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INFLAMMATORY BOWEL DISEASE AND PREGNANCY
Patients with inflammatory bowel disease (IBD), Crohn’s disease or ulcerative colitis often wonder about their capacity to safely have children and the effects these diseases and medications could have if they become pregnant. There are other concerns such as the effects of medication on breast-feeding and the chances of their children developing IBD. Fortunately, most individuals with IBD are able to have healthy, active children.
IBD does not affect the possibility that most women can become pregnant, but scarring in the abdomen can increase the risk of infertility for those individuals who have had extensive abdominal surgeries
For male patients, extensive surgeries in the pelvis can increase the risk of impotence (unable to produce an erection), and the medication sulfasalazine (which is rarely used) causes sperm abnormalities, which resolve once the medication is stopped.
PREGNANCY AND IBD
When planning a pregnancy, it is important for the patient to try to be in remission at the time of conception. Evidence suggests that if a woman is in remission when she conceives she is more likely to stay in remission during the pregnancy. Conversely, in patients who have active IBD at the time of conception the disease is most likely to remain active during the pregnancy. If the mother is not ill during the pregnancy the fetus is most likely to develop normally. If a woman has a flare-up of IBD during pregnancy it is important to treat it to try to get her back into remission. If the mother is not healthy and is malnourished the fetus is also more likely to have issues as it develops, including low birth-weight and premature delivery.
During pregnancy, care is usually shared between the Obstetrician and the Gastroenterologist; how frequent visits need be with the Gastroenterologist depends on the severity of the disease during the pregnancy.
If investigations are needed to direct medical management, flexible sigmoidoscopies appear to be safe, but x-ray tests and colonoscopies should be avoided during pregnancy if possible.
Prior to delivery, a woman will usually have a discussion with her physician regarding types of delivery. Patients can often have normal vaginal deliveries, but a Cesarean section may be the preferred approach if a Crohn’s patient has disease around the vagina, or if an ulcerative colitis patient has had a pouch procedure.
Some women who have done well and been in remission during their pregnancies have a flare-up after delivery (post-partum.) This is often a challenging time as the family is adjusting to a new member and there are a lot of changes.
To find out which medications can pass into breast milk, go to the Medications section below.
Sulfasalazine does not cause any risks to fertility, pregnancy or breastfeeding.
Ciprofloxacin is not recommended in pregnant or breastfeeding women. Short courses of Metronidazole are safe during pregnancy.
5-ASA or Mesalamine:
5-ASA or mesalamine (Mezavant®, Asacol®, Salofalk®, Mesasal®, Pentasa®) are probably safe during pregnancy and should be taken if needed during pregnancy to maintain remission. In some infants who are breastfed, there is associated diarrhea in the infant.
Steroids such as prednisone are probably safe in pregnancy. Some studies have raised the possibility of a cleft palate or cleft lip in the baby if steroids are taken in the first trimester, but the cause could be the underlying inflammatory bowel disease rather than the use of the drug. Women on steroids during pregnancy are more likely to have problems with high blood pressure or diabetes during their pregnancy. If a woman is on steroids during her pregnancy she is usually given increased doses of IV steroids (into the vein) after delivery, as sometimes her body has problems producing enough steroids for the ‘stress’ of labour and delivery. These medications are probably safe to take while breastfeeding.
Azathioprine (Imuran®) and 6-Mercaptopurine:
Most individuals on these medications are on the more severe end of the spectrum and they can be continued during pregnancy if there are no other types of treatment possible. There are some data to suggest that these medications can cause birth defects and miscarriage. It is necessary to weigh the benefits of staying in remission during the pregnancy versus the risk of having a flare-up of IBD and its effect on fetal well being.
When men and women are considering conception they are often advised to stop taking these medications for at least 3 months before trying to conceive. Again, the benefits and risk of their disease flaring up has to be weighed. There are no good data regarding the risk of breastfeeding, and therefore it is often advised to avoid breastfeeding.
Infliximab is probably safe during pregnancy, but the data are limited. It is generally only given in pregnancy if clearly needed and the benefits have to be weighed against the risks of having a flare-up during pregnancy. It is not clear whether it is excreted into breast milk and the risks to the infant are unknown. It is generally suggested that women do not breastfeed when taking this medication.
Primate studies have not revealed harm to the fetus during pregnancy. There is no good data in humans. In general, adalimumab is given during pregnancy only if it is clearly needed.
RISK TO CHILDREN
There is an increased risk for children of IBD patients to develop IBD themselves. The results of studies vary, but a child who has two parents with IBD is considered to be at higher risk than a child who has only one parent with the disease. For children who have one parent with IBD there is a 5%–10% risk of also having the disease; if both parents have IBD, the risk increases to about 30%. The risk of offspring developing IBD is higher for parents with Crohn’s disease than ulcerative colitis. The diagnosis of a Crohn’s or Colitis in parents with IBD is usually made earlier because the parents are sensitized to this possibility.