& Inflammatory Bowel Disease (IBD)

Pregnancy

KEY POINTS:

Women with IBD can get pregnant and have safe pregnancies (for both mom and baby) similar to women without IBD.
Having a diagnosis of IBD does not have to change your decision to have a family. However it is important to speak to your doctor before pregnancy to maintain the best health possible for the mother and baby.
When planning a pregnancy or during a pregnancy, you may be concerned about the impact of IBD on your health and the health of your baby.
If upper or lower endoscopy is required in pregnancy it can safely be done.
Women with IBD may experience more complications during pregnancy and delivery compared to women without IBD. The risk of having a complication may depend on disease activity, and the likelihood of needing a cesarean section may depend on the presence or absence of perianal disease

IBD during pregnancy:

Women may worry that becoming pregnant will make their disease more active
If you have inactive disease when you become pregnant, you will most likely have inactive disease during pregnancy. This is why doctors recommend women plan a pregnancy when their disease is well controlled.
If you have Crohn’s disease, becoming pregnant does not increase the likelihood of developing a flare.
If you have ulcerative colitis, there is a slightly higher risk of developing a flare during pregnancy or after delivery.

IBD medications in pregnancy:

Many women are concerned about the use of common IBD medications during pregnancy and while a baby is breastfeeding. There are worries that these medications might harm the developing baby or be passed to the child through breast milk.
There is no evidence that the commonly used medications in IBD such as 5ASA, Azathioprine/6 mercaptopurine or anti-TNF adversely impact on the health of the mother during pregnancy. High doses of steroids have been associated with an increased risk for maternal infections during pregnancy.
There is less evidence regarding the safety of vedolizumab or ustekinumab in pregnancy but what evidence is available suggests that both are safe to use during pregnancy and breastfeeding.
There is a good deal of experience with the medicines used to treat IBD during pregnancy; most medications used to treat IBD do not cause problems during pregnancy and while breastfeeding.
Lowering the dose or stopping IBD medications during pregnancy can increase the risk of a flare in symptoms during pregnancy, which in turn may result in preterm delivery and/or a lower birth weight.
Speak to your doctor when you are planning a pregnancy and before making any changes in your medicine. Your doctor will be able to discuss specific factors about pregnancy and your health.

Specific medicines

5-Aminosalicylates (Asacol®, Salofalk ®, Pentasa ®, Mezavant ®, sulfasalazine)

This class of drugs is generally considered safe for pregnancy. It is usually advised NOT to lower the dose during pregnancy if you are on an effective dose prior to getting pregnant.
If you are taking sulfasalazine, speak to your doctor about folic acid supplementation prior to getting pregnant. You may need a higher dose than in prenatal vitamins.
If you are taking Asacol, speak to your doctor about switching medications PRIOR to getting pregnant, as a precaution. It may be best to avoid this medicine because of a substance in the coating of the tablets.
These drugs do not cross the placenta
Small amounts of these drugs are found in breast milk, but it is usually recommended that women can breastfeed while using these medications.

Azathioprine , 6-mercaptopurine (Imuran, Purinethol)

This class of drugs used to be considered unsafe in pregnancy but now is generally considered safe at the doses that are used for treatment of IBD
Some studies have shown an association between the use of this drug and preterm birth. HOWEVER it is not known whether this association is due to the drug itself or the underlying inflammatory bowel disease. One small study showed that these drugs could be associated with a low hemoglobin level (a blood count level) in the babies.
Small amounts of these drugs may cross the placenta
Small amounts of these drugs are found in breast milk, but it is usually recommended that woman can breastfeed while using these medications.

Methotrexate

This medicine needs to be discontinued at least 3 months prior to becoming pregnant and not used at all during pregnancy and breastfeeding, due to safety concerns.
There is a significant risk of miscarriage and/or birth defects if methotrexate is taken within 3 months of getting pregnant or during pregnancy. If you used this drug during this time, notify your doctor. In this situation it is usually recommended that you have an assessment by a doctor who specializes in fetal health immediately so that the health of the fetus can be assessed.

Anti-TNF (anti-tumour necrosis factor) medications (Infliximab, Adalimumab, Simponi)

This class of drugs is generally considered safe for pregnancy
Stopping or delaying these drugs during pregnancy may potentially increase risk of side effects or decrease effectiveness of these drugs once you restart
These drugs may cross the placenta
Small amounts of these drugs are found in breast milk, but it is usually recommended that women can breastfeed while using these medications.
If these drugs are used after 22 weeks of pregnancy, the infant cannot receive live vaccines the first 6 months of life. Live vaccines include rotavirus vaccine and MMR vaccine. Other routine vaccinations recommended through public health the first 6 months of life are safe.
There is a slight increased risk of infection to women in their third trimester of pregnancy who are on anti-TNF drugs. However, the anti-TNF drugs should only be stopped to prevent third trimester infection, at the beginning of the third trimester in women who are in remission or have had mild disease.

Vedolizumab and Ustekinumab

There is much less experience with the use of these agents during pregnancy than the experience with anti-TNF. However, what experience there is suggests that these drugs are also safe to use during pregnancy for both the mother and the baby.
If these drugs are used during pregnancy then babies should not have live vaccines until at least 6 months of age.

IBD and baby delivery

Some women with IBD are concerned that delivering a baby vaginally may increase the risk of developing bowel incontinence. Most women with IBD can have a vaginal delivery without risk of future problems controlling bowel movements.
A cesarean section MAY be required in some situations. For example, women with an actively draining fistula or an abscess around their anus need a caesarean section. If you have had a pouch procedure for ulcerative colitis, a cesarean section may be considered to minimize the risk of future problems with bowel control.
You should discuss the type of delivery (vaginal or caesarean) with your doctors (family doctor, gastroenterologist, obstetrician) to help with planning.

References

Bortoli A, Pedersen N, Duricova D, et al. Pregnancy outcome in inflammatory bowel disease: prospective European case-control ECCO-EpiCom study, 2003-2006. Alimentary Pharmacology & Therapeutics 2011;34:724–734.

Broms G, Granath F, Linder M, et al. Birth outcomes in women with inflammatory bowel disease: effects of disease activity and drug exposure. Inflammatory Bowel Diseases. 2014;20:1091–1098.

Desai RJ, Bateman BT, Huybrechts KF, et al. Risk of serious infections associated with use of immunosuppressive agents in pregnant women with autoimmune inflammatory conditions: cohort study. BMJ. 2017 Mar 6;356:j895.

Kanis SL, de Lima-Karagiannis A, de Boer NKH, van der Woude CJ. Use of Thiopurines During Conception and Pregnancy Is Not Associated With Adverse Pregnancy Outcomes or Health of Infants at One Year in a Prospective Study. Clin Gastroenterol Hepatol. 2017 Mar 22. pii: S1542-3565(17)30319-1

Khan N, Asim H, Lichtenstein GR. Safety of anti-TNF therapy in inflammatory bowel disease during pregnancy. Expert Opinion on Drug Safety. 2014;13(12):1699-1708. doi: 10.1517/14740338.2014.973399.

Leung YP, Kaplan GG, Coward S, Tanyingoh D, Kaplan BJ, Johnston DW, Barkema HW, Ghosh S, Panaccione R, Seow CH, Alberta IBD Consortium and the APrON Study Team. Intrapartum corticosteroid use significantly increases the risk of gestational diabetes in women with inflammatory bowel disease. Journal of Crohns and Colitis. 2015;9(3):223-230. doi: 10.1093/ecco-jcc/jjv006.

Mahadevan U, Sandborn WJ, Li DK, et al. Pregnancy outcomes in women with inflammatory bowel disease: a large community-based study from Northern California. Gastroenterology 2007;133:1106–1112.

Moens A, van der Woude CJ, Julsgaard M, et al. Pregnancy Outcomes in Inflammatory Bowel Disease Patients Treated With Vedolizumab, anti-TNF or Conventional Therapy: Results of the European CONCEIVE Study. Alimentary Pharmacology and Therapeutics 2020; 51 (1): 129-138.

Nguyen GC, Boudreau H, Harris ML, et al. Outcomes of obstetric hospitalizations among women with inflammatory bowel disease in the United States. Clinical Gastroenterology and Hepatology 2009;7:329–334.

Nguyen GC, Seow CH, Maxwell C, Huang V, Leung Y, Jones J, Leontiadis GI, Tse F, Mahadevan U, van der Woude CJ; IBD in Pregnancy Consensus Group; Canadian Association of Gastroenterology. The Toronto Consensus Statements for the Management of Inflammatory Bowel Disease in Pregnancy. Gastroenterology. 2016 ;150(3):734-757.e1.doi: 10.1053/j.gastro.2015.12.003. Epub 2015 Dec 11.

Last reviewed: March 2020

For more information and fact sheets about IBD and its treatment please visit: http://www.crohnsandcolitis.ca

Disclaimer: This information is provided for educational purposes only. Always consult a qualified health care professional for your specific care.

Source: This summary provides scientifically accurate information. It was prepared in a research review by researchers with the IBD Clinical and Research Centre, University of Manitoba with assistance from colleagues in Canada and internationally.

Acknowledgement: Preparation of this material was supported by funding from the Canadian Institutes of Health Research.

©2016 Charles N. Bernstein, John R. Walker on behalf of Manitoba IBD Clinical and Research Centre. This work is licensed under a Creative Commons Attribution-nonCommercial-NoDerivs 2.5 Canada License. You are free to copy and distribute this material in its entirety as long as: 1) this material is not used in any way that suggests we endorse you or your use of the material, 2) this material is not used for commercial purposes, 3) this material is not altered in any way (no derivative works). View full license at http://creativecommons.org/licenses/by-nc-nd/2.5/ca/.