By Dr. Christopher Cutler
Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the digestive tract that includes Crohn’s disease and ulcerative colitis. Many women worry about how pregnancy can affect their IBD, and more importantly,how treatment for IBD may affect their baby. However, with appropriate treatment and follow up, most women can have a normal pregnancy and deliver a healthy baby.
For patients whose IBD is in remission, the chance of becoming pregnant is the same as the general population. However, for patients with active disease, there may be a decrease in fertility. Therefore, women with inflammatory bowel disease should attempt conception at a time when they have no symptoms. Prior extensive abdominal and pelvic surgery may also decrease fertility by scarring the ovaries and fallopian tubes. Certain medications can decrease fertility in men. The use of sulfasalazine in men may cause a reversible decrease in sperm production.
Children of parents with IBD are 3-20 times more likely to develop Crohn’s disease or ulcerative colitis than the general population. If the mother has IBD, the risk of passing it on to her child is 4-8%. If both parents have inflammatory bowel disease, the risk can increase to up to 30%.
Two thirds of women with inactive disease at the time of conception remain in remission throughout the pregnancy. However, should a relapse occur, it usually occurs during the first trimester. 70% of patients with active disease at the time of conception have continuous or worsening symptoms throughout the pregnancy. Disease activity in the first pregnancy does not predict problems with future pregnancies.
Pregnant women with Crohn’s disease may be at increased risk of having an infant with low birth weight or experiencing premature delivery.
Procedures during pregnancy
Endoscopy during pregnancy should be performed only if there is a strong indication to do so and even then, the procedure should be postponed until the second trimester if possible. However, flexible sigmoidoscopy carries a low risk in any trimester. The data on colonoscopies is limited. Propofol sedation is safe, but should be administered by an anesthesia provider. CAT scans and plain X-rays should be avoided. Ultrasounds and MRIs (without contrast) can be safely performed during pregnancy.
IBD medications during pregnancy
- Sulfasalazine – Use is safe during pregnancy but women should be sure to also take folic acid 2 mg daily. Sulfasalazine use in men may cause a decreased sperm production. Therefore, men should stop sulfasalazine and start a 5-ASA medication 4-6 months before planned conception.
5-ASA medications – These medications are generally safe during pregnancy. However, the enteric coating on Asacol and Asacol-HD may be harmful to the fetus, and thus these two 5-ASA medications should not be used by pregnant women as a treatment for IBD.
Steroids – The use of prednisone and budesonide (Entocort or Uceris) overall is safe, but the lowest dose to control symptoms should be used. Use should be avoided during the first trimester due to the risk of oral clefts. Long-term use in the mother may also increase the risk of fetal adrenal insufficiency and low birth weight infants. Women on steroids may also be more likely to develop gestational diabetes and high blood pressure.
Azathioprine (Imuran) and 6-MP – The use of these medications is a bit controversial. They may be associated with preterm birth, but not with birth defects. They should be continued if IBD symptoms can’t be managed with other medications.
Methotrexate – The use of methotrexate is contraindicated in pregnancy. It may cause miscarriages and birth defects. It should be stopped both in men and in women six months prior to planned conception.
Inflimab (Remicade) – The use of biologics in pregnancy is safe. The main concern is transport of the medication throughout the umbilical cord to the baby during the third trimester. This may increase the risk of infection and lead to a suboptimal response to vaccines. Thus, if patients are doing well and their disease is controlled, Remicade should be stopped 8-10 weeks before the estimated due date. Babies should not receive live vaccines for the first six months of life.
Adalimumab (Humira) – This is safe in pregnancy, but like Remicade, it may cross the placenta and thus should be discontinued 4-5 weeks prior to the expected due date.
Vedolizumab (Entyvio) – This is safe in pregnancy, but should also be stopped 8-10 weeks prior to delivery.
Certolizumab (Cimzia) – Unlike the other biologics, there is minimal placental transfer of Cimzia, thus it can be continued throughout the pregnancy.
Metronidazole (Flagyl) – Short courses are probably safe, but not during the first trimester.
Ciprofloxacin (Cipro) – This medication is not recommended during pregnancy due to its effect on growing cartilage.
Lomotil and Imodium – The safety of these medications is controversial, and thus they should be avoided during pregnancy.
Most women with IBD can undergo vaginal deliveries. However, women with active perianal disease, active Crohn’s disease of the rectum, and a prior colon resection with ileoanal anastomosis should probably undergo a cesarean section.
Inflammatory bowel disease has implications on fertility, pregnancy, and delivery. Before becoming pregnant, patients with IBD are encouraged to discuss their plans with their gastroenterologist and obstetrician to ensure a safe, healthy pregnancy.