Pregnancy and IBD
Inflammatory Bowel Disease (IBD) refers to long-term or chronic inflammation of the digestive tract, which can affect young men, and women of childbearing age. The most common types of IBD are Crohn's disease and ulcerative colitis. The majority of women with these conditions encounter no complications related to pregnancy or fertility, but many people will have concerns about how their IBD may affect them and their baby.
While all of the information here is based upon the best available medical evidence, it is advisable to discuss any specific concerns you may have with your gastroenterologist and your obstetrician. Disease location, activity and complications differ between patients; therefore, we recommend an individualised approach to pregnancy-related concerns.
Before you conceive: Thinking about having a baby
Preconception counselling is advised if you and your partner are considering becoming pregnant, so it is important to speak to your gastroenterologist and IBD nurse before you become pregnant. This gives your healthcare team an opportunity to check that your vitamins and minerals are sufficient, and that you are at a point in your healthcare journey when it is safe to become pregnant.
For most women and men, IBD will not reduce your ability to get pregnant if the disease is well-controlled and in remission. Six to twelve-month remission before conception reduces the risk of disease flares during pregnancy and the postpartum period.
Preconception remission is promoted by adherence to therapies, smoking cessation, optimising nutritional status, iron and folate supplementation. All patients considering pregnancy should take folic acid supplements, 400 micrograms per day, for at least three months before conceiving.
If you are a smoker you should stop smoking prior to becoming pregnant, as there is strong evidence that smoking during pregnancy is detrimental to your baby's development. It is also important to cut down on the amount of alcohol and caffeine you consume. You cannot drink alcohol during pregnancy.
Preconception counselling also includes discussion about the genetic risk of having a child affected by IBD. The genetic risk is higher in Crohn's disease (CD) than ulcerative colitis (UC).
Before you conceive, your IBD healthcare team will review the medications that you are taking.
While most of the medications used to treat IBD are safe to continue in pregnancy there are some which may need to be changed.
Men with IBD should be aware that use of sulfasalazine, a medicine commonly used in the treatment of IBD, may cause a decreased sperm count and therefore decreased fertility. This effect, however, is totally reversible and sperm counts return to normal within two months of stopping this drug.
For women on sulfasalazine, we advise that you take a higher dose of folic acid (5 mg per day) as this medication can impact how your body uses folic acid.
Methotrexate must be stopped at least three months before conceiving as it can affect the development of the foetus.
The goal in pre-conception counselling is to ensure that you are on stable medication doses and have stable IBD to help you become pregnant, and experience a healthy worry-free pregnancy.
Methotrexate: Stop this at least 3 months before conception. You may need to change to a new medicine
Thalidomide: Stop before and during pregnancy
Tofacitinib: Stop before pregnancy and throughout breastfeeding
Sulfasalazine: talk to your doctor about alternative treatment in men, and about increasing folic acid in women
All other features of a safe pregnancy apply - this means taking folic acid, no smoking and no alcohol.
Fertility and Assisted Reproduction / IVF
It is important to note that women whose disease is in remission (well controlled) and who have never had surgery have fertility rates that are no different to the general population. Women who have had abdominal surgery can have fertility issues due to inflammation and scarring of the tubes that carry the egg from the ovary to the womb for fertilisation (fallopian tubes). Active or flaring IBD reduces the likelihood of you either getting pregnant or having a healthy pregnancy.
Assisted reproductive technology (ART) can be used as a method to increase the likelihood of conception. IBD patients (especially patients with previous pelvic surgery) who are unsuccessful in conceiving for six months should be referred to a fertility specialist. It has been shown that IBD treatments have no effect on egg freezing or ART success. Hormones used in ART treatment have no effect on IBD activity. ART is less effective in people with IBD than infertile women in general population. It is also less effective in women with CD who have had previous surgery.
Pregnancy; Medical Management of IBD during Pregnancy
All pregnant women are advised to avail of the flu (Influenza) vaccine annually, as are patients with a chronic disease, including IBD. It is safe and advisable to have the flu vaccine during pregnancy. Talk to your IBD health team about when to time the vaccine around your biologic treatment, if you are on these medications.
For most medications, the benefits of continuing medical treatment for IBD in pregnancy outweigh the risks. However, there are some specific medications that have to be stopped because of the risk to the baby:
- Thalidomide: Stop before conceiving and during pregnancy
- Methotrexate: Stop before conceiving and during pregnancy
- Tofacitinib (Xeljanz): Stop before conceiving and while breastfeeding.
Biologics are drugs which are given intravenously or through an injection administered by the patient at home. There have been extensive studies of the safety of many of these drugs before, during and after pregnancy. These studies demonstrate that we can recommend that you continue these during pregnancy and breastfeeding after discussion with your IBD healthcare team. These specific medications are listed below.
- Vedolizumab (Entyvio)
- Ustekinumab (Stelara)
- Golimumab (Simponi)
- Certolizumab (Cimzia)
Imuran and Purinethol are also low-risk in pregnancy and breastfeeding. It is recommended that you continue these unless told to stop by your doctor.
Continuing these medications is associated with fewer flares, better control of disease, fewer flares after the baby is born, and give you the best chance of a good pregnancy outcome.
Corticosteroids may increase the risk of gestational diabetes; however, they may be used in the short-term for disease flares.
Most 5-ASA compounds (Asacolon/Pentasa/Mezavant/Salofalk) are safe to continue while pregnant and breastfeeding, but discuss with your healthcare professional first. There is no evidence that they have any effect on the developing foetus. As they may affect the metabolism of folic acid, it is recommended that you take a higher dose of folic acid, 5 mg, if you are taking these drugs.
What if I have an unplanned pregnancy?
Don't panic. If you have an unplanned pregnancy, contact your GP and your IBD healthcare team as soon as possible. Your medications and IBD activity will be reviewed to optimise your health as much as possible and to check the safety of your current medications.
Some medications should not be continued during pregnancy including methotrexate, and thalidomide.
Always talk to your doctor and IBD health team before pregnancy to transition to stable medication doses, with a safe medication for you and the baby
Do not stop your biologic IBD medication during pregnancy without discussion with your doctor first
Flares during pregnancy, what do I do?
With ulcerative colitis, approximately one-third of patients will experience a flare of their symptoms during pregnancy. Cohn's disease may flare in approximately one-quarter of patients during pregnancy. Disease exacerbations occur most frequently in the very early stages of pregnancy or following delivery. If you have a flare, contact your IBD healthcare team. You may be advised to take a medication, or brought in for investigations. Every case is considered individually.
Tests: You may be asked to give a stool sample to look for inflammation or for bacteria. Your doctor may ask you to have a sigmoidoscopy camera test. Conscious sedation is not used if you are pregnant - talk to your doctor about this. Enemas, suppositories and rectal therapies may be used.
Acute flares can be treated with steroids - recent studies have shown no increased risk of congenital abnormalities in the baby. Sometimes you may need to start a biologic drug like Infliximab during pregnancy. This is a decision made by you and your doctor, to increase the chances of controlling the IBD and having a good pregnancy outcome and healthy baby.
Pregnant women, especially those with IBD are at an increased risk of blood clots. Therefore, preventative anticoagulation (blood thinners) is a crucial step in the management of a flare of IBD in pregnancy. This involves giving an injection once a day if you are having a flare. Again, this is a decision made by you and your doctor.
Mode of Delivery
A normal vaginal delivery is possible for most women with IBD. A caesarean section may be advised in patients with Crohn's disease who have scarring of the tissues around the vagina and anus. You should discuss your delivery preference with your obstetrician.
Vaginal delivery is safe in women with ostomies (stomas). For women with ileal pouch anal anastamosis (IPAA), family size is important when choosing the method of delivery; if patients wish to have multiple births, vaginal delivery may be safer.
Discussion with your obstetrician is advised.
General Management of Pregnancy by your Obstetrician
Your pregnancy will be managed jointly by a consultant obstetrician and your gastroenterologist. It is advisable to see an obstetrician as early as possible in your pregnancy. Your first visit to the hospital will involve a detailed history and physical examination. An ultrasound is usually performed at this stage to confirm that the pregnancy is progressing well and to confirm the expected date of delivery of the baby. A further ultrasound will be scheduled for later in the pregnancy to perform a detailed examination of the baby and rule out any major structural abnormalities.
Further visits with your obstetrician will take place at regular intervals throughout the pregnancy. These visits will involve checking your blood pressure and urine and monitoring the baby's growth. This antenatal care may be shared with your general practitioner if your obstetrician deems this suitable. It is important that you monitor your baby's wellbeing on a daily basis by observing his or her movement pattern. If you have concerns regarding your baby's movement, you should attend your doctor immediately.
Visits to your gastroenterologist during pregnancy will depend on the severity of your disease; however, pregnant patients with IBD are closely monitored.
Management of Ostomies during pregnancy
Stretching of the abdominal wall during pregnancy can cause complications with your stoma, such as displacement, enlargement, retraction, stenosis and prolapse.
Input may be required from colorectal surgeons and stoma care nurse specialists for the management of complications.
Vaginal delivery can proceed in patients with an ostomy.
After Birth: Management of Mother
Biologic drugs can be given from 24 hours after vaginal delivery and from 48 hours after caesarean delivery if there is no evidence of infection.
Breastfeeding is recommended as it has many benefits for both mother and baby.
Breastfeeding may reduce the risk of development of IBD in the offspring of mothers with IBD. With regard to the effect of breastfeeding on the course of your inflammatory bowel disease, there is no evidence that it will worsen because of breastfeeding. It is recommended that you discuss your plans for feeding with your obstetrician and gastroenterologist.
No IBD therapies have been shown reduce the milk supply of a lactating mother.
The vast majorities of IBD treatments are either undetectable in breast milk or are present in such low concentrations that they would not be expected to cause harm to the infant.
Methotrexate and Tofacitinib should not be taken if you are breastfeeding.
After Birth: Management of Baby (Childhood vaccinations and antibiotic therapies)
For most women with IBD, routine childhood vaccinations are recommended to be given on the usual schedule recommended for general population except for mothers who were treated with any biologic therapy during pregnancy. As we mentioned above, these include infliximab, adalimumab, golimumab, ustekinumab, vedolizumab and certolizumab. If the mother has been treated with a biologic in pregnancy, it is recommended that the infant should avoid live vaccines until after their first birthday. Therefore, Rotavirus Vaccination and BC are to be avoided until the baby is 1 year old. MMR is given after the first birthday so does not need to be delayed. Some women also choose to give their baby the chickenpox (Varicella) vaccination. This should not be given until the baby turns 1 year old.
Always check with your IBD healthcare team about your individual case.
Diet and Pregnancy
A special diet is not recommended for people with inflammatory bowel disease who are pregnant. The most important thing is to eat a healthy balanced diet. The food pyramid provides guidance for a healthy diet. During pregnancy it is common to experience nausea and bloating. Therefore it is recommended that you eat small amounts and eat often.
There are certain foods which should be avoided in pregnancy because they may make you ill or cause harm to your baby.
Foods to avoid:
Soft cheeses (e.g. Brie, Camembert), blue-veined cheeses and unpasteurised cheeses: They may contain bacteria called Listeria which can cause harm to the developing foetus.
Pâté: Meat and vegetable pâtés can contain Listeria.
Foods containing raw or undercooked eggs: There is a risk of
Salmonella food poisoning form undercooked eggs.
Undercooked meat: All meat should be well cooked and it is advisable to avoid raw meats such as salami, Parma ham etc. This is to avoid the risk of contracting Toxoplasmosis which cause birth defects.
Toxoplasmosis can also be picked up from cat litter and soil so always wear gloves if dealing with these.
Fish: Most fish is safe in pregnancy and is important as part of a balanced diet. Certain fish contains high levels of mercury which can affect development of the baby's nervous system. Shark, swordfish and marlin all contain very high levels of mercury and should be avoided in pregnancy. Tuna also contains relatively high levels of mercury and consumption of tuna during pregnancy should be limited to no more than two tuna steaks or four medium-sized cans of tuna per week.
Contraceptives are an important part of family planning, particularly during times of high disease activity and symptoms. All forms of contraception are acceptable in patients with IBD and do not increase the risk of flares and relapses, although there are specific considerations.
Oral contraception pills (OCP) and active IBD are both associated with increased risk for blood clots. The effectiveness of OCPs may be reduced in women with CD who have small bowel disease and malabsorption. The general advice for women using OPs, who have been vomiting or have severe diarrhea for more than 24 hours, is to follow instructions for missed pils.
The depot medroxyprogesterone acetate injection should be avoided in patients at risk for osteopenia or low bone density. If you are not sure, you should ask your IBD healthcare team about this.
Intrauterine devices and implants are the most effective form of contraception and is the first line of recommendation.
The publication of this patient information was made possible through an educational grant by Tillotts Pharma Limited. Written by Caroline Lardner IBD Nurse, Dr Clare Foley, Dr Aoibhlinn O'Toole, Dr Karen Boland, Department of Gastroenterology, Beaumont Hospital, Dublin
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