When IBD Necessitates Surgery During Pregnancy

Inflammatory bowel disease (IBD) incidence peaks during a woman’s reproductive years.

Pregnant women who have IBD are more likely to deliver prematurely, have babies with low birth weight, and need caesarean delivery.

Providers prefer conservative non-toxic medical treatment in pregnancy, but when perforation, transfusion-dependent anemia, toxic megacolon, and obstruction develop, surgery is vital.

Gastroenterologists, obstetricians, colorectal surgeons, and neonatologists are urged to collaborate in pregnant and post-partum surgery candidates to identify optimal strategies. The bulk of published evidence on this topic predates biologic IBD therapy and the advent of minimally invasive surgical techniques.

An article published ahead-of-print in Colorectal Disease indicates that pregnant IBD surgical candidates need a multidisciplinary approach that considers disease severity, complications, and fetal status.

The authors conducted a systematic review of all published series or case reports of IBD patients undergoing surgery during pregnancy or within 6 weeks post-partum published between January, 1950 and July, 2015. This review included 24 articles on ulcerative colitis and eight articles on Crohn’s disease. The researchers used the Dindo-Clavien classification to grade maternal complications.

The published literature covers 86 cases over a 65 year time span. Surgeon reluctance to operate near a gravid uterus, radioactive contrast contraindication, and fears of fetal mortality drive the paucity of cases.

Providers used plain X-rays, MRI, and endoscopy to identify surgical indication and guide the intervention. The American Society of Gastroenterology recommends colonoscopy with moderate sedation in the lateral decubitus position for patients in the third trimester. Removal of the rectum can cause hemorrhage from the engorged pelvic venous plexus necessitating emergency hysterectomy.

Every case of uterine manipulation in patients beyond 28 weeks gestation induced a premature delivery. The investigators recommend simultaneous caesarean section in these patients. Many surgeons believe laparotomy is preferable based on their experiences with non-pregnant patients, but there are only two cases published that describe laparotomy in pregnant women. High maternal mortality was common place in the past but cases since 1980 have been much more successful.

The investigators proposed a treatment algorithm for complicated IBD in pregnant patients, and suggested gastroenterologists, colorectal surgeons, obstetricians and neonatal specialists should weigh maternal complications, fetal condition, disease severity, and gestational age before surgical intervention.