Management of Inflammatory Bowel Disease and Pregnancy using Prophylactic Low Dose Low Molecular Weight Heparin and Corticosteroids

Abstract

The circulating nonspecific immune complexes, complement system peptides and auto-antibodies may induce inflammatory/ thrombotic events at the placenta and impairment of endometrial receptivity as well as disturbed fetal perfusion in Inflammatory Bowel Disease (IBD) cases. The aim of the case series was to assess the effect of “Low Molecular Weight Heparin” (LMWH) and Low Dose Corticosteroids (LDC) against possible thromboembolic and inflammatory processes happening at the maternal fetal interface and to assess their efficiency in pregnancy outcomes. Nine cases of IBD, referred during the first trimester of their pregnancies, were retrospectively evaluated {Ulcerative Colitis (UC) (n=7) and Crohn’s Disease (CD) (n=2)}. Patients were under aminosalicylate treatment (eight cases mesalamine and one case sulfasalazine) during their admittance to the program and were all in remission. Aminosalicylate treatment was stopped between 8th and 12th gestational weeks and then continued until the appearance of early signs of uterine contractions and/or fetal “discomfort/distress”. Following tests for thrombophilia, patients presenting risk factors were included to the study group and were given low dose LMWH (Enoxaparine 1x2000 Anti-XA IU/0.2 ml/day), prophylaxis plus LDC (Methylprednisolone 4 mg/day). The mean age of the patients was 28.2±4.05 (20-35). No patient had a flare up during their pregnancy. One UC patient with homozygotic Methylenetetrahydrofolate Reductase (MTHFR) 677 polymorphism experienced preterm premature rupture of membranes (PPROM) at the 31th gestational week and was delivered at 32nd gestational week by caesarean section. The other eight cases also delivered between 36-39th gestational weeks by caesarean section due to obstetrical reasons and/or fetal distress. All neonates were discharged from hospital without any complications. Mean gestational age at birth was 258 days (36 weeks 6 days) and mean birthweight was 2772.2±619.3 grams (1530-3670). In this small case series we were able to obtain successful pregnancy outcomes with the current protocol. Both UC and CD have potential risks of affecting “endothelial/trophoblastic/epithelial” tissues of placenta, impairing endometrial receptivity or fetal perfusion. Control of autoimmune inflammatory processes and thrombotic events by combination of low dose LMWH and LDC may maintain better pregnancy outcome without exacerbation of the IBD.

Keywords

• crohn’s disease
• pregnancy immunology
• ulcerative colitis