Kamilė Piesliakaitė1, Živilė Sabonytė – Balšaitienė2, 3, Diana Ramašauskaitė2, 3, Virginija Paliulytė2, 3
1Vilnius University, Faculty of Medicine, Vilnius, Lithuania
2Vilnius University, Faculty of Medicine, Clinic of Obstetrics and Gynecology, Vilnius, Lithuania
3Vilnius University Hospital Santaros Clinics, Center of Obstetrics and Gynecology, Vilnius, Lithuania
Abstract
Background. Autoimmune diseases of the digestive tract are more prevalent in women and have a negative impact on maternal or fetal health. Most common of these diseases are celiac disease, inflammatory bowel disease, autoimmune hepatitis, primary sclerosing cholangitis, and primary biliary cholangitis. Even though they usually tend to go into remission, the underlying pathological pathways may cause complications. Most frequent pregnancy risks include preterm birth, miscarriage, cesarian section, or low birth weight newborn.
Aim: the aim of the study is to analyze and review the evidence-based scientific literature describing the relationship between autoimmune diseases and pregnancy, maternal or fetal complications.
Methods. International databases PubMed and Google Scholar were used for literature review. 53 scientific articles were selected for this literature review.
Results. Celiac disease poses a risk of cesarean section, recurrent miscarriages, low birth weight and preterm delivery, especially for untreated women. Inflammatory bowel disease may cause hemostatic complications in women, preterm birth, small for gestational age birth weight, or stillbirth. Autoimmune hepatitis could lead to fetal loss premature delivery. Primary sclerosing cholangitis and primary biliary cirrhosis increase the risk of cesarean section and preterm birth.
Conclusions. Autoimmune diseases of the digestive tract are not common in pregnancy and most cases will be in remission. Preterm birth, caesarean section or small for gestational age fetus are most common complications. Careful multidiscipline follow-up of obstetrician-gynecologist and gastroenterologist is crucial for reducing pregnancy, maternal, or fetal risks.
Keywords: pregnancy; celiac disease; inflammatory bowel disease; autoimmune hepatitis; primary sclerosing cholangitis; primary biliary cholangitis
https://doi.org/10.53453/ms.2023.5.4
Autoimmune diseases of the digestive system during pregnancy
Kamilė Piesliakaitė
1
, Živilė Sabonytė – Balšaitienė
2,3
, Diana Ramašauskaitė
2,3
, Virginija Paliulytė
2,3
1
Vilnius University, Faculty of Medicine, Vilnius, Lithuania
2
Vilnius University, Faculty of Medicine, Clinic of Obstetrics and Gynecology, Vilnius, Lithuania
3
Vilnius University Hospital Santaros Clinics, Center of Obstetrics and Gynecology, Vilnius, Lithuania
Abstract
Background. Autoimmune diseases of the digestive tract are more prevalent in women and have a negative impact
on maternal or fetal health. Most common of these diseases are celiac disease, inflammatory bowel disease,
autoimmune hepatitis, primary sclerosing cholangitis, and primary biliary cholangitis. Even though they usually
tend to go into remission, the underlying pathological pathways may cause complications. Most frequent
pregnancy risks include preterm birth, miscarriage, cesarian section, or low birth weight newborn.
Aim: the aim of the study is to analyze and review the evidence-based scientific literature describing the
relationship between autoimmune diseases and pregnancy, maternal or fetal complications.
Methods. International databases PubMed and Google Scholar were used for literature review. 53 scientific
articles were selected for this literature review.
Results. Celiac disease poses a risk of cesarean section, recurrent miscarriages, low birth weight and preterm
delivery, especially for untreated women. Inflammatory bowel disease may cause hemostatic complications in
women, preterm birth, small for gestational age birth weight, or stillbirth. Autoimmune hepatitis could lead to
fetal loss premature delivery. Primary sclerosing cholangitis and primary biliary cirrhosis increase the risk of
cesarean section and preterm birth.
Conclusions. Autoimmune diseases of the digestive tract are not common in pregnancy and most cases will be in
remission. Preterm birth, caesarean section or small for gestational age fetus are most common complications.
Careful multidiscipline follow-up of obstetrician-gynecologist and gastroenterologist is crucial for reducing
pregnancy, maternal, or fetal risks.
Keywords: pregnancy; celiac disease; inflammatory bowel disease; autoimmune hepatitis; primary sclerosing
cholangitis; primary biliary cholangitis
Journal of Medical Sciences. 11 May, 2023 - Volume 11 | Issue 4. Electronic - ISSN: 2345-0592
Medical Sciences 2023 Vol. 11 (4), p. 35-45, https://doi.org/10.53453/ms.2023.5.4
35
Autoimuninių virškinamojo trakto ligų pasireiškimas nėštumo
metu
Kamilė Piesliakaitė
1
, Živilė Sabonytė – Balšaitienė
2,3
, Diana Ramašauskaitė
2,3
, Virginija Paliulytė
2,3
1
Vilniaus universitetas, Medicinos fakultetas, Vilnius, Lietuva
2
Vilniaus universitetas, Medicinos fakultetas, Akušerijos ir ginekologijos klinika, Vilnius, Lietuva
3
Vilniaus universiteto ligoninė Santaros klinikos, Akušerijos ir ginekologijos centras, Vilnius, Lietuva
Santrauka
Įvadas. Autoimuninėmis virškinamojo trakto ligomis dažniau serga moterys. Jei serga nėščioji, šios ligos gali
turėti neigiamą poveikį motinos ar vaisiaus sveikatai. Dažniausios autoimuninės virškinamojo trakto ligos yra
celiakija, uždegiminė žarnų liga, autoimuninis hepatitas, pirminis sklerozuojantis cholangitas ir pirminis biliarinis
cholangitas. Nors nėštumo metu paprastai pasiekiama remisiją, pagrindiniai patologiniai mechanizmai vis tik gali
sukelti komplikacijų. Didžiausia yra priešlaikinio gimdymo, persileidimo, cezario pjūvio operacijos arba mažo
svorio naujagimio rizika.
Tikslas. Išanalizuoti ir apžvelgti įrodymais pagrįstą mokslinę literatūrą, aprašančią autoimuninių ligų ir nėštumo
ryšį, komplikacijas nėščiajai ar vaisiui.
Metodai. Literatūros apžvalgai naudotos tarptautinės duomenų bazės PubMed ir Google Scholar. Buvo atrinkti
53 moksliniai straipsniai šiai literatūros apžvalgai.
Rezultatai: celiakija didina cezario pjūvio operacijos, pasikartojančių persileidimų, mažo gimimo svorio ir
priešlaikinio gimdymo riziką, ypač negydomoms moterims. Uždegiminė žarnyno liga moterims gali sukelti
hemostazinių komplikacijų. Taip pat didėja priešlaikinio gimdymo, mažo gimimo svorio pagal gestacinį amžių
naujagimio arba negyvagimio rizika. Autoimuninis hepatitas gali sukelti savaiminį persileidimą, priešlaikinį
gimdymą. Pirminis sklerozuojantis cholangitas ir pirminis biliarinis cholangitas didina cezario pjūvio operacijos
ir priešlaikinio gimdymo tikimybę.
Išvados. Autoimuninės virškinamojo trakto ligos nėštumo metu nėra dažnos ir daugeliu atvejų liga yra remisijos
stadijoje. Priešlaikinis gimdymas, cezario pjūvio operacija arba mažas vaisius pagal gestacinį amžių yra
dažniausios komplikacijos. Atidus multidisciplinis gydytojo akušerio – ginekologo ir gydytojo gastroenterologo
stebėjimas yra labai svarbus, siekiant sumažinti nėštumo, motinos ar vaisiaus komplikacijų riziką.
Raktažodžiai: nėštumas; celiakija; uždegiminė žarnų liga; autoimuninis hepatitas; pirminis sklerozuojantis
cholangitas; pirminis biliarinis cholangitas
Journal of Medical Sciences. 11 May, 2023 - Volume 11 | Issue 4. Electronic - ISSN: 2345-0592
36
1. Introduction
It is widely known that autoimmune diseases affect
more women than men. This tendency may be
explained due to influence of sex hormones (1).
Hormones are an important part of pregnancy
because they cause immunological changes in the
uterus that help successful implantation and
gestation (1). However, hormonal changes during
pregnancy affect autoimmunity which has an
immense impact on fertilization, pregnancy, adverse
maternal and fetal outcomes (1). Autoimmunity is
related to autoantibodies, which can damage
different organ systems. It manifests differently in
the digestive system, adversely affecting organs and
causing clinical symptoms. Autoimmune diseases of
the digestive system may be classified into three
categories: associated with human leukocyte antigen
(HLA), immunoglobulin G4-related diseases (IgG4-
RD), and other autoimmune gastrointestinal
diseases (2,3).
One of these diseases is celiac disease. The
symptoms appear in only 0.2 % of patients and most
of the symptomatic people are women (4).
Untreated it can lead to infertility or cause adverse
fetal outcomes (4). Inflammatory bowel disease
(IBS) is divided into Crohn’s disease and ulcerative
colitis. The incidence of this disease is highest
during reproductive years, and it can cause
spontaneous abortion, preterm birth, or other
complications (5). Autoimmune hepatitis occurs
more frequently in women of young age (6). The
flares of the disease occurring during pregnancy are
related to adverse outcomes (6). Immune-mediated
cholangiopathies – primary sclerosing cholangitis
(PSC) and primary biliary cholangitis (PBC) cause
symptoms by the accumulation of activated T-
lymphocytes in bile ducts (7). PBC is usually
diagnosed in middle-aged females rather than males.
PSC, however, affects more males (7). These
autoimmune diseases can affect women of
reproductive age and have unfavorable outcomes on
their pregnancies. It is important to know outcomes
and help women to treat these diseases.
2. Materials and methods
International databases PubMed and Google Scholar
were used for literature review. 1016 articles based
on the keywords or their combination. After reading
abstracts and full texts 53 scientific articles were
selected - meta-analyses, systematic reviews,
literature reviews, clinical studies. Articles not in
English were rejected.
3. Results
3.1 Celiac disease
Celiac disease is an immune-mediated gluten-
sensitive enteropathy. Meaning that manifestation of
celiac disease can include extra-digestive organs,
sometimes gynecological-obstetric symptoms might
be the only noticeable ones (menstrual cycle
disorders, infertility, early miscarriages) (8). Tissue
transglutaminase (tTG EC 2.3.2.13) is a specific
autoantigen. The body produces antibodies against
it. In pregnancy, tTG is present on the outer layer of
the syncytiotrophoblast microvillous membrane,
decidual cells, and mother-embryo interface (9). It
has a high affinity to fibronectin (9). Cross-linked
they both support cell adhesion in the uterus. This
autoantigen on the syncytiotrophoblast microvillous
membrane is directly exposed to maternal
autoantibodies in the blood (9). The interaction
between tTG and autoantibodies might cause
obstetric complications. During peri-implantation
period anti-tissue-transglutaminase (anti-tTG)
reduces the proliferation and migration of
trophoblast and might even cause its apoptosis (10).
Moreover, the ineffective clearance of apoptotic
cells might lead to uterine inflammation, which is
usually seen in miscarriages (10).
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37
One population-based cohort study has shown that
cesarean section is increased by 30% for women
with celiac disease (11). This number is also
increasing as women age. Furthermore, the risk of
assisted delivery is also greater. Miscarriages are
slightly more common in women with celiac
disease (11). Additionally, the preterm birth risk is
increased for both treated and untreated women.
However, treated women have a 20% lower risk
compared to untreated women (12). Complications,
such as intrauterine growth restriction, stillbirth, low
birth weight and small for gestational age newborns
are also more common (12). Up to 50 % of untreated
patients might experience miscarriage or adverse
pregnancy outcomes (13). Recurrent miscarriages
(two or more consecutive spontaneous abortions of
unknown origin) or intrauterine growth retardation
might be signs of subclinical celiac disease (13).
Spontaneous abortions might occur due to anti-tTG
induced trophoblast apoptosis, immunity, and
nutrient deficiency (for example zinc and folic acid)
but many more pathogenetic mechanisms are being
investigated (14). Moreover, normal development
and function of the placenta depends on the
extravillous trophoblast (EVT) invasion to the
maternal decidua, followed by vascular growth (15).
Trophoblasts produce some proteins and hormones
involved in the maintenance of the pregnancy. Due
to apoptosis of EVT, recurrent miscarriages or
intrauterine growth retardation might occur (15,16).
Furthermore, a study has showed an increased EVT
apoptosis of women, non-compliant with a gluten-
free diet. It also has been consistently linked to low
birthweight of newborns (15). A population-based
Swedish cohort study has found that women with
undiagnosed celiac disease were more likely to have
offspring with low birth weight and very low birth
weight (17). Besides, the offspring of women with
undiagnosed celiac disease had an increased risk for
preterm and very preterm birth. Newborns of women
with the diagnosed disease did not have a greater
risk (17).
So far, the only treatment for celiac disease is a
gluten-free diet. It is crucial to avoid barley, wheat,
and rye to reduce symptoms, autoantibodies, and
villous atrophy (18). Nevertheless, the diet has
several disadvantages: high cost, vitamin and
mineral deficiency, psychological impact,
constipation, and cardiovascular disease risk (18).
On the other hand, a gluten-free diet might not only
improve the mother’s health, and histological
damage but also lower the risk of miscarriage or
intrauterine fetal death (19). Women should be
offered preconception counseling and supervision of
a multidisciplinary team. A gluten-free diet should
be advised and the anti-tTG levels should be
monitored (4).
3.2 Inflammatory bowel disease
Inflammatory bowel disease (IBD) is categorized
into Crohn’s disease (CD) and ulcerative colitis
(UC). Crohn’s disease is more common in women
and patients are most often diagnosed between 15
and 35 years (20). According to the Olmsted County
study, the adjusted annual incidence of Crohn’s
disease from 2000-2010 was 10.7 cases per 100,000
person-years, while that of ulcerative colitis was
12.2 per 100,000 person-years (20). It is challenging
to differentiate both diseases because the main
symptom is chronic diarrhea (bloody stools are more
common in UC). Abdominal pain, weight loss, and
extraintestinal manifestations are also frequent. IBD
manifests as flares or remissions, and treatment is
indicated for those who have a complicated disease
(21). A prospective European ECCO-EpiCom Study
of 209 pregnant women found that pregnant patients
with CD have more probability to remain in
remission during pregnancy than patients with UC,
respectively 81 % and 65 % (22). Additionally,
women with UC are more likely to experience a
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38
relapse during the first 6 months postpartum. When
the disease was active at conception, 56% of CD and
33% of UC women had persistently active disease
during pregnancy (22). Another study has found that
in up to 45% of patients with ulcerative colitis who
conceive during the active phase of the disease, the
colitis worsens during pregnancy, 24% have stable
disease, and 69% go into remission (23). Among
patients with Crohn’s disease one-third experiences
remission, one-third is stably active, and one-third
worsens (23).
Women with IBD might have fertility issues and
negative pregnancy outcomes. Adverse outcomes
such as preterm birth, small for gestational age birth
weight, or stillbirth were reported in a meta-
analysis (24). An indicated preterm delivery may be
performed for fetal growth restriction or
oligohydramnios that is the result of placental
insufficiency or for non-reassuring fetal status (25).
In addition, the stress response of a growth-restricted
fetus may result in stimulation of the hypothalamic-
pituitary-adrenal (HPA) axis, a key step in the
cascade of events that results in spontaneous preterm
birth (25). The odds of preterm birth are higher for
those who have an unspecified form of IBD. UC and
CD carry a similar risk of this pregnancy outcome
(24). Some studies have found an increased risk of
congenital anomalies, such as limb, urological and
neurological defects, and UC to confer a greater risk
than CD, but the results must be interpreted with
caution due to methodological flaws (26). Moreover,
IBD is associated with severe preeclampsia, preterm
premature rupture of membranes, and medically
indicated preterm delivery in women using systemic
corticosteroids during pregnancy as well as with low
5-minute Apgar score in term infants (27). A
population-based study has found that women with
UC and CD have an increased chance of elective
cesarean delivery. Besides women with UC have a
4-fold increased risk of venous thromboembolism
during pregnancy, and with CD – a 2-fold increased
risk of antepartum hemorrhage (28). Fortunately, no
hypertensive disorders were associated with IBD
(28). It is crucial to determine the mode of delivery
in IBD. Vaginal delivery has risks for anal sphincter
or perineal damage, which lead to worsening
perianal disease in CD or pouch dysfunction in
patients with IPAA prior to pregnancy. Cesarian
section should be performed in women with active
perianal disease, ileoanal pouch, and considered for
inactive perianal disease (29,30).
Crucial part of successfully delivering a healthy
offspring is a preconception counseling for women
with IBD. An important part of counseling is to
assess and optimize disease activity, review
medication safety, suggest folate supplementation,
smoking cessation as well as education (26).
Gastroenterologists should proactively initiate
preconception counseling conversations with all
men and women of childbearing age (26). Usually,
amino salicylates, corticosteroids,
immunomodulators, biologic therapy, or surgical
treatment are offered for the patients (31). However,
some medications have a negative impact on
pregnancy or fetal outcomes. British Society of
Gastroenterology consensus guidelines recommend
women to discontinue methotrexate due to its
teratogenic and embryotoxic effect 6 months prior to
conception (strong recommendation) (31). If a
patient becomes pregnant while on methotrexate, the
usage should be immediately ceased, and high dose
of folic acid (15 mg daily) provided for at least 6
weeks (31). It is an antimetabolite that interferes in
purine synthesis by decreasing the availability of
tetrahydrofolate (32). Growth deficiency, cranial
abnormalities, microcephaly, meningomyelocele,
hydrocephaly, micrognathia, and limb hypoplasia
have been associated with “MTX embryopathy”
(32). Recommendation guidelines also suggest
continuing anti-TNF therapy for those with active
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39
disease or a high risk of relapse but advise
discontinuing therapy at the start of the third
trimester, for those who wish to stop it (very low–
quality evidence) (31). Anti-TNF medications may
be safely discontinued in the second trimester in
women with quiescent disease (31). A Danish study
of 219 women treated in the third trimester with anti-
TNF medications, revealed no increased risk of low
birth weight or preterm birth, but 66% experienced
moderate to severe disease, which was associated
with low birth weight and preterm birth (33). The
same council advises treating flares and controlling
the disease as normal with 5-ASA, thiopurines, anti-
TNF, nutrition, and steroids. Indications for surgery
are the same as for non-pregnant patients (31).
3.3 Autoimmune hepatitis
Autoimmune hepatitis (AIH) is an immune-
mediated chronic liver disease of unknown
etiology (34). The prevalence is 16 to 18 cases per
100,000 people in Europe (35). If left untreated, AIH
leads to chronic hepatitis, progressive fibrosis,
eventually leading to liver cirrhosis and cancer.
Women, especially those of childbearing age, are
more affected by autoimmune hepatitis (36). One
study showed that around 73% of pregnant women
are in remission at conception and others experience
a flare during their pregnancy (37). In this study, for
9 % of patients serious maternal complications
occurred and high rate (52 %) of postpartum flares
was observed (37). A higher risk complication was
reported in patients with type 2 or 3 autoimmune
hepatitis. The unexplained adverse pregnancy
outcomes were associated with anti-SLA/LP and
anti-Ro/SSA antibodies (37). Another study has
reported that fetal loss rate is 29.4 %, usually before
the 20
th
week (38). Also, premature delivery
occurred in 11.8 % of patients (38). In the same
study, 54.9 % of pregnant patients had elevated
aminotransferases during pregnancy or in the
postpartum period (38). 31.4 % of women
experienced a relapse of autoimmune hepatitis and
13.7% had flares in the postpartum period, with a
median time of 75 days after the delivery (38). There
are not many studies, conducted with patients with
autoimmune hepatitis, but overall good obstetric and
maternal outcomes could be expected.
For the treatment of autoimmune hepatitis
corticosteroids, azathioprine, mycophenolate
mofetil, biological therapy or other
immunosuppressive agents could be used (39).
Regardless of remission, some patients still require
treatment during pregnancy. Azathioprine (50 to
100 mg/d) does not increase the rate of birth defects,
although it was associated with lower birthweight,
lower gestational age, and prematurity (39).
Breastfeeding during the treatment with
azathioprine is usually not recommended, although
only 1.2% is excreted in the breast milk (38).
Prednisone is not associated with fetal teratogenicity
and does not cross the placenta. Therefore,
prednisone is the preferred treatment to control
disease activity during pregnancy and is allowed
during breastfeeding. Mycophenolate mofetil is
contraindicated in pregnancy because it causes
congenital malformations (6,40).
3.4 Primary sclerosing cholangitis and primary
biliary cirrhosis
Primary sclerosing cholangitis (PSC) is a chronic
liver disease when bile ducts are inflamed and
scarred. When the disease progresses, they narrow
and cause cholestasis. About 2/3 of the patients have
coexistent IBD (75 % ulcerative colitis) (41). As
mentioned, the disease is insidious, and abnormal
liver function tests are usually the only sign of the
disease. The most common symptoms are
abdominal pain, pruritus, jaundice, or fatigue (42).
PSC disrupts maternal-fetal bile salt metabolism as
in obstetric cholestasis (43). Cholestasis may occur
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40
due to hormonal influence on the bile salt export
pump and the hepatocytes. Elevated bile acid levels
may be toxic to the fetus, and it also affects
myometrial contractility, which can cause
vasoconstriction of chorionic veins in the placenta.
This may lead to preterm delivery and fetal
distress (43).
Primary biliary cirrhosis (PBC) is a chronic and
slowly progressive autoimmune liver disease that
may lead to liver cirrhosis (44). It affects more
women than men (differently from PSC) and is
thought to be triggered by environmental factors.
PBC may overlap with autoimmune hepatitis (44).
Even though there are not many studies done on the
relation between pregnancy and PBC, one
retrospective study of clinical case has found, that in
30 % of pregnancies flares occur (45). Clinical
improvement or stabilization of disease activity was
observed in 70 % of pregnancies. Postpartum flares
were noted in 60 % of pregnancies (45). It may be
due to decreasing estrogen concentrations in blood
after delivery. This facilitates a cytokine shift to the
inflammatory cytotoxic type 1 profile (46).
Considering, that these diseases are rare, there are
not many studies published about their relation to
pregnancy. But one study reported a higher cesarean
section rate (47 %) in women with PSC compared to
women with PBC (20 %) (47). Moreover, preterm
delivery rate also increased (27 %) in women having
PBC or PSC, compared to a healthy population (47).
The rates of preterm birth correlated with higher
serum bile acid levels and higher ALT concentration
at booking also was associated with early delivery.
Fortunately, no correlation was found between the
MELD score in women with cirrhosis and preterm
birth (47). A Swedish cohort has found that women
with liver cirrhosis have an increased risk of
cesarean delivery, low birth weight, and preterm
birth (48). No risk of preeclampsia, small for
gestational age fetus, gestational diabetes, stillbirth,
or fetal malformations was noted (48). In another
study, liver cirrhosis was associated with
intrahepatic cholestasis in pregnancy, the induction
of labor, puerperal infections, preterm birth, large
for gestational age infants, and neonatal respiratory
distress (49). PSC is associated with a higher
miscarriage rate. In patients, who got diagnosed with
PSC after they became pregnant, the miscarriage
rate is 14 %, and 21 % when patients got pregnant
with already established diagnosis (50).
Recommended treatment for PBC and PSC is
ursodeoxycholic acid (UDCA) (51). It is usually
continued throughout most of pregnancy and
breastfeeding. The medication might lower maternal
serum bile levels, reduce the passage of the bile to
the fetus and decrease bile levels in colostrum (51).
A Cochrane Review has found that UDCA has better
outcomes in pruritus (52). Additionally, no
significant differences in fetal distress and
spontaneous preterm birth were observed. Less
preterm deliveries were noted in UDCA-treated
patients (52). UDCA is presumed to be safe during
the second and third trimesters but safety data
regarding UDCA during the first trimester and
breastfeeding are scarce. However, one study
reported no adverse fetal outcomes in PSC patients
treated with UDCA throughout all gestational
trimesters (53). It was also noted that liver enzymes
remained stable in treated patients compared to
untreated (53).
4. Conclusions
To sum up, autoimmune diseases such as celiac
disease, inflammatory bowel disease, autoimmune
hepatitis, primary sclerosing cholangitis, or primary
biliary cholangitis are not common in pregnancy.
Celiac disease poses a risk of cesarean section,
recurrent miscarriages, low birth weight and preterm
delivery, especially for untreated women and so far,
the only treatment is a gluten-free diet.
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41
Inflammatory bowel disease usually remains in
remission during pregnancy but may cause
hemostatic complications. Moreover, preterm birth,
small for gestational age birth weight, or stillbirth
may occur. Autoimmune hepatitis usually flares up
during postpartum. Nevertheless, the disease may
cause pregnancy complications: fetal loss and
premature delivery. For inflammatory bowel disease
and autoimmune hepatitis immunosuppressive
therapy is recommended to avoid the relapse.
Primary sclerosing cholangitis and primary biliary
cirrhosis are not common diseases in young women.
However, the higher risk of cesarean section,
preterm birth is observed. The safe treatment during
pregnancy is ursodeoxycholic acid. Even though
these autoimmune diseases do not pose a high risk
of negative outcomes, a careful multidiscipline
follow-up by obstetricians and gastroenterologists is
crucial for preventing pregnancy, maternal or fetal
complications.
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