ObstetricsTier 1Disease (DEADMAN)

Irritable bowel disease

Description

IBD (Crohn's/UC) in pregnancy - despite the note title, the clinically important entity is inflammatory bowel disease, not IBS
Disease activity at conception is the single strongest predictor of pregnancy outcome - quiescent disease behaves like the general population

Peak IBD incidence overlaps reproductive years - common comorbidity in obstetric practice
Fertility near-normal in quiescent UC/Crohn's; reduced after pelvic surgery (IPAA, perianal Crohn's)
Active disease at conception -> higher risk of flare persisting/worsening in pregnancy

Pregnancy itself does not reliably worsen or improve IBD - course mirrors pre-conception activity
Active disease -> impaired implantation, placental inflammation -> inc miscarriage, preterm birth, growth restriction, low birth weight
Flares in pregnancy often reflect non-adherence (fear of medication harm) rather than pregnancy-driven biology

Pre-conception counselling ideal - assess and optimise disease activity before conceiving
Faecal calprotectin - remains useful and interpretable in pregnancy
Endoscopy - safe if genuinely needed, defer to 2nd trimester where possible, avoid bowel prep dehydration
Imaging - ultrasound/MRI preferred over CT; avoid ionising radiation where alternatives suffice

Principle: continue effective therapy - the biggest risk is a flare, not the drug

5-ASA compounds - safe throughout pregnancy and breastfeeding
Thiopurines (azathioprine/6-MP) - safe to continue if already effective; not usually initiated fresh in pregnancy given lag to effect
Biologics (anti-TNF: infliximab, adalimumab; vedolizumab; ustekinumab) - continue through pregnancy, standard of care - active disease is the greater risk
- Anti-TNF crosses placenta increasingly in 3rd trimester - timing of last dose considered case-by-case, but reflex stopping is discouraged
- Live vaccines deferred in infant if biologic exposure in utero (per specific agent/timing) - discuss with paediatrics
Corticosteroids - used for flares as in non-pregnant patients, short courses
Methotrexate contraindicated - teratogenic, must be stopped and effective contraception used pre-conception (at least 3-6 months washout recommended)
Mode of delivery - active perianal Crohn's disease is an indication for caesarean (avoid perineal trauma extending fistulating disease); otherwise vaginal delivery is not contraindicated

Active disease -> miscarriage, preterm birth, small for gestational age, low birth weight
Perianal Crohn's disease -> obstetric consideration for delivery mode
Nutritional deficiency (iron, B12, folate) - screen and replace, compounded by pregnancy demands

Quiescent disease at conception -> pregnancy outcomes approach the general population
Flare during pregnancy - treat promptly and as aggressively as outside pregnancy; undertreatment is the dominant cause of poor outcomes, not medication
Postpartum flare risk - increased in first few months post-delivery, especially if medication reduced/stopped during pregnancy

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