Pregnancy and IBD


Women who wish to become pregnant may be concerned about how their inflammatory bowel disease (IBD) will impact pregnancy, as well as how pregnancy will affect their condition.  Having IBD does not necessarily affect the ability to have children.  With the careful supervision of both a gastroenterologist and obstetrician, most women with IBD can have a healthy pregnancy and a healthy baby. However, there are some important considerations.


Conception
Generally speaking, women whose ulcerative colitis or Crohn’s disease is in remission can become pregnant as easily as other women of the same age. However, women with active IBD may have more difficulty becoming pregnant. Conceiving during a disease flare is not advised. If conception occurs during a flare-up, the disease is more likely to remain active throughout the pregnancy and the risk is greater for problems such as miscarriage, premature delivery, or having a baby with low birth weight. Women who have had surgery in the pelvis, particularly a colectomy with J-pouch, may have lower fertility rates. Because methotrexate can cause abortion and congenital malformations, it should be stopped three months before conception in both men and women, and should not be taken while pregnant or breastfeeding. Pregnancy.The best time for a woman with IBD to become pregnant is when her IBD is in remission for at least 3-6 months and she is off steroids. It is also not advised that a woman become pregnant when starting a new medication. Having active disease during pregnancy can increase the risk of having a baby born prematurely or with a low birth weight. Therefore, to maintain a state of remission and prevent IBD flares during pregnancy, it is important to continue taking prescribed medications. Many IBD medications have been shown to cause minimal risk to the pregnancy (see Medications section below).Women with IBD usually have healthy pregnancies and infants. However, they are more likely to have a complication of pregnancy (such as miscarriage, premature delivery, or complications of labor/delivery) than women without IBD, even if their disease is in remission. Therefore, all women with IBD should be followed as high-risk OB patients. 


Medication
In most cases, medication schedules are maintained during pregnancy.  However, there are some considerations and exceptions.  It is also important to note that if a woman’s condition changes, drugs or dosages may be altered.
• Aminosalicylates. Sulfasalazine (Azulfidine®) and other 5-ASA compounds such as mesalamine (Asacol®, Pentasa®, Rowasa®, Canasa®, Lialda®), balsalazide (Colazal®), and olsalazine (Dipentum®) do not appear to increase complications or harm the fetus. Sulfasalazine may cause nausea and heartburn. As sulfasalazine lowers folic acid levels, women should be on at least 2 mg of folic acid daily. Women can breastfeed while taking a 5-ASA compound.

• Corticosteroids. Prednisone and other corticosteroids are not recommended for planned maintenance therapy during pregnancy. If a woman becomes pregnant while on steroids, the doctor usually tries to minimize the dose. Nursing infants of women on moderate-to-high dosages of prednisone should be monitored by a pediatrician.

• Immunomodulators. Immunomodulators, such as Azathioprine (Imuran®), 6-mercaptopurine (6-MP, Purinethol®), and cyclosporine A (Sandimmune®, Neoral®), appear low risk during pregnancy in standard dosages. Both men and women should avoid methotrexate [see above].

• Biologics. Most biologics, such as infliximab (Remicade®), and adalimumab (Humira®), are considered low risk. They also do not appear in breast milk. However, both adalimumab and infliximab cross the placenta in high levels late in pregnancy so your doctor may want to give the last dose in the middle of your third trimester. Certolizumab (Cimzia®) may be continued throughout pregnancy.

• Antibiotics. If possible, these should be avoided during pregnancy, and are used for perianal disease and pouchitis.

• Thalidomide. Because this drug can cause birth defects and fetal death, it should always be avoided during pregnancy.


Diagnostic Procedures
If necessary, many diagnostic procedures—including colonoscopy, sigmoidoscopy, upper endoscopy, rectal biopsy, and abdominal ultrasound—can be safely performed during pregnancy. CT scans and standard X-rays should not be taken during pregnancy unless a medical emergency requires them. MRIs can be done safely in pregnancy, however the use of gadolinium should be avoided in the first trimester.

Surgery
Previous bowel resections do not appear to have any negative effects on pregnancy in women with Crohn’s disease. Women have also had successful pregnancies after ileoanal anastomosis for ulcerative colitis—a procedure in which the colon and rectum are removed and the ileum (the last segment of the small bowel) is connected to the anus.

It appears that women who have undergone colectomies with ileostomies or J pouches for ulcerative colitis or Crohn’s disease have slightly decreased fertility rates. If this procedure is not urgently needed and you plan to have children, speak with your doctor about the best timing for such surgery and the option of leaving the rectum intact. Women who have had an ileostomy can have a prolapse (drop) or obstruction of the ileostomy during pregnancy. Waiting a year after the surgery before becoming pregnant reduces that likelihood. 

Women with Crohn’s disease who have developed fistulas (abnormal passages), abscesses (collections of pus) around the rectum and vagina, or perianal disease that is active at the time of delivery should have a Caesarian section. Unless the patient’s condition is serious and unresponsive to drugs, surgery should be postponed until after delivery. Any abdominal surgery poses a risk to the fetus though modern surgical rates suggest it can be done safely.

Nutritional Needs
All pregnant women—including those with IBD—should eat a well-balanced diet and remain on any vitamins they were taking before becoming pregnant. That includes folic acid to prevent spina bifida and other neural tube birth defects. Folic acid (2 mg daily) is particularly important for women taking sulfasalazine, which inhibits folic acid absorption. Patients should discuss use of prenatal vitamins with their doctor, and nutritionist.

Heredity
It is possible, but certainly not inevitable, that a child of a parent with IBD will have it too. If a mother has Crohn’s disease, the risk of a child developing the condition is approximately 2.7%; the risk of a mother has ulcerative colitis is 1.6%. Small studies have found that if both parents have IBD, the risk may be greater than 30%.

Helpful resources:

• IBD Parenthood Project: http://www.ibdparenthoodproject.gastro.org/
• Wecareinibd.com www.wecareinibd.com
• Lactmed https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm

References:

1. Mahadevan U et al. Inflammatory bowel disease in pregnancy clinical care pathway: A report from the American Gastroenterological Association IBD Parenthood Project Working Group. Gastroenterology 2019 Jan 15; [e-pub].

2. Moller FT, Andersen V, Wohlfahrt J, et al. Familial risk of inflammatory bowel disease: a population-based cohort study 1977-2011. Am J Gastroenterol 2015; 110:564-571.

3. Bennett RA, Rubin PH, Present DH. Frequency of inflammatory bowel disease. Gastroenterology 1991; 100:1638-1643.

4. Laharie D, Debeugny S, Peeters M, et al. Inflammatory bowel disease in spouses and their offspring. Gastroenterology 2001;120:816-819.


Disclaimer: The Crohn’s & Colitis Foundation provides information for educational purposes only. We encourage you to review this educational material with your health care professional. The Foundation does not provide medical or other health care opinions or services. The inclusion of another organization’s resources or referral to another organization does not represent an endorsement of a particular individual, group, company or product.



For further information, call Crohn's & Colitis Foundation's IBD Help Center: 888.MY.GUT.PAIN (888.694.8872).

The Crohn's & Colitis Foundation provides information for educational purposes only. We encourage you to review this educational material with your health care professional. The Foundation does not provide medical or other health care opinions or services. The inclusion of another organization's resources or referral to another organization does not represent an endorsement of a particular individual, group, company or product.

About this resource

By: Pregnancy and IBD Factsheet
Published: April 1, 2020

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