Introduction
Crohn's disease is a long-lasting disease primarily caused by hereditary and microorganisms. The risk of the disease can be controlled by keeping the disease under control for a time frame of three to six months before pregnancy occurs. Earlier, people with Crohn's disease voluntarily opted out not to get pregnant because of the adverse effects they would face after getting pregnant. Crohn's disease has a high chance of reducing pregnancy by affecting the fallopian tube and ovaries, causing inflammation.
How Does Crohn's Disease Occur?
Scientists have identified that some genes can increase the risk of developing Crohn's disease. These genes work by providing instructions for making proteins that are involved in the immune system. When these genes get disturbed, it impacts the ability of cells in the intestine to respond to bacteria that is present in them, leading to chronic inflammation and other symptoms of the disease.
Whom Should the Patient Consult?
Both gastroenterologists and obstetricians are responsible for offering the necessary support needed with proper counseling combined with other treatment measures to reduce the severity of the disease.
What Are the Symptoms and Signs Seen in a Pregnant Woman Having Crohn’s Disease?
The symptoms of the disease include:
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Nocturnal diarrhea or diarrhea at night.
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Abdominal pain.
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Weight loss.
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Bleeding from the anus, otherwise known as rectal bleeding.
The signs of the disease include:
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The individual's skin and mucous membranes become light and pale.
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Marked weight and muscle loss leading to a condition called ‘wasting syndrome.'
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Abdominal tenderness.
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Perianal fissure is a tear in the anus lining which can occur in this disease due to inflammation.
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Inflammation inside the stomach has the tendency to spread through all the layers of the intestine, which can cause small leaks and abscesses. These abscesses can make holes in the chamber, which are called fistulas. These are more commonly formed in the butt region.
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Intestinal obstruction.
How to Diagnose?
The diagnosis of this disease is based on the endoscopic, radiographic, and pathological findings.
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Endoscopy: This procedure is performed by inserting a thin tube that has a camera and a light source attached to it through the anus into the digestive tract to see the inside of the digestive tract to check for any signs of bleeding or ulcers.
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Colonoscopy: In a colonoscopy, the doctor will insert a thin tube with a camera and a light source attached to it into the rectum to check for any signs of lesions or ulcers.
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Cholangioscopy: This procedure is used to inspect the bile ducts, where an endoscope with a camera and a light source is inserted through the anus into the biliary tract to check for any signs of bleeding or inflammation.
Are These Diagnostic Procedures Safe?
These techniques are safe during pregnancy but should be used only if necessary and with caution. These procedures can be carried out during the second trimester of pregnancy. Serological studies analyzing antibodies against microorganisms like Saccharomyces Cerevisiae, antineutrophil antibodies, and outer membrane prion of E.Coli bacteria are good indicators of this disease.
What Are the Steps to Be Taken to Reduce the Severity of the Disease?
In women, the active disease reduces the chances of getting pregnant, but one in four women gets pregnant during the active phase of the disease. Disease control should be done at the earliest since if the patient has an active disease during pregnancy, there is a higher chance of miscarriage, fetal growth restriction, and preterm birth of the unborn child. Women who have active Crohn's disease at conception are at greater risk of getting affected by the disease badly.
What Nutrients Can Be Given?
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Women with this disease tend to have iron and vitamin B12 deficiency; thus, levels must be checked, and supplements should be given accordingly. Folic acid supplements with a dosage of five mg help in neural tube development during pregnancy and should be started before conception.
How to Treat This Disease?
The main aim of this disease is to reduce inflammation which causes complications.
Therapeutic drugs can be a good option but can be given by analyzing the
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Location of the disease, as in where it is located.
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The severity of the disease, as in how severe the disease has been, increased.
Women who have Crohn's disease are counseled to get pregnant during the inactive stage of the disease since the chance of the disease occurring again during the phase of pregnancy is low. The drugs which are used in the management of Crohn's disease are
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5 aminosalicylic acid. Corticosteroids like Prednisone and Budesonide.
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Immunomodulators (Azathioprine, six Mercaptopurine).
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Antibiotics (Metronidazole,Ciprofloxacin).
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Tumor Necrosis Factor(TNF) blockers are FDA-approved: Infliximab, Adalimumab, and Certolizumab pegol.
Administration of anti-TNF antibodies is safe during the pre-pregnancy and the first trimester period since IgG antibodies do not cross the placental barrier at this time. The risk happens only during the last trimester, putting the neonate at risk. A 28 year old female received infliximab throughout her pregnancy since she had Crohn's disease. After that, at three months of age, the baby was given BCG (Bacille Calmette Guerin), a vaccine for tuberculosis but died due to disseminated BCG. Thus it is now recommended that live vaccines like influenza and BCG be withheld for 12 months in neonates who had exposure to anti-TNF agents during their intrauterine life. Methotrexate, Ciclosporin, Allopurinol, and Tofacitinib are contraindicated during pregnancy and breastfeeding. A recent London study has recommended certolizumab to be compatible with breastfeeding and has a low risk of conception during pregnancy.
What Mode of Delivery Is Advisable for Patients With This Disease?
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Vaginal delivery is considered safe for most individuals.
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In the case of an inflamed rectum (the part of the large intestine which is present close to the anus) and perineum (a diamond-shaped structure present below the pelvic diaphragm) due to Crohn's disease, a cesarean is preferred due to perineal inelasticity.
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A population-based survey has stated that the number of cesarean delivery is more than vaginal delivery in patients with this disease.
Conclusion
Crohn's disease during pregnancy remains a common complication. With proper counseling and guidance from gastroenterologists, this can easily be managed. The key lies in the time of getting pregnant. Women should choose to conceive when the disease is inactive. Maintenance of a disease-free phase before and during pregnancy plays a crucial role in delivering healthy offspring. Advancements in therapies and treatment techniques have made pregnancy following the diagnosis of Crohn's disease a safe option for women.