Pregnancy outcomes after stoma surgery for inflammatory bowel disease: The results of a retrospective multicentre audit

Needs of women that experience pregnancy with an ostomy: A scoping review

BACKGROUND

The presence of intestinal elimination ostomies concomitant with pregnancy poses complex challenges for health professionals in providing antenatal care to these women and their families. In this context, identifying the specific needs of these pregnant women is crucial for effective care.

AIM

This scoping review aims to map the evidence on the needs of women with intestinal elimination ostomies during pregnancy.

METHODS

This review was based on the Joanna Briggs Institute guidelines. The search was carried out on the EBSCOhost platform using the MEDLINE Ultimate, CINAHL Ultimate, MedicLatina and Cochrane Database of Systematic Reviews databases and on the PubMed and SciELO platforms, with no time limits.

FINDINGS

We identified 570 studies, 6 websites and one citation of which 16 were included. The selected records were published between the years 1957 and 2024. The results were categorised into four types which summarise the pregnant women's needs: daily life permeated by stoma care requirements, to be supported, challenges in assessing foetal well-being and having a plan.

CONCLUSIONS

Attending to the needs of these women requires health professionals with specific training and the involvement of a multidisciplinary team. Given the scarcity of articles identified and the publication dates, it is considered necessary to develop primary research addressing this issue.

Pregnancy in Patients with Inflammatory Bowel Disease: A Narrative Review

Background

The incidence of inflammatory bowel diseases (IBDs) peaks in the fertile age of both women and men. There is a significant lack of knowledge regarding disease-specific aspects of guiding IBD patients through conception, pregnancy, and delivery in clinical routine.

Summary

Patients with IBD often remain voluntarily childless, primarily due to a lack of knowledge. Fertility is generally unaffected in IBD patients, except in those with high disease activity or who have undergone specific abdominal surgeries that may lead to changes in the abdominal cavity, such as inflammatory or postoperative adhesions. Immunosuppressive and immunomodulatory medications are generally considered safe during pregnancy and should be continued to reduce the likelihood of relapses. If flares occur, close monitoring of the mother and the fetus is mandatory, and therapeutic options (conservative, interventional, surgical) have to be weighed thoroughly. Despite advances in treatment, IBD patients remain at increased risk of preterm labor, small-for-gestational-age newborns and are at risk of C-sections, although the current literature suggests vaginal delivery is possible for most patients. C-sections are recommended in patients with active perianal disease.

Key Messages

Patients with IBD wishing to conceive should receive comprehensive preconception counseling about pregnancy-specific aspects of IBD management from an interdisciplinary team of specialists, including IBD gastroenterologists, obstetricians, and colorectal surgeons.

Surgical Management of Pregnant Patients with Inflammatory Bowel Disease

Pelvic surgery for inflammatory bowel disease (IBD) can reduce fertility. Pregnant women with IBD have higher rates of pregnancy loss and adverse outcomes. Awareness of these factors and adequate multidisciplinary monitoring throughout these high-risk pregnancies is important. Surgeons may need to manage stoma complications, assist in cesarean delivery, or even operate for severe flares or obstruction during pregnancy. In experienced hands and with adequate support from maternal fetal medicine, surgery can be safely performed in any trimester. Overall, the greatest risk to the mother and fetus remains active disease, not the medical and surgical therapies used to treat it.

Complications of Ileus and Bowel Obstruction During Pregnancy in Women Who Have Had Surgery for Inflammatory Bowel Disease: A Population-Based Study

INTRODUCTION

Women with inflammatory bowel disease (IBD) who have IBD surgery before pregnancy have an increased risk of adverse maternal and fetal outcomes. Very few studies have examined the risks of gastrointestinal complications during pregnancy in this group of women.

METHODS

Using the Danish national registries, we identified live born children of mothers with ulcerative colitis (UC) or Crohn's disease (CD) who had IBD surgery before pregnancy. We compared the outcomes of ileus/bowel obstruction during pregnancy in women with UC or CD who had surgery compared with women with UC or CD who did not have surgery before pregnancy.

RESULTS

IBD surgery before pregnancy was more common in women with CD than in women with UC (31.5% vs 6.3%). For live births, 7.1% of mothers with UC surgery and 1.8% of mothers with CD surgery had a diagnosis of ileus/bowel obstruction during pregnancy. Patients who had UC surgery had an adjusted odds ratio (aOR) of 71.98 (95% confidence interval [CI] 33.13-156.39) of an ileus/bowel obstruction compared with those with UC who had not had surgery. For UC: permanent ileostomies: aOR 128.69 (95% CI 57.57-287.63) and ileal pouch-anal anastomosis with diverting ostomy: aOR 40.14 (95% CI 11.19-143.96). Patients who had CD surgery had an aOR of 10.00 (95% CI 4.64-21.55). For CD: intestinal surgery (no stoma): aOR 7.96 (95% CI 3.48-18.22) and intestinal surgery (with stoma): aOR 43.89 (95% CI 17.40-110.69).

DISCUSSION

There is a significant risk of ileus/bowel obstruction during pregnancy in women who had IBD surgery before pregnancy.

Pregnancy With a Stoma is Feasible, Though Associated With Manageable Complications

BACKGROUND

Inflammatory bowel disease (IBD) is often diagnosed in young adults, and therefore frequently coincides with pregnancy. Patients may require surgery that includes (temporary) stoma placement. Literature on the occurrence of stoma-complications during pregnancy and the effect on pregnancy outcomes is limited. To evaluate stoma- complications peri- and postpartum, a retrospective study was performed in women who were pregnant while having a stoma.

METHODS

This multicentre cohort and survey study included all pregnant patients with IBD and a stoma who delivered between 2016 and 2023 from 5 Dutch university hospitals. Stoma-complications and pregnancy outcomes were retrospectively collected from electronic patient files. A questionnaire assessed patient-reported complications and long-term stoma-related complaints.

RESULTS

In total, 50 patients were included (median age at conception 31.0 years; 55.2% Crohn's disease and 44.8% ulcerative colitis), comprising 67 pregnancies, 5 of which ended in pregnancy loss. Stoma complications occurred in 44 full-term pregnancies (71.0%), most commonly obstruction (35.5%) and decreased output (29.0%). Surgery was required in four pregnancies due to obstruction (n = 3) and prolapse (n = 2). In the first-year postpartum, 7 patients required surgery for stoma-complications. Amongst 29 women who completed the questionnaire, 10 (34.5%) reported unresolved complications 6 months postpartum. Cesarean sections were performed in 31 (50.0%) pregnancies. Adverse pregnancy outcomes included prematurity (n = 9, 14.5%), low birth weight (n = 9, 14.5%), and dysmaturity (n = 5, 8.1%).

CONCLUSIONS

Pregnancy with a stoma is feasible, though manageable complications often occur. Counseling before pregnancy and close monitoring of symptoms during pregnancy and postpartum are essential for women with IBD and a stoma.

Does Surgery Before Pregnancy in Women With Inflammatory Bowel Disease Increase the Risk of Adverse Maternal and Fetal Outcomes? A Danish National Cohort Study

INTRODUCTION

Up to 15% of women with Crohn's disease (CD) or ulcerative colitis (UC) undergo bowel surgery before pregnancy, and there is little data on pregnancy outcomes in this population. We aimed to assess maternal/fetal outcomes in women with CD or UC who underwent surgeries before pregnancy.

METHODS

In this nationwide study, we included all pregnancies in women with CD or UC from 1997 to 2022 and examined 6 categories of CD and UC surgeries before pregnancy. We used multilevel logistic regression to compute crude and adjusted odds ratios (aOR) with 95% confidence intervals (95% CI) for the risk of pregnancy and offspring complications in women who did, vs did not, undergo surgery before pregnancy.

RESULTS

There were 833 UC and 3,150 CD pregnancies with prior surgery and 12,883 UC and CD 6,972 pregnancies without surgery. For UC, prior surgery was associated with Cesarian section (C-section) (ileoanal pouch: aOR: 20.03 [95% CI 10.33-38.83]; functional ileostomy: aOR:8.55 [6.10-11.98]; diverting ileostomy: aOR: 38.96 [17.05-89.01]) and preterm birth (aOR: 2.25 [1.48-3.75]; 3.25 [2.31-4.59]; and 2.17 [1.17-4.00]) respectively. For CD and prior intestinal surgery, the risks of C-section (aOR: 1.94 [1.66-2.27]), preterm birth (aOR: 1.30 [1.04-1.61]), and low 5-minute Apgar (aOR: 1.95 [95% CI 1.07-3.54]) increased and premature rupture of membranes (aOR: 0.68 [0.52-0.89]) decreased. For CD with only prior perianal surgery, the risk of C-section (aOR: 3.02 [2.31-3.95]) increased and risk of gestational hypertension/preeclampsia/eclampsia (aOR: 0.52 [0.30-0.89]) decreased.

DISCUSSION

Providers should be aware there is an increased likelihood of C-section and certain perinatal complications in patients with CD or UC surgery before pregnancy.

Pregnancy and stomas: a 9-year retrospective series at a major metropolitan hospital in Brisbane Queensland

BACKGROUND

Over 42 000 Australians live with a stoma, and this number increases annually. Pregnancy in stoma patients is a rare but complex condition and there is limited published literature regarding surgical and obstetric complications in pregnant stoma patients. The aim of this paper was to review stoma outcomes, perinatal morbidity and mortality, and early postpartum period in pregnant stoma patients.

METHODS

Data was retrospectively obtained on women of childbearing age, with a stoma, who had been pregnant and birthed in the last nine years at the Royal Brisbane and Women's Hospital between January 2014 to December 2022. Data recorded included patient demographics, type of stoma, indication for stoma, need for additional abdominal surgeries, method of conception, pregnancy complications, length of stay, neonatal outcomes and post pregnancy stomal complications.

RESULTS

In total, there were 16 births from 13 mothers with stomas. Of 10 births to IBD patients, 40% experienced a serious stomal complication. Caesarean section (CS) rate was 90% for IBD and 83% for non-IBD. In-vitro fertilisation rates were 40% in IBD patients and 0% in non-IBD patients. The average gestational age at delivery was 36 weeks in IBD and 35 weeks in non-IBD patients. Neonates delivered to IBD mothers had a birth weight under 2500g in 40% of cases and in non IBD mothers at 33.3% (p = 0.62). Of the sixteen births there was five complications (31.25%) associated with the stoma either during pregnancy or during the sixty-day postpartum period.

CONCLUSION

Pregnancy in stoma patients is a rare occurrence and appears to be associated with high rates of CS, preterm delivery, low birth weight and stomal complication.

Extraperitoneal Cesarean Section after two Medial Laparotomies, Anus Prater, and Surgical Treatment of the Rectovaginal Fistula in a Patient with Crohn's Disease: A Case Report

The aim of this case report is to show the advantages of the extraperitoneal cesarean section (ECS) approach in a pregnant patient with multiple previous abdominal transperitoneal colon surgeries and Crohn's disease. A pregnant nulliparous woman with Crohn's disease was admitted for delivery. After delivery, a large rupture and lesion of the rectum was observed. Suturing of the vagina, rectum and sphincter was performed by an abdominal surgeon. Because of a very large and irregularly shaped rectum rupture, the patient underwent infraumbilical medial laparotomy and sigmoidostomy. After 18 months, the patient started to experience vaginal discharge and Y-shaped rectovaginal fistula was confirmed. Surgical reconstruction was performed. The patient's second pregnancy began one year later. At 38 weeks of pregnancy, elective extraperitoneal cesarean section was performed. A healthy newborn was delivered. Follow-up showed full and fast recovery after the ECS. In cases of pregnant women who have had multiple colon surgeries, gynecology surgeons can choose to perform an ECS to avoid transperitoneal entrance into the abdomen. ECS avoids lysis of postoperative adhesions after repetitive gastrointestinal surgeries, the formation of new adhesions by lysis of the old adhesions, and most importantly, the possibility of colon or small intestine lesions during lysis of dense or firm adhesions.

Saudi consensus guidance for the management of inflammatory bowel disease during pregnancy

ABSTRACT

The management of inflammatory bowel disease (IBD) in pregnant women is challenging and must be addressed on a patient-by-patient basis. Optimal patient management requires a multidisciplinary team and clear evidence-based recommendations that cater to this subset of patients. In this article, we provide concise guidelines and clinical care pathway for the management of IBD in pregnant women. Our recommendations were developed by a multidisciplinary working group that includes experts from the Saudi Ministry of Health in collaboration with the Saudi Gastroenterology Association and the Saudi Society of Clinical Pharmacology. All recommendations are based on up-to-date information following an extensive literature review. A total of 23 evidence-based expert opinion recommendations for the management of IBD in pregnant women are herein provided.

Inflammatory bowel disease in pregnancy and breastfeeding

Inflammatory bowel disease (IBD) has a peak age of diagnosis before the age of 35 years. Concerns about infertility, adverse pregnancy outcomes, and heritability of IBD have influenced decision-making for patients of childbearing age and their care providers. The interplay between the complex physiology in pregnancy and IBD can affect placental development, microbiome composition and responses to therapy. Current evidence has shown that effective disease management, including pre-conception counselling, multidisciplinary care and therapeutic agents to minimize disease activity, can improve pregnancy outcomes. This Review outlines the management of IBD in pregnancy and the safety of IBD therapies, including novel agents, with regard to both maternal and fetal health. The vast majority of IBD therapies can be used with low risk during pregnancy and lactation without substantial effects on neonatal outcomes.

Obstetric Considerations in Pregnant Women with Crohn's Disease

Crohn's disease affects many women of childbearing age. Fecundity rates are often lower than in the general population due to reduced fertility during active inflammation, effects of pelvic surgery or voluntary childlessness. Many women have concerns regarding the effects of pregnancy on their Crohn's, any potential effect of medication on the fetus, and passing on Crohn's disease to the offspring. International guidelines on reproduction for women with Crohn's disease provide evidence-based advice to patients and health care professionals. There is an increasing literature on the safety of advanced medication for Crohn's disease during pregnancy. This review article therefore focuses on obstetric considerations beyond medication safety. We provide information on fertility, factors affecting pregnancy and fetal outcomes, obstetric complications, factors influencing mode of delivery, management of intestinal stomas during pregnancy and general considerations around breast feeding.

The Benefits and Drawbacks of Staging Pelvic Pouches

Since the mid-20th century, physicians have searched for way to improve the lives of patients with ulcerative colitis (UC). Early attempts of curative resection left the patients with a permanent stoma with only primitive stoma appliances available. Gradually, stoma care improved and operations were devised to give the patient bowel continuity without the need for a permanent ostomy. As these operations were evolving, benefits and drawbacks related to fertility, ease of small bowel reach to the pelvis, and postoperative pelvic sepsis were observed. In this article, we will elucidate the various ways pelvic pouches are used to treat UC and the rationale for the timing of surgery as well as the evolution of stoma care.