Surgery for Crohn’s disease during pregnancy: a difficult decision

Inflammatory bowel disease (IBD) affects young people who are at the height of their personal and professional development, and therefore reproductive issues frequently arise. The factor that most influences the appearance of complications during pregnancy is undoubtedly disease activity.^1,2 When conception occurs during a period of remission, the risk of relapse is similar to the risk in non-pregnant IBD patients. However, if the patient conceives during active disease, the risk of having persistent activity during pregnancy increases. Therefore, appropriate treatment should be maintained in those patients who wish to become pregnant in order to reduce the risk of flares during gestation. Furthermore, acute flares during pregnancy should be treated aggressively and without delay in order to prevent complications.^1–3

In this regard, most IBD medications are considered to be of low risk during pregnancy.^4–7 However, in some cases, all medical treatments fail, and patients need to undergo surgery due to refractory disease or complications. Information on the safety of surgery in pregnant patients with IBD is very limited.

In their article ‘Surgery for Crohn’s disease during pregnancy: a nationwide survey from the GETAID Chirurgie’, Germain et al. describe the outcomes of 15 Crohn’s disease (CD) patients who underwent surgery during pregnancy and their offspring between 1992 and 2015. ⁸ The majority of these mothers underwent surgery due to fistulising complications (perforations or fistulae). With respect to IBD treatment, only two women were exposed to anti-tumour necrosis factor (TNF) agents at the time of surgery, and three patients were given thiopurines. Of note, only one patient underwent image-guided percutaneous drainage before surgery for treating an abdominal abscess.

Despite the fact that in this case series all patients were managed by multidisciplinary teams – involving gastroenterologists, surgeons and gynaecologists with significant experience in the field – both the mothers’ and babies’ outcomes were poor. In this respect, two-thirds of the patients had postoperative complications requiring further surgery, with stoma creation in some cases, and one patient died. Regarding pregnancy outcomes, there were two elective abortions and two miscarriages. Four babies needed to be admitted to the intensive care unit, and one of them died. ⁸

Germain et al. found similar results to those previously published, confirming the poor prognosis of surgery in pregnant CD patients. ⁹ These findings highlight the importance of disease control and treatment optimisation before conception. In addition, pregnancy does not protect against the appearance of severe disease complications. Therefore, appropriate treatment for CD should be maintained, and potential flares should be treated early with the most effective drugs available.^1–3 In this respect, it is already known that steroids, thiopurines and anti-TNF agents are safe during pregnancy and in the offspring. In recent years, new drugs – such as vedolizumab, ustekinumab and tofacitinib – have become part of the therapeutic armamentarium for patients with IBD.^1–3 Information on the safety of these drugs during pregnancy and in the offspring is still very limited. In this sense, registries such as the DUMBO (‘Safety of IBD Drugs During Pregnancy and Breastfeeding: Mothers and Babies’ Outcomes’, ClinicalTrials.gov identifier: NCT03894228) or the PIANO (‘A Multicenter National Prospective Study of Pregnancy and Neonatal Outcomes in Women with Inflammatory Bowel Disease’, ClinicalTrials.gov identifier: NCT00904878) are necessary to assess the safety of these new molecules in this particular clinical scenario.

The European Crohn’s and Colitis Organisation’s guidelines recommend surgery in pregnant women with IBD for the same indications as in non-pregnant patients (obstruction, perforation, abscess, haemorrhage or active disease refractory to medical treatment).^1,10 A temporary stoma might be preferred over primary anastomosis to prevent postoperative complications. With respect to the timing of surgery during pregnancy, some small series have reported a higher risk of miscarriage in the first trimester and of preterm delivery in the third trimester. However, urgent surgery should not be delayed, as even higher complications should be expected otherwise.

Taking into consideration the morbidity and mortality associated with surgery in pregnant IBD patients, medical options and percutaneous drainage of abscesses should be tried before referring patients for surgery. Nevertheless, the risk of active IBD should be weighed against the risk of surgery, as sustained illness is associated with higher morbidity for the mother and the foetus. When the indication for surgery is finally established, the interventions should be carried out by referral teams involving gastroenterologists, colorectal surgeons, obstetricians and neonatal specialists in a multidisciplinary manner within a single unit in order to perform the procedure with the greatest probability of success.