IBD and Pregnancy: What You Need to Know

Although they face special challenges, women with IBD can and do have successful experiences with pregnancy, delivery, and motherhood. If you have Crohn's disease or ulcerative colitis and want to have children, it is natural for you to have concerns. Among the questions you may be asking yourself are:

• Will I have trouble becoming pregnant?
• Will the pregnancy make my IBD worse?
• Will the disease or my medications hurt the baby, before or after birth?
• Will I be able to breastfeed?

This article will explore these issues to give you a better idea of what to expect. Ultimately, any decisions you make regarding your pregnancy will reflect your individual circumstances and should be made in close consultation with your gastroenterologist and obstetrician.

IBD and Conception

In general, women with ulcerative colitis or with Crohn's disease in remission can become pregnant as easily as other women. Women with active Crohn's disease may have more difficulty becoming pregnant.

What If It's the Man Who Has IBD?

Sulfasalazine (Azulfidine®), a medication commonly used for IBD, decreases a man's sperm count. If a couple is trying to conceive, he should stop taking sulfasalazine or switch to another 5-ASA compound such as mesalamine, balsalazide, or olsalazine, as long as his doctor approves of the change.

Men should not take the immunosuppressive drug methotrexate for three months before conception, and women should not take it before or during a pregnancy or while breastfeeding. This drug is extremely toxic to a developing fetus or newborn.

Men are also strongly advised to stop taking 6-MP and azathioprine for three months prior to conception. (Please see the section below on "Drugs for IBD and Pregnancy" for more information.)

Can Pregnancy Harm a Woman with IBD?

"Women should be well before considering a pregnancy," says Sunanda Kane, M.D., a gastroenterologist and Associate Professor of Medicine at University of Chicago Hospitals, who specializes in IBD and women's health. "It is best not to begin a pregnancy when the disease is flaring, when the woman has recently begun a new treatment, or if she is on steroid medications. If she is pregnant already, she should continue on the regimen that has kept her well, even if it includes steroids. In this case, her doctor will try to minimize the steroid dose."

"Pregnant women with IBD tend to be most concerned about the health of their baby," says Dr. Kane. "As a physician, my biggest concern is the health of the mother. The baby can't do well if the mother doesn't do well." She stresses that it is very important for a pregnant woman with IBD to remain on her prescribed medications and for her obstetrician to be in communication with her gastroenterologist. "Often women will stop all medication when they find they are pregnant because they worry it will damage the baby. If their disease flares as a result, it can be very difficult to get it back under control." However, even if a disease flare leads to hospitalization, there is still a good chance of maintaining the pregnancy.

Women with Crohn's disease sometimes stop their medications after delivery because they are afraid of their effects on nursing. This can cause the disease to worsen during the postpartum period.

In some cases pregnancy causes an improvement in IBD symptoms. "Many of my patients report that they felt the best when they were pregnant," says Dr. Kane. This has to do with a phenomenon that occurs during all pregnancies: The body has to suppress its immune system so as not to reject the fetus. "Since symptoms of IBD result from an overactive immune response, the damping down of the immune system during pregnancy often puts the disease into remission. The more genetically different a woman is from her baby, the more her immune system has to shut down so as not to reject the fetus and the better she is likely to feel."

One study of women with Crohn's disease suggests that pregnancy may also protect against further flare-ups and may diminish the need for future operations. This has to do with a hormone produced by pregnant women called relaxin that prevents the uterus from prematurely contracting. It is thought that relaxin also prevents the future formation of scar tissue, which frequently causes Crohn's disease patients to need surgery.

Can IBD Affect the Pregnancy or Harm the Baby?

In general, a woman with IBD is as likely as anyone else to have a normal pregnancy and delivery. Problems occur more often in pregnant women with active Crohn's disease, since the disease can make them malnourished and anemic. It also creates proteins that cause inflammation. These inflammation-causing proteins flow through the body and can interfere with the normal functioning of many organs, as well as with a growing fetus in the uterus. Therefore, there is a greater risk of miscarriage, premature delivery, or stillbirth in pregnant women with active Crohn's disease. If a woman's symptoms worsen to the point that she must have surgery during pregnancy, this further puts the baby at risk.

Drugs for IBD and Pregnancy

Active IBD, especially Crohn's, almost always threatens a pregnancy more than the medications used to control the disease. Therefore, medication schedules are usually maintained during pregnancy. If the woman's condition deteriorates, drugs or their doses may be adjusted.

Aminosalicylates

Sulfasalazine (Azulfidine®) and other 5-ASA compounds such as mesalamine (Asacol®, Pentasa®, Rowasa®, Canasa®), balsalazide (Colazal®), and olsalazine (Dipentum®) have been shown not to increase complications or harm the fetus.

Sulfasalazine may cause nausea and heartburn, exacerbating the common symptoms that can occur during any pregnancy.

A mother can safely nurse her baby while taking a 5-ASA compound. Some sulfasalazine does get into breast milk, but the concentration is low and hasn't been shown to hurt infants.

Corticosteroids

Corticosteroid drugs, including prednisone, are safe during pregnancy. However, it is better for a woman not to be on steroids at the beginning of a pregnancy. Since corticosteroids have significant side effects, patients are usually weaned from them as soon as possible. During pregnancy, changes to medication need to be made very judiciously to avoid any potential flaring of the disease. So if a woman becomes pregnant when she is on steroids, her doctor will usually not eliminate them but rather try to minimize the dose.

A nursing baby of a woman taking a moderate-to-high dosage of prednisone needs to be monitored by the pediatrician.

Antibiotics

Antibiotics should be avoided during pregnancy, if possible.

Immunomodulators (Immunosuppressives)

Immunosuppressive drugs such as azathioprine (Imuran®), 6-mercaptopurine (6-MP, Purinethol®), and cyclosporine A (Sandimmune®, Neoral®) have not been shown to adversely affect pregnancies when given in standard dosages for IBD.

The picture is somewhat different in men. According to recent research, there are questions surrounding the safety of azathioprine and 6-MP prior to and during fertilization. To be on the safe side, it would be prudent to withhold 6-MP and azathioprine therapy in men with IBD for 3 months before conception.

Important: One immunosuppressive drug, methotrexate, causes fetal death and congenital abnormalities, whether the man or the woman has taken it. If the man is on methotrexate, couples must avoid pregnancy for at least three months after he stops it. If the woman is taking methotrexate, she should stop the drug and wait for a full ovulation cycle to pass before becoming pregnant. If pregnancy occurs while either partner is on methotrexate, therapeutic abortion is usually recommended. A woman should not breastfeed while on methotrexate.

Thalidomide

Thalidomide, even a single dose, can cause fetal death and severe birth defects. Needless to say, it should not be taken during pregnancy.

Biologics

Infliximab (Remicade®), a biologic compound approved for the treatment of both Crohn's disease and ulcerative colitis, has now been studied in pregnant women. It does not seem to be associated with increased risks to the developing fetus or with an increase in pregnancy complications. It has not been found in breast milk, nor does it damage sperm.

For detailed information about medications, please visit http://www.ccfa.org/info/treatment/medications.

Diagnostic Procedures

If necessary, many diagnostic procedures—including colonoscopy, sigmoidoscopy, upper endoscopy, rectal biopsy, and abdominal ultrasound--can safely be performed during pregnancy. MRI, CT scans and standard X-rays should not be taken during pregnancy unless a medical emergency makes them necessary. While MRI is safer than CT and X-ray, there is still some risk.

Surgery During Pregnancy

Unless the patient's condition is extreme and is not responding to drugs, surgery should be put off until after the baby is born. There have been instances of successful intestinal resections and ileostomies (a procedure in which the entire large intestine is removed and the ileum--the very end of the small intestine--is brought through the abdominal wall) performed during pregnancy, but any abdominal surgery poses a risk to the fetus.

Previous Bowel Surgery

A previous bowel resection doesn't seem to adversely affect the pregnancy of a woman with Crohn's disease. If the operation caused a remission of her symptoms, this would only have improved her chances of having a successful pregnancy.

Women have also had successful pregnancies after ileoanal anastomosis for ulcerative colitis. (In this operation the colon and rectum are removed and the ileum—the very end of the small bowel—is connected to the anus.)

Recent research has shown that women who have undergone ileostomies for ulcerative colitis or Crohn's disease have a slightly decreased rate of fertility. If this procedure isn't needed urgently and you are planning to have children, talk to your doctor about the best time to have such surgery. A woman who has had an ileostomy can also have a prolapse (slippage) or obstruction of the ileostomy during a pregnancy. This is less likely to occur if she waits a year after the surgery before becoming pregnant so that her body has time to adjust to it.

If a woman with Crohn's disease has developed fistulas (abnormal passages) or abscesses (collections of pus) in the region of the rectum and vagina, she should probably not have an episiotomy during labor to widen the birth canal. Delivery is often done by Caesarian section in these situations.

For more information about surgical options, please visit http://www.ccfa.org/info/surgery.

If a Parent has IBD, What Are the Chances That a Child will Develop It?

If one parent has Crohn's disease or ulcerative colitis, the child has about a 9% chance of developing either of these conditions. If both parents have IBD, the child's chances of developing IBD can be as high as 36%. Research also suggests that people inherit a genetic susceptibility to IBD, and that active disease develops when their immune systems over-respond to bacteria or other substances in the intestines. People of certain ethnic groups are more prone to develop IBD. For instance, the percentage of American Jews of European descent with IBD is four to five times higher than that of the general population.

Nutritional Needs During Pregnancy

Pregnant women with IBD should remain on any vitamins they took before becoming pregnant and should eat a well-balanced diet (as should all pregnant women). All women who are pregnant or may become pregnant should take folic acid to prevent neural tube birth defects such as spina bifida. This is especially true of women taking sulfasalazine, which inhibits folic acid absorption.

Your Emotions

Emotional stress can make symptoms worse at any time, including pregnancy and the postpartum period. But, says Dr. Kane, "There is no more or less risk of postpartum depression in patients with IBD. In my experience, patients with Crohn's disease or ulcerative colitis are usually glad to discover they can have successful pregnancies and are very happy to become parents."

--CLAUDIA KAPLAN

Date Posted: October 21, 2005