Not Too Late to Make Cutting-Edge Decisions: Editorial Response to ‘Predictors of Cesarean Delivery in Pregnant Women with Inflammatory Bowel Disease’

In this issue of JCAG, Sharaf and Nguyen report on the predictors of Cesarean delivery in pregnant women with inflammatory bowel disease (IBD) (1). This retrospective study reviewed all deliveries over an 8-year period at a tertiary referral institution. Consistent with existing literature, which have demonstrated up to a two-fold risk of Cesarean delivery in the IBD population over the general population (2), Sharaf et al. reported 52% of those with Crohn’s disease and 48% with ulcerative colitis underwent Cesarean delivery.

The Toronto Consensus Statements for the Management of IBD in Pregnancy (which includes three statements addressing mode of delivery) was published in Gastroenterology in 2016 (3), postdating the study period (2006–2014) of Sharaf’s paper (1). The panel, which included expertise in IBD, obstetricians and maternofetal medicine, provided a strong recommendation that the decision regarding Cesarean delivery should be based on obstetric considerations and not the diagnosis of IBD alone (statement 21) (3).

However, exceptions may be made in two specific scenarios: the presence of active perianal disease and patients who have undergone an ileal pouch anal anastomosis (statements 21 and 22). Sharaf et al. observed that a history of perianal disease was the strongest predictor of Cesarean delivery in women with CD, with an adjusted odds ratio of 13.6 (95% CI, 3.87–47.5). However, it should be noted that the guidelines specify that this strong recommendation is reserved for women with active perianal disease, as disease activity may be a risk factor for worsening symptoms (4) and perineal lacerations (5). In Sharaf et al.’s cohort, only 42% of women with perianal disease had active symptoms during pregnancy, suggesting the presence of other risk factors for Cesarean delivery.

Overall, prior Cesarean delivery was the strongest predictor of Cesarean delivery in women with CD (aOR 22.2; 95% CI, 6.16–80.2), highlighting the importance of initial judicious decision-making by obstetrics, other medical care providers and patients regarding mode of delivery. While there are emergency, elective, obstetric, and gastroenterologic indications, and not withstanding personal preference for Cesarean delivery, elective gastroenterologic indications should constitute the minority of procedures. The other scenario in which Cesarean delivery should also be considered is in women with IBD who have undergone an ileal pouch anal anastomosis (IPAA), in order to reduce the risk of anal sphincter injury which may lead to fecal incontinence. Sharaf et al. report that within the UC population, prior colectomy increased the odds five-fold of requiring a Cesarean delivery; however, the proportion of these women who had a ileostomy versus an IPAA at time of pregnancy was not reported (1).

Overall, Sharaf and Nguyen’s study contributes to the growing body of evidence that women with IBD undergo Cesarean delivery at a rate exceeding the general population and perhaps contrary to the defined indications outlined by the 2016 Toronto Consensus Statements for the Management of IBD. Future studies could take into account factors including the publication of the guidelines, geographical variation and institution (academic versus community). Accordingly, more targeted education can be provided with the hope that outcomes such as mode of delivery for pregnant women with IBD can more closely approximate that of the general public.