were able to conceive. T h i s w o u l d a p p e a r to a ~ e e w i t h the conclusion of M a d d i x 13 that colitic p a t i e n t s become pregn a n t as often as o t h e r female m e m b e r s of the g e n e r a l p o p u l a t i o n . G o l i g h e r et al.S stated t h a t a y o u n g female colitic p a t i e n t has a n even chance of a n a t t a c k of colitis in a n y given year w h e t h e r o r n o t she is p r e g n a n t at t h a t time. de D o m b a l e t al. 6 f o u n d no adverse effect on ulcerative colitis in 107 p r e g n a n c i e s in 72 patients. T u r n b u l l a n d H a w k t~ r e p o r t e d e i g h t s t i l l b o r n or s p o n t a n e o u s a b o r t i o n s , two p r e m a t u r e b i r t h s a n d two a b n o r m a l fetuses in 34 p r e g n a n c i e s with C r o h n ' s disease a n d two stillbirths of 31 p r e g n a n c i e s in chronic ulcerative colitis. M c E w a n 14 rep o r t e d an 8 p e r cent a b o r t i o n r a t e i n 50 p r e g n a n c i e s in 38 colitic patients. C r o h n

Dis. Col. &Reet. Nov..Dee. 1975

et al., 4 f o l l o w i n g 110 f e m a l e p a t i e n t s for as

l o n g as 23 years, f o u n d t h a t p r e g n a n c y exercised an u n f a v o r a b l e i n f l u e n c e o n ulcerative colitis; Jacobs a n d J a n o w i t z 10 r e a c h e d the same conclusion. T h i s was true especially when the colitis was active at the t i m e of c o n c e p t i o n o r w h e n it d e v e l o p e d d u r i n g p r e g n a n c y . C r o h n et al. 3, 5, o b s e r v e d t h a t t h e i r p a t i e n t s w i t h ileitis seemed to tolerate p r e g n a n c y b e t t e r t h a n those w i t h ulcerative colitis, a l t h o u g h p r e g n a n c y d i d e x e r t a n u n f a v o r a b l e effect on the ileitis. F i e l d i n g a n d Cooke7 f o u n d no evidence of adverse effect of p r e g n a n c y on C r o h n ' s disease; r a t h e r , sterility was the m a i n p r o b l e m . Jones a n d Soltau tl felt t h a t t e r m i n a t i o n of p r e g n a n c y was n o t i n d i c a t e d even in the presence of active C r o h n ' s disease. ~Vebb a n d Sedlack, a6 in r e v i e w i n g the M a y o C l i n i c exp e r i e n c e of 86 consecutive cases of u l c e r a t i v e colitis, felt t h a t the fertility rate, spontaneous a b o r t i o n rate, a n d u l t i m a t e successful o u t c o m e of p r e g n a n c y d i d n o t a p p e a r to be influenced by the disease process to a n unacceptable extent. I n o u r series, 75 p e r cent

TABLE 5. Complications Chronic Ulcerative Colitis Severe anemia Toxemia Hypertension Fever Excessive weight loss Excessive weight gain from steroids Constipation Rectovaginal fistula Ileostomy prolapse Unremitting nausea Postpartum hemorrhage Early ruptured membranes Placenta praevia Hemorrhoids Retained placenta Bleeding during pregnancy Cervicitis Kidney infection Severe varicose veins

2 2 1 1 l 1 4 2 1 2 1 1 3

Crohn's Disease

I

1 2

1

1 1

2 1 I 1 27

7

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COLITIS AND PREGNANCY

of the patients with C r o h n ' s disease felt that their i n t e s t i n a l symptoms had b e e n alleviated d u r i n g pregnancy, c o m p a r e d with only 16 per cent w i t h ulcerative colitis. T w o of o u r patients h a d been misdiagnosed as h a v i n g ulcerative colitis clinically a n d pathologically a n d p r o v e n to have t r a n s m u r a l disease o n re-evaluation; b o t h felt i m p r o v e d d u r i n g pregnancy. Of the five p a t i e n t s w i t h ulcerative colitis who rep o r t e d i m p r o v e m e n t d u r i n g pregnancy, n o n e has come to surgery. It has b e e n suggested that the high relapse rate after c h i l d b i r t h a n d increased symptoms i n the first trimester are related to a low level of p l a s m a cortisol which occurs at that time. t3 T h e r e was n o cases of toxic dilat a t i o n of the colon, which is rare i n pregnancy. 14 Post-episiotomy rectovaginal fistula does n o t a p p e a r to be m e n t i o n e d as a comp l i c a t i o n of C r o h n ' s disease occurring i n pregnancy. T o t a l colectomy a n d ileostomy do not negate a successful pregnancy. T h e r e m a y be a n increased tendency of the stoma 9 to prolapse.

o u r series were a p p r o x i m a t e l y 80 per cent. A n u n u s u a l c o m p l i c a t i o n in two of o u r patients with C r o h n ' s disease was a postp a r t u m , postepisiotomy rectovaginal fistula. T h i s m a y i n d i c a t e a possible d a n g e r of episiotomy i n p a t i e n t s who have C r o h n ' s disease. References 1. Banks BM, Korelitz BI, Zetzel L: T h e course of nonspecific ulcerative colitis: Review of

2. 3. 4. 5. 6. 7. 8. 9.

SUlTUnalT~

A retrospective study of w o m e n i n the child-bearing age with i n f l a m m a t o r y disease of the bowel seems to suggest that these w o m e n become p r e g n a n t as often as other w o m e n i n the general p o p u l a t i o n . I n this small study it was 100 per cent. T h e incidence of subjective difficulty with concept i o n is likewise small. Patients with C r o h n ' s disease a p p e a r to feel better i n p r e g n a n c y w i t h r e g a r d to their i n t e s t i n a l problems, while more t h a n 60 per cent of the p a t i e n t s with ulcerative colitis a p p e a r to do poorly. T h e l i v e - b i r t h rates for b o t h c o n d i t i o n s i n

709

t0.

I1, 12. 13. 14. 15. 16.

twenty ],'ears' experience and late results. Gastroenterology 32: 983, 1957 Becker IM: Pregnancy and toxic dilatation of the colon. Am J Dig Dis 17: 79, 1972 Crohn BB: Regional Ileitis. New York, Grune and Stratton, 1949, p 86 Crohn BB, Yarnis H, Crohn EB, et al: Ulcerative colitis and preg-nancy. Gastroenterology 30: 391, 1956 Crohn BB, Yarnis H, Korelitz BI: Regional ileitis complicating pregnancy. Gastroenterology 31: 615, 1956 deDombal FT, Watts JM, Watkinson G, et al: Ulcerative colitis and pregnancy. Lancet 2: 599, 1965 Fielding JF, Cooke WT: Pregnancy and Crohn's disease. Br Med J 2: 76, 1970 Goligher JC, de Dombal laW, Watts JbI, et al: Ulcerative Colitis. Baltimore, Williams and Wilkins, 1968, p 194 Hunter PG: Ulcerative colitis and pregnancy. J Maine Med Assoc 62: 294, 1971 Jacobs WH, Janowitz HD: The digestive tract. In Rovinsky JJ, Guttmacher AF (eds) : Medical, Surgical, and Gynecologic Complications of Pregnancy. Ed 2. Baltimore, Williams and Wilkins, 1965, chapter 10, p 177 Jones RL, Soltau DH: Pregnancy in association with Crohn's disease. J Obstet Gynaecol Br Commonw 65: .811, 1958 MacDougall I: Ulcerative colitis and pregnancy. Lancet 2: 641, 1956 Maddix BL: Ulcerative colitis and pregnancy. Minn Med 45: 1097, 1962 McEwan HP: Ulcerative colitis in pregnancy. Proc R Soc Med 65: 279, 1972 Turnbull RB, Hawk ~NA: Crohn's disease and pregnancy (correspondence). Br Med J 2: 364, 1970 Webb MJ, Sedlack RE: Ulcerative colitis in pregnancy. Med Clin North Am 58:823 (July) 1974

Inflammatory colorectal disease and pregnancy: report of a case.

A retrospective study of women in the child-bearing age with inflammatory disease of the bowel seems to suggest that these women become pregnant as of...
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