Inflammatory Bowel Disease (IBD) encompasses chronic conditions like Crohn’s disease and ulcerative colitis, affecting the digestive tract. For individuals with IBD, pregnancy introduces unique considerations due to the interplay between the condition and gestation. With careful planning and consistent medical oversight, most individuals with IBD can achieve healthy pregnancies and welcome healthy babies.
Planning for Pregnancy with IBD
Achieving disease remission prior to conception significantly improves pregnancy outcomes. Active disease at conception is associated with higher risks of adverse outcomes, including miscarriage, preterm birth, and low birth weight. Gastroenterologists recommend a sustained remission, typically three to six months, before attempting to conceive.
Pre-conception counseling involves discussions with both a gastroenterologist and an obstetrician specializing in high-risk pregnancies. This multidisciplinary approach aligns IBD management with obstetric considerations. The healthcare team reviews the individual’s disease history, current activity, and medication regimen to formulate a personalized plan.
Medication review and adjustment are important for pre-conception planning. Many IBD medications are safe for conception and early pregnancy, including aminosalicylates like mesalamine, thiopurines such as azathioprine and mercaptopurine, and most biologics like infliximab and adalimumab. Corticosteroids may be used for short-term flare management, but long-term use is discouraged due to potential risks. Some medications, such as methotrexate, are contraindicated and must be discontinued well in advance of conception, typically three months prior for both men and women, due to their teratogenic effects.
Individuals with IBD generally have fertility rates similar to the general population when their disease is in remission. Active inflammation, particularly in Crohn’s disease affecting the pelvis or with perianal disease, can impact fertility by causing scarring or adhesions that interfere with reproductive organ function. Surgical interventions, such as ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, can also reduce fertility rates in some women due to pelvic adhesions.
Managing IBD During Pregnancy
Continuous monitoring of IBD activity is important throughout pregnancy. Regular clinical assessments, including symptom evaluation and laboratory tests like C-reactive protein (CRP) and fecal calprotectin, help track disease status without invasive procedures. Endoscopic procedures are avoided unless necessary for diagnosis or severe flare management; flexible sigmoidoscopy is safer than colonoscopy when required.
Most IBD medications can be continued during pregnancy to maintain remission and manage flares. Aminosalicylates, such as mesalamine, are considered safe due to minimal systemic absorption. Biologic therapies, including TNF-alpha inhibitors like infliximab, adalimumab, and certolizumab pegol, are often continued throughout pregnancy, especially if the disease is moderate to severe, to prevent flares. Certolizumab pegol is often preferred due to minimal placental transfer.
Managing IBD flares during pregnancy requires prompt, effective treatment to prevent adverse pregnancy outcomes. Oral corticosteroids, such as prednisone, may be used for short courses to control flares, with careful consideration of risks like gestational diabetes or pre-eclampsia. Antibiotics like metronidazole or ciprofloxacin might be used for specific complications, though their use is limited and weighed against potential fetal effects.
When IBD is well-controlled and in remission throughout pregnancy, risks are minimized. The benefits of maintaining remission with medication outweigh theoretical risks of medication exposure to the fetus.
Nutritional considerations are important, as active IBD can lead to malabsorption and nutrient deficiencies. Folic acid supplementation is recommended for all pregnant individuals. Those with IBD may require additional iron, vitamin B12, and vitamin D supplementation. A balanced diet is encouraged to support maternal health and fetal development.
Delivery and Postpartum Care
Choosing the method of delivery for individuals with IBD involves balancing maternal IBD status with obstetric factors. For individuals with Crohn’s disease, active perianal disease or a history of complex perianal fistulas may favor a planned C-section to avoid worsening perianal symptoms from vaginal delivery. If perianal disease is inactive and there are no other contraindications, a vaginal delivery may be considered.
For individuals with ulcerative colitis who have undergone an ileal pouch-anal anastomosis (IPAA), a C-section is often recommended to prevent damage to the anal sphincter muscles, which could lead to pouch dysfunction or incontinence. A vaginal delivery might be considered for those with an IPAA if they have a fully functional pouch and no other risk factors. For those with ulcerative colitis who have not had IPAA surgery, a vaginal delivery is preferred unless obstetric complications arise.
The postpartum period carries a heightened risk of IBD flares. This increased risk relates to hormonal shifts, immune system changes, and the stress of childbirth and newborn care. Continued monitoring of symptoms and adherence to prescribed medications are important for preventing recurrence.
Most IBD medications can be safely continued while breastfeeding. Aminosalicylates, thiopurines, and biologics have low transfer into breast milk or are largely inactivated in the infant’s gut, making them compatible with breastfeeding. Corticosteroids can be used, though timing doses around breastfeeding sessions is suggested to minimize infant exposure. Follow-up with gastroenterologists and obstetricians is important for managing postpartum IBD and reviewing medication safety for both parent and infant.