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Patient education: Inflammatory bowel disease and pregnancy (Beyond the Basics)

Patient education: Inflammatory bowel disease and pregnancy (Beyond the Basics)
Literature review current through: Jan 2024.
This topic last updated: Nov 01, 2023.

OVERVIEW — Inflammatory bowel disease (IBD) is the name for conditions that cause inflammation of the digestive tract, including Crohn disease and ulcerative colitis (UC). Many people worry about how the changes of pregnancy will affect their IBD, and if IBD treatments will harm their baby. With appropriate therapy, most people can have a normal pregnancy and a healthy baby.

IBD therapy during pregnancy is most successful when you receive regular medical care and follow your treatment plan closely. Before trying to get pregnant, it is best to talk with your gastroenterologist about plans for your care. If you find out that you are pregnant, you should continue taking your IBD medications (except methotrexate) until speaking to a health care provider. If possible, it is best to have a medication plan in place before you get pregnant. 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. Expert medical societies in both obstetrics and gastroenterology have published guidance on caring for people with IBD during 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) that is under good control does not affect a person's ability to become pregnant. However, active disease may make it more difficult to conceive.

Extensive abdominal or pelvic surgery (eg, removal of the colon) can increase the risk of impotence (inability to maintain an erection) in males. In females, 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, though at lower rates than in the general population.

Male fertility can also be affected by one of the drugs used to treat UC, sulfasalazine (brand name: Azulfidine). This medication causes sperm abnormalities in about 80 percent of males. These abnormalities resolve when the drug is discontinued.

Genetics — Males and females 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 person's disease when they become pregnant appears to influence the course of disease during pregnancy. About two-thirds of people in remission will stay in remission, and people 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 pregnancy loss (miscarriage), and more likely to have complications such as preterm birth. Thus, doctors recommend trying to conceive when IBD has been in remission, the person is off steroids, and medication doses have been stable for at least three months.

Care before pregnancy — These recommendations apply to anyone who is considering pregnancy:

Take a daily 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 problem 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. (See 'Medications' below.)

Stop smoking and consuming alcohol or any recreational drugs (eg, marijuana) before trying to become pregnant.

Discuss all prescription and non-prescription medications you take with your health care provider. Some medications are safe during pregnancy while others are not. In some cases, an alternate medication can be substituted for an unsafe drug. If you have IBD and are of reproductive age (meaning that it is possible for you to get pregnant), it's a good idea to review any new medication you start with your gastroenterology provider, even if you do not have plans for pregnancy in the near future. This way they can confirm that the medication is safe to take in the event that you do become pregnant.

Limit caffeine to less than 250 mg a day while trying to become pregnant and during pregnancy. The table lists the caffeine content of several common beverages (table 1).

Talk to your health care provider about whether you need any tests. 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 — Inflammatory bowel disease (IBD) may impact the growth and development of a fetus and the outcome of a pregnancy. In general, the health of the baby and risk of premature birth depends upon the type, severity, and extent of IBD before and during pregnancy and the treatments used during pregnancy. People with more severe disease have an increased risk of giving birth prematurely and having a low birth weight infant.

In some cases, studies of IBD and pregnancy include only people with UC, only people with Crohn disease, or people 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 people with other types of IBD are affected.

People with Crohn disease are at increased risk for having a low birth weight infant and giving birth prematurely. In studies, significantly more infants of mothers with Crohn disease weighed less than 2500 grams (5.5 pounds) and were born prematurely [1].

People whose IBD is in remission when they get pregnant are likely to remain in remission during pregnancy. People with UC are more likely to have disease flares during pregnancy than people with Crohn disease [2,3]. The course of a person's first pregnancy does not necessarily predict the course of future pregnancies.

In contrast, people 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; however, surgery increases the risk of premature labor or pregnancy loss (miscarriage). Most people who have had surgery for UC before pregnancy can have a normal pregnancy and birth, including a vaginal birth.

Care during pregnancy — During pregnancy, your medical care may be shared between a gastroenterologist and an obstetrical provider, with at least one consultation visit with a maternal fetal medicine specialist.

Visits with your gastroenterologist are scheduled based upon the severity of disease during pregnancy. You will most likely see your obstetrical provider every two to four weeks until 28 weeks of pregnancy. Between 28 and 36 weeks, most people are seen every two weeks; the frequency increases to weekly between 36 weeks and birth. At every visit, your blood pressure will be checked, and urine tests will be done.

To monitor the baby's growth during pregnancy, it is important to have an accurate due date. If you cannot remember the date of your last menstrual period or are unsure of when you conceived, you will get an ultrasound before 12 weeks of pregnancy. Due date estimates are most accurate when measured during this time.

After 10 to 12 weeks of pregnancy, the fetal heart rate will be measured at every visit. An ultrasound is usually recommended between 18 and 20 weeks of pregnancy to ensure that the fetus is growing and developing normally.

Some people, 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.

People who are at increased risk for preeclampsia (including people with IBD) should start low-dose aspirin daily starting around week 12 of pregnancy. This has been shown to reduce rates of preeclampsia and has not been associated with increased flares. Aspirin should always be taken with food in the stomach.

Additional information about preeclampsia is available separately. (See "Patient education: Preeclampsia (Beyond the Basics)".)

Testing during pregnancy — Flexible sigmoidoscopy appears to be safe at any time during pregnancy, as are magnetic resonance enterography (without gadolinium contrast) and intestinal ultrasound. Blood tests for IBD, like tests for anemia (hemoglobin), protein (albumin), and inflammation (C-reactive protein), can be abnormal due to changes that happen in the body during pregnancy; this does not always mean the IBD is active.

Fetal monitoring — The developing baby's well-being is monitored during regular medical visits throughout pregnancy. Once you are more than 24 weeks pregnant, you should monitor the baby's movements every day. If the baby is not moving normally, contact your obstetrical provider immediately.

Medications — People with IBD often require medications to control their disease. Most of these medications are low risk during pregnancy and breastfeeding. In other cases, there is not enough information about the medication to determine if they are safe or not. If you take one or more of these medications during pregnancy, it's important to talk with your health care provider. They can talk to you about the medications you take, whether you should make any changes during pregnancy, and the risks of stopping medications and having a significant flare. A flare carries a greater risk to pregnancy than most IBD medications.

The right combination of medications depends on your individual situation, and you will need to discuss all the risks and benefits with your health care provider. Below is some general information about some of the medications used to treat IBD.

Sulfasalazine – People 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 congenital anomalies (problems a baby can be born with). Folic acid 2 mg/day should be taken with sulfasalazine.

Antibiotics – Antibiotics are not frequently required in the treatment of IBD and should be reserved for treating active infection or pouchitis. Amoxicillin-clavulanic acid is a low-risk antibiotic during pregnancy, but if needed, ciprofloxacin and metronidazole can be used as well.

5-aminosalicylate (5-ASA) drugs – Studies suggest that the 5-ASA drugs can be taken during pregnancy and breastfeeding.

Steroids – Steroids are associated with increased complications of pregnancy among people with IBD. However, it is difficult to separate this from the effect of active disease itself. People 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. People who are taking steroids during pregnancy will need to get a "stress dose" of steroids by IV (into a vein) during labor and birth. The increased dose helps the body respond normally to the physical stresses of childbirth.

Steroids (eg, prednisone) can be used during breastfeeding.

Azathioprine and 6-mercaptopurine – Azathioprine and 6-mercaptopurine can be continued during pregnancy. Studies in people with IBD have not shown an increase in congenital anomalies with the use of these medications. If azathioprine is being used in combination with a biologic therapy (eg, infliximab), some patients may be able to stop azathioprine to reduce infection risk for the baby. People 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 can be taken during pregnancy. Extensive international studies have not reported an increase in the rate of congenital anomalies with the use of any of the anti-tumor necrosis factor (TNF) medications (infliximab, adalimumab, certolizumab, golimumab) and they should be continued throughout pregnancy. However, infliximab, adalimumab, and golimumab can cross the placenta and be present in the baby for up to nine months from birth. Ideally, the last dose should not be given within two weeks of giving birth. If you are on one of these medications, your 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 congenital anomalies has not been reported with adalimumab. Adalimumab also crosses the placenta and is continued until the last two weeks of pregnancy. If you are on one of these medications, your 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 congenital anomalies 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.

Other agents:

Golimumab – Though data are limited, the safety of golimumab should be similar to other anti-TNF agents (eg, adalimumab).

Ustekinumab – Though data are limited, there does not appear to be an increase in the rate of congenital anomalies. 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 rates of pregnancy loss or congenital anomalies. As with other biologics, there is placental transfer and trivial transfer into breastmilk.

Tofacitinib – Animal data suggests an increase in congenital anomalies when given at very high doses, and human data are limited. This should be used with caution in pregnancy and avoided in breastfeeding.

Ozanimod – No human data on the use of ozanimod during pregnancy or breastfeeding are available. Ozanimod should be avoided in pregnancy and breastfeeding.

Upadacitinib – Animal data shows congenital anomalies at doses used in humans. Upadacitinib should be avoided in pregnancy, particularly in the first trimester, and in breastfeeding.

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, BIRTH, AND THE POSTPARTUM PERIOD — If you are pregnant and have inflammatory bowel disease (IBD), discuss your labor and birth plans with your health care provider. IBD may affect your options for medications and treatments during labor, birth, and the postpartum period.

In people with Crohn disease or ulcerative colitis, the type of birth (vaginal versus Cesarean) depends upon the health of the tissues around the vagina and anus, the person and clinician's preference, and how labor progresses. If Crohn disease affects the areas around the vagina and perineum, or if a person has an ileoanal pouch, a Cesarean birth may be preferred to reduce the risk of developing fistulas and incontinence.

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 many benefits for both women and infants.

People who take medications for IBD should discuss the safety of these medications for their breastfeeding infant with an experienced health care provider. In addition, because the quality of information regarding medication safety in breastfeeding varies, it is important 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 (https://www.ncbi.nlm.nih.gov/books/NBK501922/?report=classic).

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 health care provider is the best source of information for questions and concerns related to your medical problem. You can also read the IBD Parenthood Project, a guide that has been developed by the American Gastroenterology Association and the Society for Maternal Fetal Medicine.

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 health care 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.

Patient education: Ulcerative colitis in adults (The Basics)

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.

Patient education: Ulcerative colitis (Beyond the Basics)
Patient education: Crohn disease (Beyond the Basics)
Patient education: Deciding to breastfeed (Beyond the Basics)

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
Sulfasalazine and 5-aminosalicylates in the treatment of inflammatory bowel disease
Safety of rheumatic disease medication use during pregnancy and lactation

The following organizations also provide reliable health information.

National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

National Institute of Diabetes and Digestive and Kidney Diseases

     (www.niddk.nih.gov/)

The American Society of Colon and Rectal Surgeons

     (www.fascrs.org)

The American Gastroenterological Association

     (www.gastro.org)

The Crohn's and Colitis Foundation of America

     (www.ccfa.org)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Paul Rutgeerts, MD (deceased), who contributed as a section editor for UpToDate in Gastroenterology.

Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms. 2024© UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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