Patient education: Inflammatory bowel disease and pregnancy (Beyond the Basics)
- Mark A Peppercorn, MD
Mark A Peppercorn, MD
- Professor of Medicine
- Harvard Medical School
- Uma Mahadevan, MD
Uma Mahadevan, MD
- Professor of Medicine
- University of California, San Francisco
- Section Editors
- Paul Rutgeerts, MD, PhD, FRCP
Paul Rutgeerts, MD, PhD, FRCP
- Section Editor — Inflammatory Bowel Disease
- Emeritus Professor of Medicine
- University Hospital, Leuven, Belgium
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
Inflammatory bowel disease (IBD) is the name for conditions that cause inflammation of the digestive tract, including Crohn disease and ulcerative colitis (UC). Many women worry about how the changes of pregnancy will affect their inflammatory bowel disease and if IBD treatments will harm their baby. With appropriate therapy, most women can have a normal pregnancy and deliver a healthy baby.
IBD therapy during pregnancy is most successful when a woman receives regular medical care and follows her treatment plan closely. Before becoming pregnant, women with IBD should discuss plans for their care with a healthcare provider. Women who discover that they are pregnant should continue their IBD medications until speaking to a healthcare provider. Having a medication plan in place prior to becoming pregnant is the best way to do it. If your obstetrician and gastroenterologist agree with your medications and you understand why you are on them and feel comfortable taking them, you will have a less stressful pregnancy.
This topic review discusses the relationship between inflammatory bowel disease and pregnancy. Topics that discuss the signs, symptoms, and treatment of these conditions are available separately. (See "Patient education: Ulcerative colitis (Beyond the Basics)" and "Patient education: Crohn disease (Beyond the Basics)".)
FERTILITY AND INFLAMMATORY BOWEL DISEASE
In most cases, inflammatory bowel disease (IBD) does not affect a woman's ability to become pregnant. However, a man's fertility can be affected by one of the drugs used to treat UC, sulfasalazine (Azulfidine). This medication causes sperm abnormalities in about 80 percent of men. These abnormalities resolve when the drug is discontinued.
Extensive abdominal or pelvic surgery (eg, removal of the colon) can increase the risk of impotence (inability to maintain an erection) in men. In women, extensive surgery can increase the risk of infertility, usually as a result of the development scar tissue. In these cases, in vitro fertilization (IVF) can help achieve a pregnancy.
Genetics — Men and women with IBD have a risk of passing a susceptibility to IBD to their baby through their genes. First-degree relatives (children, siblings) of people with IBD are between 3 and 20 times more likely to develop the disease compared to relatives of people with no history of IBD. Your risk of passing IBD to your child is between 4 and 8 percent. If your partner also has IBD, it can be up to 30 percent.
PREGNANCY AND INFLAMMATORY BOWEL DISEASE
The severity and extent of a woman's disease when she becomes pregnant appears to influence the course of her disease during pregnancy. About two-thirds of women in remission will stay in remission, and women with active disease are likely to have continued active disease during pregnancy. Having active disease may make it more difficult to get pregnant, more likely to have a miscarriage, and more likely to have complications such as preterm birth. Thus, doctors usually recommend that women try to conceive while their disease is in remission.
Care before pregnancy — These recommendations apply to any woman who is considering pregnancy.
●All women should take a supplement containing at least 400 mcg of folic acid (the amount in a prenatal vitamin). Taking folic acid can reduce the risk of a specific birth defect, called a neural tube defect. Folic acid should be started before trying to conceive and continued until at least the end of the first trimester. Most prenatal vitamins contain adequate folic acid.
●Women should stop smoking and consuming alcohol or any recreational drugs (eg, marijuana) before trying to become pregnant.
●Women who take prescription or non-prescription medications should review these with a healthcare provider. Some medications are safe during pregnancy while others are not. In some cases, an alternate medication can be substituted for an unsafe drug.
●Caffeine intake should be limited to less than 250 mg per day while trying to become pregnant and during pregnancy. The table lists the caffeine content of several common beverages (table 1).
●Blood testing for rubella (German measles), varicella (chicken pox), HIV, hepatitis B, and inherited genes (eg, cystic fibrosis) may be recommended before pregnancy.
Effect of IBD on pregnancy — Studies disagree about the effects of inflammatory bowel disease (IBD) on the growth and development of a fetus and the outcome of a pregnancy. In general, the health of the baby and risk of premature delivery depends upon the type, severity, and extent of IBD before and during pregnancy and the treatments used during pregnancy. Women with more severe disease have an increased risk of delivering prematurely and having a low birth weight infant.
In some cases, studies of IBD and pregnancy include only women with UC, only women with Crohn disease, or women with both. In this topic review, we will note when the information applies to a particular disease. In these cases, it is not clear how or if women with other types of IBD are affected.
Women with Crohn disease are at increased risk for having a low birth weight infant and delivering prematurely. In studies, significantly more infants of mothers with Crohn disease weighed less than 2500 grams (5.5 pounds) and were born prematurely .
Women whose IBD is in remission at the time of conception are likely to remain in remission during pregnancy. Approximately 33 percent of women with ulcerative colitis relapse during pregnancy, commonly during the first trimester . The course of a woman's first pregnancy does not necessarily predict the course of future pregnancies.
In contrast, women whose IBD is active at the time of conception are likely to have active disease during pregnancy. Surgical treatment, including removal of the colon, is possible during pregnancy, although there is an increased risk of premature labor or miscarriage if surgery is performed. Most women who have had surgery for ulcerative colitis before pregnancy can have a normal pregnancy and delivery, including a vaginal delivery.
Care during pregnancy — During pregnancy, care of women with IBD may be shared between a gastroenterologist and an obstetrical provider. Visits with the gastroenterologist are scheduled based upon the severity of disease during pregnancy. Most women are seen by their obstetrical provider every two to four weeks until 28 weeks of pregnancy. Between 28 and 36 weeks, most women are seen every two weeks. Women are usually seen once per week between 36 weeks and delivery. At every visit, blood pressure and urine testing will be done.
To monitor the baby's growth during pregnancy, it is important to have an accurate due date. Women who cannot remember the date of their last menstrual period or are unsure of when the baby was conceived should have an ultrasound before 12 weeks of pregnancy; the due date is most accurate when measured during this time.
After 10 to 12 weeks of pregnancy, the baby's heart rate will be measured at every visit. An ultrasound is usually recommended between 18 and 20 weeks of pregnancy to ensure that the baby is growing and developing normally.
Some women, especially those who take steroids or have moderate to severe disease flares during pregnancy, will have ultrasound monitoring of the baby's growth every four weeks after 18 to 20 weeks of pregnancy.
Testing during pregnancy — Flexible sigmoidoscopy appears to be safe during pregnancy, although colonoscopy and x-rays should be avoided, if possible. Blood tests for IBD, like tests for anemia (hemoglobin), protein (albumin), and inflammation (sedimentation rate), can be abnormal just because of a normal pregnancy and not because the IBD is active.
Monitoring baby's well-being — A baby's well-being is monitored during regular medical visits throughout pregnancy. Women who are greater than 24 weeks pregnant should monitor the baby's movements every day. If the baby is not moving normally, contact your obstetrical provider immediately.
Medications — Women with IBD often require medications to control their disease. Some of these medications are probably safe during pregnancy and breastfeeding. In other cases, there is not enough information about the medication to determine if they are safe or not. Women who take one or more of these medications during pregnancy should discuss their concerns with a healthcare provider. They should also understand the risk to the pregnancy of stopping medications and having a significant flare. A flare can be more risky than some medications.
●Sulfasalazine – Women who wish to become pregnant can continue taking sulfasalazine during pregnancy and while breastfeeding. Sulfasalazine does not increase the risk of any complications of pregnancy or birth defects. Folic acid 2 mg/day should be taken with sulfasalazine.
●Antibiotics – Antibiotics are frequently required in the treatment of Crohn disease and are sometimes used for people with UC. The most common antibiotics used for treatment of IBD are ciprofloxacin and metronidazole. Short courses of metronidazole are probably safe for use during pregnancy, including the first trimester. However, ciprofloxacin is not recommended for pregnant or breastfeeding women. Amoxicillin-clavulanic acid is a low risk alternative antibiotic during pregnancy.
●5-aminosalicylate (5-ASA) drugs – Studies suggest that the 5-ASA drugs are safe when taken during pregnancy and breastfeeding and that women should continue taking these drugs during this time. However, women who take 5-ASA medications should speak to their clinician before trying to conceive. One brand, Asacol HD, has dibutyl phthalate (DBP) in the coating, which is not safe for use during pregnancy. The manufacturer of Asacol HD is changing the preparation to no longer include DBP, but until that is complete, patients should be switched to a different 5-ASA during pregnancy.
The 5-AGA drugs are compatible for use in breastfeeding mothers.
●Steroids – Some studies have suggested that there may be a very small increased risk of cleft lip or cleft palate in the babies of mothers who took oral steroid medications during the first 13 weeks of pregnancy  but further studies have not shown this to be true. Two studies found a slightly increased risk of premature delivery, and one study found a slightly increased risk of having a low birth weight baby . However, the researchers could not rule out the possibility that these effects were related to the woman's underlying medical condition rather than use of the drug.
Women who take steroids during pregnancy may be more likely to develop gestational diabetes and high blood pressure, although these conditions can be detected and managed with regular medical visits . Women who are taking steroids during pregnancy will need to be given a "stress dose" of steroids by IV (into a vein) during labor and delivery. The increased dose helps the body respond normally to the physical stresses of childbirth.
Steroids (eg, prednisone) are compatible for use with breastfeeding.
●Azathioprine and 6-mercaptopurine – Azathioprine and 6-mercaptopurine can be continued during pregnancy if other types of treatment cannot be used. Studies in patients with IBD have not shown an increase in birth defects with the use of these medications. Women taking azathioprine and 6-mercaptopurine may breastfeed. There is very minimal transfer in breast milk and virtually none four hours after taking the medication.
●Infliximab – Infliximab is probably safe during pregnancy. There is no reported increase in the rate of birth defects with the use of any of the anti-tumor necrosis factor (TNF) medications (infliximab, adalimumab, certolizumab, golimumab). However, infliximab, adalimumab and golimumab can cross the placenta and be present in the baby for up to nine months from birth. Therefore, the last dose of these medications are often given 8 to10 weeks prior to the due date. If you are on one of these medications, the baby should not get live vaccines (rotavirus) in the first six months of life, though all other vaccines can be given on schedule. Very small amounts of infliximab cross in breast milk, so breastfeeding is compatible with this drug.
●Adalimumab – As with infliximab, an increase in birth defects has not been reported with adalimumab. Adalimumab also crosses the placenta and is continued until the last four weeks of pregnancy. If you are on one of these medications, the baby should not get live vaccines (rotavirus) in the first six months of life, though all other vaccines can be given on schedule. It has been detected in very small amounts in breast milk as well, but at levels so low that breastfeeding is allowed.
●Certolizumab pegol – There is no increase in birth defects reported with the use of certolizumab. Certolizumab does not cross the placenta at the same rate as infliximab and adalimumab. Therefore, it is dosed on schedule throughout pregnancy, and vaccination schedules are unchanged. As with the other two drugs, there is the possibility of very small amounts crossing in breast milk, but at levels so low that breastfeeding is allowed.
•Ustekinumab – Though data are limited, there does not appear to be an increase in the rate of birth defects. As with other biologics, there is placental transfer and trivial transfer into breastmilk.
•Vedolizumab – Though data are limited, there does not appear to be an increase in the rate of birth defects. Placental transfer does occur but there are no breastmilk data in humans at this time.
●Antidiarrheal drugs – Antidiarrheal drugs such as diphenoxylate-atropine (Lomotil) and loperamide (Imodium) have questionable safety during pregnancy and breastfeeding. Alternate drugs, such as Kaopectate and psyllium (Metamucil), are usually recommended.
LABOR, DELIVERY, AND THE POSTPARTUM PERIOD
Pregnant women with inflammatory bowel disease (IBD) should discuss their labor and delivery plans with their healthcare provider. IBD may affect a provider's choice of medications and treatments during labor, delivery, and the postpartum period.
In women with Crohn disease, the type of delivery (vaginal versus Cesarean) depends upon the health of the tissues around the vagina and anus, the patient and clinician's preference, and the woman and baby's progress during labor. If Crohn disease affects the areas around the vagina or if a woman has an ileoanal pouch, a Cesarean delivery may be preferred to reduce the risk of developing fistulas.
Breastfeeding — There does not appear to be any risk that IBD will worsen as a result of breastfeeding. Breastfeeding is strongly encouraged because there are a number of benefits for both women and infants.
Women who take medications for IBD should discuss the safety of these medications for their breastfeeding infant with an experienced healthcare provider. In addition, because the quality of information regarding medication safety in breastfeeding varies, women are encouraged to consult a reliable source of up-to-date information. LactMed is provided by the National Library of Medicine and is available on the internet (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT).
Comprehensive information about breastfeeding is available in a separate topic review. (See "Patient education: Deciding to breastfeed (Beyond the Basics)".)
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Fertility, pregnancy, and nursing in inflammatory bowel disease
Immunomodulator therapy in Crohn disease
Sulfasalazine and 5-aminosalicylates in the treatment of inflammatory bowel disease
Safety of antiinflammatory and immunosuppressive drugs in rheumatic diseases during pregnancy and lactation
The following organizations also provide reliable health information.
●National Library of Medicine
●National Institute of Diabetes and Digestive and Kidney Diseases
●The American Society of Colon and Rectal Surgeons
●The American Gastroenterological Association
●The Crohn's and Colitis Foundation of America
- Fonager K, Sørensen HT, Olsen J, et al. Pregnancy outcome for women with Crohn's disease: a follow-up study based on linkage between national registries. Am J Gastroenterol 1998; 93:2426.
- Nielsen OH, Andreasson B, Bondesen S, Jarnum S. Pregnancy in ulcerative colitis. Scand J Gastroenterol 1983; 18:735.
- Bakhireva LN, Jones KL, Schatz M, et al. Asthma medication use in pregnancy and fetal growth. J Allergy Clin Immunol 2005; 116:503.
- Perlow JH, Montgomery D, Morgan MA, et al. Severity of asthma and perinatal outcome. Am J Obstet Gynecol 1992; 167:963.
- Park-Wyllie L, Mazzotta P, Pastuszak A, et al. Birth defects after maternal exposure to corticosteroids: prospective cohort study and meta-analysis of epidemiological studies. Teratology 2000; 62:385.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.