Crohn's Disease

Question 1

What are maternal symptoms of Crohn’s disease?

Answer 1

Diarrhea.
Fever.
Fatigue.
Abdominal pain and cramping.
Bloody stool.
Mouth sores.
Reduced appetite and weight loss.
Fistula.

Question 2

How do you counsel a patient regarding maternal and obstetric risks of Crohn’s disease and pregnancy?

Answer 2

increase the risk for

• preterm labor
• low birthweight and small for gestational age

Patients with active disease at the time of conception tend to have an active course of their inflammatory bowel disease in pregnancy.

-1/3 will experience a flare during pregnancy

There is an increased risk for cesarean delivery ( 44% which is higher than the general population).

-Cesarean delivery is recommended if there is active perineal disease.

Question 3

How do you follow a patient with Crohn’s disease during pregnancy?

Answer 3

Surveillance for Crohn’s and pregnancy is not different from nonpregnant state. If diarrhea was to occur during pregnancy it is important to differentiate between a flare versus intestinal infection especially with C. difficile using stool studies, flexible sigmoidoscopy, and/or abdominal CT or MRI.

Question 4

How do you counsel a patient regarding the use of sulfasalazine during pregnancy?

Answer 4

Most human reports on sulfasalazine therapy during pregnancy have not associated the medication with adverse pregnancy outcome.

Question 5

How do you counsel a patient regarding chronic steroid use during pregnancy?

Answer 5

-Should be used for short periods to induce remission -Use of prednisone is safe in pregnancy (increased incidence of low-birth-weight neonates)

Increased risk for maternal DM if used chronically.

Stress dose steroids can be administered to prevent Addisonian collapse if chronic use as follow:

• hydrocortisone 100mg IV as initial dose
• then followed by 50mg IV every 8 hours for 24 hours. -The usual oral dose of steroids can be restarted in the postpartum period.

Question 6

How do you counsel a patient regarding use of anti tumor necrosis factor agents during pregnancy?

Answer 6

Case reports have inconsistently shown:

• extremely premature
• lamellar ichthyosis
• spontaneous abortions
• tetralogy of Fallot.

Because patients who are taking maintenance infliximab usually have been refractory to other treatments, it is likely that their Crohn disease will flare during pregnancy if infliximab is stopped. The unknown risks and benefits must be discussed with the patient.

Question 7

Do you recommend vaginal birth in patients with Crohn’s disease? What are the indications for cesarean section?

Answer 7

Yes. Cesarean delivery is recommended if there is active perineal disease.

Question 8

How do you follow a patient with Crohn’s disease in pregnancy?

Answer 8

-Detailed anatomy, fetal growth
-Assess for flares (Sx: Diarrhea, Fever, Fatigue, Abdominal pain and cramping, Bloody stool, Mouth sores, weight loss, Fistula)
-Treat with the following:
Antidiarrheal like loperamide
Antibiotics like metronidazole if C. Diff suspected
Steroids
Sulfasalazine
5-Aminosalicylates

*** Assess for C. Diff before starting any immunomodulary drugs like azathioprine

Question 9

What are symptoms of a Crohn;s disease flare?

Answer 9

Diarrhea.
Fever.
Fatigue.
Abdominal pain and cramping.
Bloody stool.
Mouth sores.
Reduced appetite and weight loss.
Fistula.

Question 10

How do you manage a flare in pregnancy?

Answer 10

-Assess for flares (Sx: Diarrhea, Fever, Fatigue, Abdominal pain and cramping, Bloody stool, Mouth sores, weight loss, Fistula)
-Treat with the following:
Antidiarrheal like loperamide
Antibiotics like metronidazole if C. Diff suspected
Steroids
Sulfasalazine
5-Aminosalicylates

*** Assess for C. Diff before starting any immunomodulary drugs like azathioprine