Crohn’s disease is a type of Inflammatory Bowel Disease (IBD) that causes chronic inflammation in the digestive tract. While the possibility of pregnancy often causes anxiety, a healthy pregnancy is highly achievable for most individuals with Crohn’s. The key to a successful outcome lies in rigorous medical coordination and planning between a gastroenterologist and an obstetrician-gynecologist. With proactive care, most women can carry a pregnancy to term and deliver a healthy baby.
Fertility and the Importance of Disease Status
Active Disease Risks
Crohn’s disease itself does not typically cause infertility, and women in disease remission have fertility rates similar to the general population. However, the activity of the disease is the most significant factor influencing the ability to conceive and maintain a pregnancy. Active inflammation, or a flare-up, can temporarily impair conception through systemic effects like fever and nutritional deficiencies, and may also reduce ovarian reserve. Conceiving during a flare is discouraged because active disease increases the risk of complications like miscarriage, preterm birth, and low birth weight.
Surgical Impact on Fertility
Active inflammation is considered to pose a greater risk to the mother and fetus than the majority of medications used to treat the disease. Prior surgeries for Crohn’s, particularly those involving the pelvis like a proctocolectomy with ileal pouch-anal anastomosis (IPAA) or creation of a permanent ostomy, can sometimes decrease fertility due to the formation of scar tissue around the fallopian tubes and ovaries. Newer laparoscopic surgical techniques may reduce this risk compared to older open procedures.
Essential Pre-Conception Planning
The most crucial step before attempting conception is achieving and maintaining sustained disease remission. Healthcare providers generally recommend being in a steroid-free remission for at least three to six months prior to trying to conceive. This period of stability significantly improves the chances of an uncomplicated pregnancy and a healthy delivery. Pre-conception counseling with a multidisciplinary team, including a gastroenterologist and a high-risk obstetrician, is a mandatory step for personalized guidance. This team will work to optimize the person’s overall health and nutritional status before pregnancy begins.
Nutritional Optimization
Blood tests should be performed to check for common deficiencies, such as Vitamin D, Vitamin B12, and iron, which are often depleted due to Crohn’s inflammation or resection of parts of the small intestine. Optimizing nutritional status involves ensuring adequate intake and often supplementation of essential micronutrients. Folic acid supplementation is particularly important, with a recommended dose of 0.5 to 1 mg daily for all women planning pregnancy, increasing to 2 mg or more daily if taking sulfasalazine. Any necessary adjustments to the medication regimen should be made during this planning phase, before stopping contraception, to ensure the disease remains inactive on a pregnancy-safe treatment plan.
Medication Safety During Conception and Pregnancy
Maintaining disease remission throughout pregnancy with appropriate medication is safer for both mother and baby than risking a flare-up. The vast majority of Crohn’s treatments are considered low-risk and safe to continue during gestation. The primary goal is never to stop all medication, as the danger posed by active Crohn’s disease to the pregnancy is significantly higher than the risk from most necessary treatments.
Pregnancy-Safe Treatments
- The 5-aminosalicylates (5-ASAs), such as mesalamine and sulfasalazine, are generally safe for use throughout pregnancy and do not increase the risk of congenital abnormalities.
- Immunomodulators like azathioprine and 6-mercaptopurine (6-MP) are considered reasonably safe to continue, as the risks of uncontrolled disease outweigh the potential risks of the drugs.
- Biologic agents, particularly anti-TNF drugs, are safe during the first and second trimesters. Certolizumab pegol is often continued throughout all three trimesters because it only passively transfers across the placenta.
- Corticosteroids, such as prednisone, are generally avoided for maintenance therapy during pregnancy but can be used safely in short-term courses to treat a flare.
Methotrexate is the main medication that must be stopped well in advance of conception, ideally three to six months prior, because it is a known abortifacient and teratogen that can cause birth defects.
Management and Monitoring During Pregnancy
Once pregnancy is achieved, continued close monitoring by the specialized multidisciplinary team is necessary to track both maternal and fetal well-being. Active disease at conception greatly increases the chance of a flare during pregnancy, but even women in remission have a small risk of relapse. Flares are statistically most common in the first trimester and the postpartum period, although they can occur at any time. Monitoring involves regular clinical assessments, blood work, and stool tests, such as fecal calprotectin, to detect subclinical inflammation early.
Fetal Monitoring and Flare Treatment
Active disease in the mother can restrict fetal growth, so additional fetal growth ultrasound scans, particularly in the third trimester, are often recommended to screen for low birth weight. If a flare does occur during pregnancy, aggressive treatment is necessary to minimize the risk of adverse outcomes. Managing a flare often involves temporarily increasing the dose of current maintenance medication or introducing a short course of corticosteroids, such as prednisone or prednisolone. Maintaining remission is paramount because active Crohn’s disease significantly increases the risk of preterm delivery and low birth weight, making prompt and effective treatment of a flare a priority.
Delivery and Postpartum Considerations
For most women with Crohn’s disease and inactive perianal disease, a vaginal delivery is generally considered safe and is the preferred mode of delivery, following the same criteria as the general population. However, the presence of active perianal disease, such as perianal fistulas or abscesses, may necessitate a planned Cesarean section. The concern is that the trauma associated with a vaginal delivery could worsen the perianal disease, potentially leading to new or recurrent fistulas or complications with the surgical site.
Postpartum Management and Breastfeeding
The immediate postpartum period carries a risk of disease flare-up, which may be related to the discontinuation of medication or hormonal changes. For this reason, it is important to continue all maintenance medications after delivery to sustain remission. Most Crohn’s medications, including 5-ASAs, immunomodulators, and biologic agents, are compatible with breastfeeding. The amounts of these drugs that transfer into breast milk are typically very low, and the benefits outweigh the risks of the majority of medications, with the exception of methotrexate. Working closely with the gastroenterologist and pediatrician ensures that both maternal disease activity and infant safety are prioritized during the postpartum and breastfeeding period.