Advertisement

Inflammatory Bowel Disease in Pregnancy

  • Sunanda Kane
Chapter

Abstract

Inflammatory bowel disease (IBD) occurs in women during their childbearing years. There is a lot of concern on the part of patients in regards to the effect of IBD on a pregnancy as well as the potential effects of pregnancy on disease activity. Understanding the risks of certain medications and the potential outcomes in women with IBD is important for appropriate counseling. Overall, fertility in IBD patients is not impaired, with the exception of women status post an ileal pouch anal anastomosis (IPAA) procedure for ulcerative colitis or active colonic disease in women with Crohn’s. Consistent outcomes in pregnancies in women with IBD include small for gestational age, low birth weight, and preterm. However, there is no data to suggest that there is any increased risk for congenital abnormalities. Medications used to treat IBD for the most part are low risk during pregnancy, as uncontrolled inflammation is thought to be more detrimental to a pregnancy than medical therapy. Mesalamine has been demonstrated as safe in any form. Controversial is the use of thiopurines due to their category D rating; however, population-based studies have failed to identify any increased risk for birth defects in children born to women or men on these agents. Biologics cross the placenta starting around week 20 and levels have been detected in cord blood and neonates. C-sections appear to be performed more frequently in women with IBD but apparently more from fear of the obstetrician than medical reasons. The most important management point is that active inflammation is detrimental to a pregnancy and that it needs to be controlled via whatever means necessary to ensure a successful pregnancy.

Keywords

Inflammatory Bowel Disease Ulcerative Colitis Spontaneous Abortion Inflammatory Bowel Disease Patient Crohn Disease 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Peyrin-Biroulet L, Loftus Jr EV, Colombel JF, Sandborn WJ. Long-term complications, extraintestinal manifestations, and mortality in adult Crohn disease in population-based cohorts. Inflamm Bowel Dis. 2011;17(1):471–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Silverstein MD, Lashner BA, Hanauer SB, Evans AA, Kirsner JB. Cigarette smoking in Crohn disease. Am J Gastroenterol. 1989;84:31–3.PubMedGoogle Scholar
  3. 3.
    Suris JC, Resnick MD, Cassuto N, Blum RW. Sexual behavior of adolescents with chronic disease and disability. J Adolesc Health. 1996;19:124–31.PubMedCrossRefGoogle Scholar
  4. 4.
    Newacheck P, Halfon N. Prevalence and impact of disabling chronic conditions in childhood. Am J Public Health. 1998;88:610–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Gittes EB, Strickland JL. Contraceptive choices for chronically ill adolescents. Adolesc Med. 2005;16:635–44.CrossRefGoogle Scholar
  6. 6.
    Wakeman J. Exacerbation of Crohn disease after insertion of a levonorgestrel intrauterine system: a case report. J Fam Plann Reprod Health Care. 2003;29(3):154.PubMedCrossRefGoogle Scholar
  7. 7.
    Cottone M, Camma C, Orlando A, et al. Oral contraceptive and recurrence in Crohn disease. Gastroenterology. 1999;116:A693.CrossRefGoogle Scholar
  8. 8.
    Timmer A, Sutherland LR, Martin F. Oral contraceptive use and smoking are risk factors for relapse in Crohn disease. The Canadian Mesalamine for Remission of Crohn Disease Study Group. Gastroenterology. 1998;114(6):1143–50.PubMedCrossRefGoogle Scholar
  9. 9.
    Cornish JA, Tan E, Simillis C, et al. The risk of oral contraceptives in the etiology of inflammatory bowel disease: a meta-analysis. Am J Gastroenterol. 2008;103(9):2394–400.PubMedCrossRefGoogle Scholar
  10. 10.
    Coley RL, Chase-Lansdale PL. Adolescent pregnancy and parenthood: recent evidence and future direction. Am Psychol. 1998;53:152–66.PubMedCrossRefGoogle Scholar
  11. 11.
    Mayberry JF, Weterman IT. European survey of fertility and pregnancy in women with Crohn disease: a case control study by European collaborative group. Gut. 1986;27:821–5.PubMedCrossRefGoogle Scholar
  12. 12.
    Woolfson K, Cohen Z, McLeod RS. Crohn disease and pregnancy. Dis Colon Rectum. 1990;33:869–73.PubMedCrossRefGoogle Scholar
  13. 13.
    Birnie GG, McLeod TI, Watkinson G. Incidence of sulphasalazine-induced male infertility. Gut. 1981;22:452–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Burnell D, Mayberry J, Calcraft BJ, Morris JS, Rhodes J. Male fertility in Crohn disease. Postgrad Med J. 1986;62:269–72.PubMedCrossRefGoogle Scholar
  15. 15.
    Dejaco C, Mittemaier C, Reinisch W, et al. Azathioprine treatment and male fertility in inflammatory bowel disease. Gastroenterology. 2001;121:1048–53.PubMedCrossRefGoogle Scholar
  16. 16.
    Nørgård B, Pedersen L, Jacobsen J, Rasmussen SN, Sørensen HT. The risk of congenital abnormalities in children fathered by men treated with azathioprine or mercaptopurine before conception. Aliment Pharmacol Ther. 2004;19(6):679–85.PubMedCrossRefGoogle Scholar
  17. 17.
    Rajapakse RO, Korelitz BI, Zlatanic J, Baiocco PJ, Gleim GW. Outcome of pregnancies when fathers are treated with 6-mercaptopurine for inflammatory bowel disease. Am J Gastroenterol. 2000;95(3):684–8.PubMedCrossRefGoogle Scholar
  18. 18.
    Banks B, Korelitz BI, Zetzel L. The course of non-specific ulcerative colitis: a review of twenty years of experience and late results. Gastroenterology. 1957;32:983–1012.PubMedGoogle Scholar
  19. 19.
    Miller JP. Inflammatory bowel disease in pregnancy: a review. J R Soc Med. 1986;79:221–5.PubMedGoogle Scholar
  20. 20.
    Willoughby CP, Truelove SC. Ulcerative colitis and pregnancy. Gut. 1980;21:469–74.PubMedCrossRefGoogle Scholar
  21. 21.
    Fonager K, Sorensen HT, Olsen J, Dahlerup JF, Rasmussen SN. Pregnancy outcome for women with Crohn disease: a follow-up study based on linkage between national registries. Am J Gastroenterol. 1998;93:2426–30.PubMedCrossRefGoogle Scholar
  22. 22.
    Moser MA, Okun NB, Mayes DC, Bailey RJ. Crohn disease, pregnancy, and birth weight. Am J Gastroenterol. 2000;95:1021–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Cornish J, Tan E, Teare J, et al. A meta-analysis on the influence of inflammatory bowel disease on pregnancy. Gut. 2007;56(6):830–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Porter RJ, Stirrat GM. The effects of inflammatory bowel disease on pregnancy: a case-controlled retrospective analysis. Br J Obstet Gynaecol. 1986;93:1124–31.PubMedCrossRefGoogle Scholar
  25. 25.
    Kane SV, Hanauer SB, Kiesel J, Shih L, Tyan D. HLA disparity determines disease activity through pregnancy in women with IBD. Am J Gastroenterol. 2004;99(8):1523–6.PubMedCrossRefGoogle Scholar
  26. 26.
    Nwokolo C, Tan WC, Andrews HA, Allan RN. Surgical resections in parous patients with distal ileal and colonic Crohn disease. Gut. 1994;35:220–3.PubMedCrossRefGoogle Scholar
  27. 27.
    Riis L, Vind I, Politi P, et al. Does pregnancy change the disease course? A study in a European cohort of patients with inflammatory bowel disease. Am J Gastroenterol. 2006;101(7):1539–45.PubMedCrossRefGoogle Scholar
  28. 28.
    Shoenut JP, Semelka RC, Silverman R, Yaffe CS, Micflikier AB. MRI in the diagnosis of Crohn disease in two pregnant women. J Clin Gastroenterol. 1993;17:244–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Brent RL. The effect of embryonic and fetal exposure to x-ray, microwaves, and ultrasound: counseling the pregnant and nonpregnant patient about these risks. Semin Oncol. 1989;16:347–68.PubMedGoogle Scholar
  30. 30.
    Cappell MS, Colon VJ, Sidhom OA. A study at 10 medical centers of the safety and efficacy of 48 flexible sigmoidoscopies and 8 colonoscopies during pregnancy with follow-up of fetal outcome and with comparison to control groups. Dig Dis Sci. 1996;41:2353–61.PubMedCrossRefGoogle Scholar
  31. 31.
    Qureshi WA, Rajan E, Adler DG, et al. ASGE guideline: guidelines for endoscopy in pregnant and lactating women. Gastrointest Endosc. 2005;61(3):357–62.PubMedCrossRefGoogle Scholar
  32. 32.
    Sachar D. Exposure to mesalamine during pregnancy increased preterm deliveries (but not birth defects) and decreased birth weight. Gut. 1998;43:316.PubMedCrossRefGoogle Scholar
  33. 33.
    Warrell D, Taylor R. Outcome for the foetus of mothers receiving prednisolone during pregnancy. Lancet. 1968;1:117–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Coelho J, Beaugerie L, Colombel JF. Pregnancy outcome in patients with inflammatory bowel disease treated with thiopurines: cohort from the CESAME Study. Gut. 2011;60(2):198–203.PubMedCrossRefGoogle Scholar
  35. 35.
    Einarson A, Mastroiacovo P, Arnon J, et al. Prospective, controlled multicenter study of loperamide in pregnancy. Can J Gastroenterol. 2000;14:185–7.PubMedGoogle Scholar
  36. 36.
    Bonapace E, Fisher RS. Constipation and diarrhea in pregnancy. Gastroenterol Clin North Am. 1998;27:197–211.PubMedCrossRefGoogle Scholar
  37. 37.
    Briggs G, Freeman R, Yaffee S. Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk. New Jersey: Lippincott Williams & Wilkins; 2008.Google Scholar
  38. 38.
    Hanauer SB, Present DH. The state of the art in the management of inflammatory bowel disease. Rev Gastroenterol Disord. 2003;3:81–92.PubMedGoogle Scholar
  39. 39.
    Esbjorner E, Jarnerot G, Wranne L. Sulphasalazine and sulphapyridine levels in children to mothers treated with sulphasalazine during pregnancy and lactation. Acta Paediatr Scand. 1987;76:137–42.PubMedCrossRefGoogle Scholar
  40. 40.
    Moody GA, Probert C, Jayanthi V, Mayberry JF. The effects of chronic ill health and treatment with sulphasalazine on fertility amongst men and female patients with inflammatory bowel disease in Leicestershire. Int J Colorectal Dis. 1997;12:220–4.PubMedCrossRefGoogle Scholar
  41. 41.
    Hernandez-Diaz S, Werler MM, Mitchell AA, et al. Folic acid antagonists during pregnancy and the risk of birth defects. N Engl J Med. 2000;343:1608–14.PubMedCrossRefGoogle Scholar
  42. 42.
    Rahimi R, Nikfar S, Rezaie A, Abdollahi M. Pregnancy outcome in women with inflammatory bowel disease following exposure to 5-aminosalicylic acid drugs: a meta-analysis. Reprod Toxicol. 2008;25(2):271–5.PubMedCrossRefGoogle Scholar
  43. 43.
    Colombel JF, Brabant G, Gubler MC, et al. Renal insufficiency in infant: side-effect of prenatal exposure to mesalazine? [letter] [see comments]. Lancet. 1994;344:620–1.PubMedCrossRefGoogle Scholar
  44. 44.
    Hernández-Díaz S, Mitchell AA, Kelley KE, Calafat AM, Hauser R. Medications as a potential source of exposure to phthalates in the U.S. population. Environ Health Perspect. 2009;117(2):185–9.PubMedGoogle Scholar
  45. 45.
    Diav-Citrin O, Shechtman S, Ornoy A, et al. Pregnancy outcome after gestational exposure to metronidazole: a prospective controlled cohort study. Teratology. 2001;63:186–92.PubMedCrossRefGoogle Scholar
  46. 46.
    Piper JM, Mitchel EF, Ray WA. Prenatal use of metronidazole and birth defects: no association. Obstet Gynecol. 1993;82:348–52.PubMedGoogle Scholar
  47. 47.
    Linseman DA, Hampton LA, Branstetter DG. Quinolone-induced arthropathy in the neonatal mouse. Morphological analysis of articular lesions produced by pipemidic acid and ciprofloxacin. Fundam Appl Toxicol. 1995;28:59–64.PubMedCrossRefGoogle Scholar
  48. 48.
    Moskovitz DN, Bodian C, Chapman ML, et al. The effect on the fetus of medications used to treat pregnant inflammatory bowel-disease patients. Am J Gastroenterol. 2004;99:656–61.PubMedCrossRefGoogle Scholar
  49. 49.
    Loebstein R, Addis A, Ho E, et al. Pregnancy outcome following gestational exposure to fluoroquinolones: a multicenter prospective controlled study. Antimicrob Agents Chemother. 1998;42:1336–9.PubMedGoogle Scholar
  50. 50.
    Beitins IZ, Bayard F, Migeon CJ, et al. The transplacental passage of prednisone and prednisolone in pregnancy near term. J Pediatr. 1972;81:936–45.PubMedCrossRefGoogle Scholar
  51. 51.
    Mogadam M, Korelitz BI, Ahmed SW, Dobbins WD, Baiocco PJ. The course of inflammatory bowel disease during pregnancy and postpartum. Am J Gastroenterol. 1981;75:265–9.PubMedGoogle Scholar
  52. 52.
    Armenti V, Ahlswede KM, Ahlswede RA, et al. National transplant pregnancy registry-outcomes of 154 pregnancies in cyclosporine-treated female kidney transplant recipients. Transplantation. 1994;57:502–6.PubMedGoogle Scholar
  53. 53.
    Ramsey-Goldman R, Schilling E. Immunosuppressive drug use during pregnancy. Rheum Clin North Am. 1997;23:149–67.CrossRefGoogle Scholar
  54. 54.
    Saarikoski S, Seppala M. Immunosuppression during pregnancy: transmission of azathioprine and its metabolites from the mother to the fetus. Am J Obstet Gynecol. 1973;115:1100–6.PubMedGoogle Scholar
  55. 55.
    Dubinsky MC. Azathioprine, 6-mercaptopurine in inflammatory bowel disease: pharmacology, efficacy, and safety. Clin Gastroenterol Hepatol. 2004;2:731–43.PubMedCrossRefGoogle Scholar
  56. 56.
    Matalon ST, Ornoy A, Lishner M. Review of the potential effects of three commonly used antineoplastic and immunosuppressive drugs. (cyclophosphamide, azathioprine, doxorubicin on the embryo and placenta). Reprod Toxicol. 2004;18:219–30.PubMedCrossRefGoogle Scholar
  57. 57.
    Francella A, Dyan A, Present DH, et al. The safety of 6-mercaptopurine for childbearing patients with inflammatory bowel disease: a retrospective cohort study. Gastroenterology. 2003;124:9–17.PubMedCrossRefGoogle Scholar
  58. 58.
    Norgard B, Pedersen L, Sorensen HT, et al. Azathioprine, mercaptopurine and birth outcome: a population-based cohort study. Aliment Pharmacol Ther. 2003;17:827–34.PubMedCrossRefGoogle Scholar
  59. 59.
    Goldenberg M, Bider D, Oelsner G, et al. Methotrexate therapy of tubal pregnancy. Hum Reprod. 1993;8:660–6.PubMedGoogle Scholar
  60. 60.
    Katz JA, Antoni C, Lichenstein GR, et al. Outcome of pregnancy in female patients receiving infliximab for the treatment of Crohn disease and rheumatoid arthritis. Am J Gastroenterol. 2004;99:2385–92.PubMedCrossRefGoogle Scholar
  61. 61.
    Kane SV, Acquah LA, Mahadevan U, Cucchiara S, Hyams JS, et al. The London Position Statement of the World Congress of Gastroenterology on Biological Therapy for IBD with the European Crohn and Colitis Organisation: pregnancy and pediatrics. Am J Gastroenterol. 2011;106(2):214–23.CrossRefGoogle Scholar
  62. 62.
    Hellwig K, Haghikia A, Gold R. Pregnancy and natalizumab: results of an observational study in 35 accidental pregnancies during natalizumab treatment. Mult Scler. 2011;17(8):958–63.PubMedCrossRefGoogle Scholar
  63. 63.
    Motta M, Ciardelli L, Marconi M, et al. Immune system development in infants born to mothers with autoimmune disease, exposed in utero to immunosuppressive agents. Am J Perinatol. 2007;24(8):441–7.PubMedCrossRefGoogle Scholar
  64. 64.
    Khan HA. Cyclosporin-A augments respiratory burst of whole blood phagocytes in pregnant rats. Immunopharmacol Immunotoxicol. 2007;29(3–4):367–74.PubMedCrossRefGoogle Scholar
  65. 65.
    Ramsey-Goldman R, Schilling E. Immunosuppressive drug use during pregnancy. Rheum Dis Clin North Am. 1997;23:149–67.PubMedCrossRefGoogle Scholar
  66. 66.
    Bertschinger P, Himmelmann A, Follath F, et al. Cyclosporine treatment of severe ulcerative colitis during pregnancy. Am J Gastroenterol. 1995;90:330.PubMedGoogle Scholar
  67. 67.
    Kornbluth A, Reddy D. Management and outcome of severe colitis in pregnancy. Am J Gastroenterol. 2002;97:P705.CrossRefGoogle Scholar
  68. 68.
    Ehrenpreis ED, Kane SV, Cohen LB, Cohen RD, Hanauer SB. Thalidomide therapy for patients with refractory Crohn disease: an open-label trial. Gastroenterology. 1999;117:1271–7.PubMedCrossRefGoogle Scholar
  69. 69.
    Vasiliauskas EA, Kam LY, Abreu-Martin MT, et al. An open-label pilot study of low-dose thalidomide in chronically active, steroid-dependent Crohn disease. Gastroenterology. 1999;117:1278–87.PubMedCrossRefGoogle Scholar
  70. 70.
    Sandborn WJ. Preliminary report on the use of oral tacrolimus (FK506) in the treatment of compicated proximal small bowel and fistulizing Crohn disease. Am J Gastroenterol. 1997;92:876–9.PubMedGoogle Scholar
  71. 71.
    Neurath MF, Wanitschke R, Peters M. Randomized trial of mycophenolate versus azathioprine for treatment of chronic active Crohn disease. Gut. 1999;44:625–8.PubMedCrossRefGoogle Scholar
  72. 72.
    Kainz A, Harabacz I, Cowlrick IS, Gadgil S, Hagiwara D. Analysis of 100 pregnancy outcomes in female patients treated systemically with tacrolimus. Transpl Int. 2000;13:S299–300.PubMedGoogle Scholar
  73. 73.
    Jacobson L, Clapp DH. Total parenteral nutrition in pregnancy complicated by Crohn disease. J Parenter Enteral Nutr. 1987;11:93–6.CrossRefGoogle Scholar
  74. 74.
    Nugent F, Rajala M, O’Shea RA, et al. Total parenteral nutrition in pregnancy: conception to delivery. J Parenter Enteral Nutr. 1987;11:424–7.CrossRefGoogle Scholar
  75. 75.
    Park YK, Meier ER, Song WO. Characteristics of teenage mothers and predictors of breastfeeding initiation in the Michigan WIC Program in 1995. Women, Infants, and Children. J Hum Lact. 2003;19:50–6.PubMedCrossRefGoogle Scholar
  76. 76.
    Kane S, Lemieux N. The role of breastfeeding in postpartum disease activity in women with inflammatory bowel disease. Am J Gastroenterol. 2005;100(1):102–5.PubMedCrossRefGoogle Scholar
  77. 77.
    Moffatt DC, Ilnyckyj A, Bernstein CN. A population-based study of breastfeeding in inflammatory bowel disease: initiation, duration, and effect on disease in the postpartum period. Am J Gastroenterol. 2009;104(10):2517–23.PubMedCrossRefGoogle Scholar
  78. 78.
    Klotz U, Harings-Kaim A. Negligible excretion of 5-aminosalicylic acid in breast milk. Lancet. 1993;342:618–9.PubMedCrossRefGoogle Scholar
  79. 79.
    Nelis GF. Diarrhoea due to 5-aminosalicyclic acid in breast milk. Lancet. 1989;1:383.PubMedCrossRefGoogle Scholar
  80. 80.
    Christensen LA. 5-Aminosalicylic acid containing drugs. Delivery, fate, and possible clinical implications in man. Dan Med Bull. 2000;47(1):20–41.PubMedGoogle Scholar
  81. 81.
    Christensen LA, Dahlerup JF, Nielsen MJ, Fallingborg JF, Schmiegelow K. Azathioprine treatment during lactation. Aliment Pharmacol Ther. 2008;28(10):1209–13.PubMedCrossRefGoogle Scholar
  82. 82.
    Nyberg G, Haljamae U, Kjemeller I, et al. Breast-feeding during treatment with cyclosporine. Transplantation. 1998;65:253–5.PubMedCrossRefGoogle Scholar
  83. 83.
    Munoz-Flores-Thiagarajan KD, Easterling T, Bond EF, et al. Breast-feeding by a cyclosporine-treated mother. Obstet Gynecol. 2001;97:816–8.PubMedCrossRefGoogle Scholar
  84. 84.
    Ost L, Wettrell G, Rane A, et al. Prednisolone excretion in human milk. J Pediatr. 1985;106:1008–11.PubMedCrossRefGoogle Scholar
  85. 85.
    Kane S. Breastfeeding and IBD: safety and management issues. Inflammatory Bowel Disease Monitor. 2004;6:50–2.Google Scholar
  86. 86.
    Kane S, Ford J, Cohen R, Wagner C. Absence of infliximab in infants and breast milk from nursing mothers receiving therapy for Crohn disease before and after delivery. J Clin Gastroenterol. 2009;43(7):613–6.PubMedCrossRefGoogle Scholar
  87. 87.
    Gibert WM, Jandial D, Field NT, et al. Birth outcomes in teenage pregnancies. J Matern Fetal Neonatal Med. 2004;16:265–70.CrossRefGoogle Scholar
  88. 88.
    Ilnyckyj A, Blanchard JF, Rawsthorne P, Bernstein CN. Perianal Crohn disease and pregnancy: role of the mode of delivery. Am J Gastroenterol. 1999;94:3274–8.CrossRefGoogle Scholar
  89. 89.
    Levine W, Diamond B. Surgical procedures during pregnancy. Am J Obstet Gynecol. 1961;81:1046–52.PubMedGoogle Scholar
  90. 90.
    Kelly M, Hunt TM, Wicks ACB, et al. Fulminant ulcerative colitis and parturition: a need to alter current management? Br J Obstet Gynaecol. 1994;101:166–7.CrossRefGoogle Scholar
  91. 91.
    Anderson JB, Turner GM, Williamson RC. Fulminant ulcerative colitis in late pregnancy and the puerperium. J R Soc Med. 1987;80:492–4.PubMedGoogle Scholar
  92. 92.
    Hill J, Clark A, Scott NA. Surgical treatment of acute manifestations of Crohn disease during pregnancy. J R Soc Med. 1997;90:64–6.PubMedGoogle Scholar
  93. 93.
    Metcalf A, Dozois RR, Baert RW, et al. Pregnancy following ileal pouch-anal anastomosis. Dis Colon Rectum. 1985;28:859–61.PubMedCrossRefGoogle Scholar
  94. 94.
    Olsen KO, Juul S, Berndtsson I, Oresland T, Laurberg S. Ulcerative colitis: female fecundity before diagnosis, during disease, and after surgery compared with a population sample. Gastroenterology. 2002;122:15–9.CrossRefGoogle Scholar
  95. 95.
    Waljee A, Waljee J, Morris AM, Higgins PD. Threefold increased risk of infertility: a meta-analysis of infertility after ileal pouch anal anastomosis in ulcerative colitis. Gut. 2006;55(11):1575–80.PubMedCrossRefGoogle Scholar
  96. 96.
    Juhasz ES, Fozard B, Dozois RR, Ilstrup DM, Nelson H. Ileal pouch-anal anastomosis function following childbirth. An extended evaluation. Dis Colon Rectum. 1995;38:159–65.PubMedCrossRefGoogle Scholar
  97. 97.
    Baldassano R, Ferry G, Griffiths A. Transition of the patient with inflammatory bowel disease from pediatric to adult care: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2002;34:245–8.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of MedicineMayo ClinicRochesterUSA

Personalised recommendations