162 Obstetrics and Gynecology Board Review •••
❍ What effect does inflammatory bowel disease have on fertility?
Women with ulcerative colitis have a similar fertility rate compared with the general population. An exception is
women who have undergone proctocolectomy with ileoanal anastomosis with J-pouch. This group has a longer
time to pregnancy, probably stemming from surgery-related pelvic adhesions. Women with Crohn disease may
have a lower fertility compared with the general population. Fertility is highest in those in remission, or following
surgical resection of active disease.
❍ What is the risk of relapse of ulcerative colitis in a patient with inactive disease during pregnancy and the
puerperium?
The same as it is in the nonpregnant state. The most likely time for relapse of inflammatory bowel disease during
pregnancy is the first trimester. The postpartum period is not necessarily a high-risk time for relapse; the degree of
postpartum disease activity correlates with activity at term.
❍ What are the risks to the pregnancy when Crohn disease is active at the time of conception?
Increased rates of spontaneous abortion, premature delivery, LBW, and neonatal vitamin K deficiency. A case
report published in 2001 linked a fetal subdural hematoma diagnosed at 22 weeks to maternal vitamin K
deficiency secondary to Crohn disease.
❍ True or False: An ileostomy precludes a vaginal delivery.
False. The rate of cesarean delivery is not affected by the diagnosis of inflammatory bowel disease, and the decision
should generally be based on obstetric indications. One exception is women with active or inactive perirectal,
perianal, or rectovaginal fistulas, who may have poor wound healing at the episiotomy site.
❍ What medications for inflammatory bowel disease are safe in pregnancy?
Category B: Balsalazide, loperamide, mesalamine, metronidazole, Remicade, and sulfasalazine.
Category C: Corticosteroids (budesonide, prednisone, prednisolone), ciprofloxacin, cyclosporine, diphenoxylate,
and olsalazine.
Category D: Azathioprine and 6-mercaptopurine.
Category X: Methotrexate.
❍ What are the normal changes in liver function tests that occur in pregnancy?
Albumin may decrease by 1 g/dL, while bilirubin and the transaminases may be normal or decreased. These
changes are due to hemodilution caused by the increased plasma volume between the 6th and 32nd weeks of
gestation. ALP is increased due to both increased bone turnover and the leakage of placental ALP into the maternal
circulation. Fibrinogen, transferrin, ceruloplasmin, and cholesterol are all increased.
❍ True or False: Spider angiomata and palmar erythema are signs of liver disease in pregnancy.
False. These are normal findings in up to 60% of pregnant women, and disappear rapidly after delivery. Their
etiology is thought to be related to the hyperestrogenemia of pregnancy.
❍ True or False: Hepatomegaly is normal during pregnancy.
False. Pregnancy has little effect on liver size and architecture; therefore, a finding of hepatomegaly should prompt
a search for an underlying pathology.