Delivery Mode in Pregnant Patients with IBD: Uncertainty Remains

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Inflammatory bowel disease is most commonly diagnosed in the reproductive years.1 Medical and surgical management of patients with inflammatory bowel disease (IBD), therefore, often involves complex decision-making around reproductive planning, pregnancy, and postpartum care. In the general population, vaginal delivery (VD) is preferred to cesarean section (CS) because of perioperative morbidity in the mother and infant, risk to future pregnancies, and higher costs.2 In patients with IBD, decision-making around delivery is complex because of immunosuppressant use, wound healing, and anatomical considerations such as rectal or perianal disease and previous or future need for pelvic surgery. Specific concerns exist about the safety of VD in patients with proctitis, perianal Crohn's disease, and those undergoing pelvic surgery, especially ileal pouch-anal anastomosis (IPAA). The 2016 European Consensus Guidelines3 and Toronto Consensus Statements4 recommend CS in patients with active perianal or rectal disease, and consider IPAA a relative indication for CS, although both groups acknowledge that the evidence supporting the recommendations is weak.
The 2 accompanying articles aim to expand our current understanding of delivery mode in patients with IBD. The study by Burke et al5 performed a single-center review evaluating delivery mode in patients with IBD, looking specifically at the rates and indications for planned or unplanned CS. They found that all patients with perianal Crohn's disease and history of IPAA underwent CS. Two-thirds (n = 16) of Crohn's patients had unplanned CS, but only one of these was for an IBD-related indication. Half of patients with ulcerative colitis (n = 20) underwent unplanned CS, and none of these was for an IBD-related indication. The results suggest that planned VD in patients with IBD is rarely compromised by IBD-specific concerns, although the clinical utility is limited in that it describes delivery patterns at a single institution and does not contain the outcomes data needed to guide decision-making.
In the second accompanying article, Foulon et al6 performed a systematic review of functional outcomes after delivery in patients with IBD. The authors found that VD was not associated with the development of new perianal Crohn's disease (12% VD, 19% CS) nor recurrence of quiescent perianal Crohn's disease (11% VD, 53% CS). In patients with IPAA, incontinence was 33% after VD and 54% after CS. The authors acknowledge that the conclusions are limited by selection bias and short follow-up, which limit evaluation of the long-term impact of delivery mode on incontinence.
The evidence to guide decision-making about delivery mode in pregnant patients with IBD remains limited. The accompanying articles contribute to our understanding, suggesting that IBD is an infrequent cause of unplanned CS among patients with IBD5 and that functional outcomes are acceptable after VD in Crohn's patients without active perianal disease as well as patients who previously underwent IPAA.6 However, these conclusions are based on low-quality evidence and clinically important questions remain unanswered. Can we predict which patients with IBD will experience complications, such as a tear or need for episiotomy, during VD? What are the consequences of VD in patients who will require IPAA after a pregnancy? Future high-quality studies are needed.
In the meantime, shared decision-making between providers and patients remains an essential component of pregnancy care for women with IBD. During these discussions, patient preferences and current evidence can be used to guide individualized decision-making, with emphasis on the great uncertainty that remains.

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