Pregnancy and Inflammatory Bowel Disease

In the past, women with inflammatory bowel disease (IBD) were counseled against pregnancy. But current IBD management strategies have made having a baby safer for both mother and baby. Having a chronic illness while pregnant requires careful supervision by qualified physicians, but a healthy pregnancy and baby are both possible.

Do Men And Women With IBD Have Decreased Fertility Rates?

Fertility rates for women with IBD are the same as for women who are in good health. Women with active Crohn's disease may have a decrease in fertility. Family planning is an important topic for any woman, but especially for those with IBD. There are circumstances where pregnancy may not be advised, such as during a flare-up or while taking certain medications.

It has been known for many years that sulfasalazine (Azulfadine), a drug used to treat these conditions, can cause temporary infertility in about 60% of men. The sulfa component of the drug can alter sperm, but this effect is reversed within two months of stopping its use. Proctocolectomy surgery in men can cause impotence, though this is rare.

According to one review of the literature, infertility occurs in 48% of women who have surgery to treat ulcerative colitis. This is presumably due to scarring in the fallopian tubes that may occur after such extensive surgery. The risk of infertility after colectomy has been in question for several years because many studies showed widely varying rates of infertility. There are similar reports of infertility in Crohn's disease patients.

The Effect of Medication on Pregnancy

Many women believe that they should discontinue medications during pregnancy, however, continuing to take IBD medications offers the best chance to avoid a flare-up.

Most medications for IBD have been shown to be safe to continue during pregnancy, and many have a long history of safe use by patients. The Food and Drug Administration (FDA) has created a classification system for the use of medications during pregnancy (see Table 1 below).

Research studies have shown that most drugs commonly used for both maintenance therapy and acute flare-ups of IBD are safe for pregnant women to use. These are:

• Sulfasalazine (Azulfidine) [Pregnancy Category B])
• Forms of mesalamine (Asacol, Pentasa, Rowasa) [Pregnancy Category B])
• Corticosteroids (prednisone [Pregnancy Category B])
• TNFi inhibitors Remicade (infliximab), Enbrel (etanercept), Humira (adalimumab), Cimzia (certolizumab pegol) and Simponi (golimumab)

When Medical Therapy Needs to Become Individualized

Most IBD medications will be safe to continue during pregnancy and should not be discontinued without direct recommendations by the gastroenterologist and the OB/GYN familiar with a woman's particular case of IBD. There are some medications, however, that might need to be adjusted during pregnancy.

Immunosuppressants: The immunosuppressive drugs azathioprine (Imuran [Pregnancy Category D]) and 6-mercaptopurine (Purinethol or 6-MP [Pregnancy Category D]) do cross the placenta and can be detected in cord blood. However, they might be recommended with caution during pregnancy by some physicians to combat a serious flare-up. These drugs do not increase the risk of birth defects.

Methotrexate and Thalidomide: Methotrexate (Pregnancy Category X) and thalidomide (Pregnancy Category X) are two immunosuppressive drugs that should not be used during pregnancy as they do have an effect on an unborn child. Methotrexate can cause abortion and skeletal abnormalities, and it should be discontinued three months prior to conception, if possible. Thalidomide is well known for causing limb defects as well as other major organ complications in a fetus. Use is only permitted with rigorous birth control and frequent pregnancy testing.

Metronidazole: Metronidazole (Flagyl [Pregnancy Category B]), an antibiotic that is occasionally used to treat complications associated with IBD, may not be safe for the fetus after the first trimester. One study showed that metronidazole did not cause birth defects in the first trimester, but no long-term studies have been conducted. Brief courses of this drug are often used during pregnancy, although longer courses are still controversial.

How Pregnancy Affects the Course of IBD

The course of IBD throughout the term of pregnancy tends to remain similar to one's condition at the time of conception. For this reason, it is important for women who are considering pregnancy to maintain their treatment regimen and work to bring or to keep their disease in remission.

Among women who conceive while their IBD is inactive, one-third improve, one-third worsen, and one-third experience no change in their disease. Among women who conceive while their ulcerative colitis is flaring, two-thirds will continue to experience active disease.

Physicians may treat a severe flare-up of IBD that occurs during an unplanned pregnancy very aggressively. Achieving remission is important to help ensure the pregnancy is as healthy as possible.

Table 1: FDA Drug Categories

Complications With Pregnancy and IBD

For women with ulcerative colitis and Crohn's disease in remission, the risks of miscarriage, stillbirth and congenital abnormality are the same as those for healthy women. A flare-up of Crohn's disease at the time of conception or during the course of pregnancy is associated with a higher risk of miscarriage and premature birth.

Hemorrhoids are a common problem for pregnant women, with up to 50% of women suffering through them. Symptoms of IBD, such as diarrhea or constipation, can actually increase the risk of hemorrhoids. There are several treatments that will shrink hemorrhoids such as Kegel exercises, keeping the anal area clean, avoiding sitting and standing for long periods of time and heavy or moderate lifting, using petroleum jelly to cool off the rectum and ease bowel movements, sitting on an ice pack for relief from burning, sitting in enough warm water to cover the hemorrhoids, and using suppositories or creams.

Does IBD Get Passed on to Children?

Some people with IBD may remain childless because of a concern that children could inherit their disease. In recent years, there has been a focus on the idea that IBD runs in families and may even be linked to particular genes. Researchers have no clear answers about how IBD is passed between generations, but there is some research on the probability of children inheriting their parent's disease.

There seems to be a stronger risk of inheriting Crohn's disease than ulcerative colitis, especially in Jewish families. However, children who have one parent with Crohn's disease have only a 7 to 9% lifetime risk of developing the condition, and just a 10% risk of developing some form of IBD. If both parents have IBD, this risk is increased to about 35%.

What Will Help Before Conception or During Pregnancy?

Women are now encouraged to get their bodies prepared for pregnancy by increasing the intake of folic acid, quitting smoking, getting more exercise, and eating healthier. For women with IBD, the greatest factor influencing the course of the pregnancy and the health of the baby is the state of disease activity. Discontinuing any medications that may be harmful to the developing fetus is also important. A pregnancy planned when the IBD is in remission has the greatest chance for a favorable outcome.