Crohn’s Disease and Pregnancy
Most women who have ulcerative colitis or Crohn’s disease, both of which are inflammatory bowel diseases (IBD), are usually able to have a normal pregnancy and a healthy baby. But there are some important considerations to be mindful of before and during your pregnancy.
If you are a woman and your ulcerative colitis or Crohn’s disease is in remission, you should be able to conceive as easily as others your age. If your Crohn’s or colitis is active, you may experience more difficulty becoming pregnant because of poor nutrition and irregular menstrual periods. It is usually not a good idea to try and get pregnant when you are experiencing a flare-up, starting a new treatment regimen or when taking steroids. Getting pregnant may also be difficult if you have had surgery in the pelvic region, especially if you’ve had a colectomy (the surgical removal of all or part of your colon) with a J pouch. This procedure is associated with lower fertility rates.
If you are a male with Crohn’s disease or ulcerative colitis, your fertility should be similar to other men your age. But, certain medications you may be taking for your disease may be problematic. Medications like sulfasalazine (Azulifidine®) affect sperm count and the quality of the sperm. With your doctor’s approval you should consider switching to another 5-ASA compound, such as mesalamine. Men with Crohn’s or colitis should also stop taking methotrexate at least three months before attempting to conceive. Methotrexate has been shown to affect sperm production in animal studies. Smoking should also be avoided by both the mother and father prior to becoming pregnant to reduce the associated complications and health risks to the developing fetus.
Crohn’s or Colitis Symptoms During Pregnancy
In some cases, Crohn’s disease or ulcerative colitis symptoms actually improve during pregnancy. The reason: when you are pregnant, your body naturally suppresses your immune system to prevent your body from rejecting the fetus. So, this suppression of the immune system may actually enhance movement toward remission during your pregnancy.
But, it is also possible that changes in the immune system may worsen disease symptoms during pregnancy and also in the post-partum stage. Having active disease during pregnancy can increase your risk of going into premature labor. It can be very difficult to regain control over your symptoms if a flare-up occurs while you are pregnant. This may then lead to poor health for you and may put the baby at higher risk for possible complications. Therefore, it is optimal that your disease is in remission before getting pregnant. This means that it is important to make sure there is no evidence of inflammation related to Crohn’s or colitis present in your bowels before getting pregnant. This is why your doctor may order tests such as a colonoscopy before you start to try to get pregnant.
Medications Before and During Pregnancy
Some women stop their Crohn’s or colitis medication when they learn they are pregnant for fear that it might harm the baby. But, the majority of medications used to treat Crohn’s disease or ulcerative colitis are safe for pregnancy. Research has shown that most Crohn’s or colitis related medications that are taken before and during pregnancy have no negative effect on the mother, fetus or newborn child. Because having a flare is associated with potentially serious problems for both the mother and fetus, most doctors feel this it the worst time to ‘take a chance’ by stopping Crohn’s or colitis medications.
The exception is methotrexate, which has been shown to cause severe birth defects or possible death to the fetus. Methotrexate is typically used apart from Crohn’s or colitis, to treat several types of cancer, rheumatoid arthritis and psoriasis. Methotrexate should be stopped at least three months prior to getting pregnant and cannot be used during pregnancy or while breastfeeding.
Let’s take a closer look at specific classes of medications that are used and how each affect the mother and baby.
The anti-inflammatory drugs mesalamine (Asacol, Rowasa, Pentasa, Salofalk) and sulfasalazine (Azulfidine, Salazopyrin) have a long history of being used to treat patients with Crohn’s disease or ulcerative colitis. Neither mesalamine nor sulfasalazine has been found to increase the risk of adverse effects during pregnancy. Extremely small amounts of aminosalicylates have been found in breast milk, but these trace levels do not pose a danger to a nursing child. The enteric coating on Asacol that keeps it from breaking down too quickly once ingested, does contain an ingredient called dibutyl phthalate (DBP). In animal studies, where high doses were given to subjects, DBP has been associated with some adverse effects. But these experimental levels are much higher than the prescribed dose for humans. Women taking sulfasalazine should also be taking a folate supplement because sulfasalazine decreases folate stores in the body.
Corticosteroids are frequently used to control inflammation in patients with Crohn’s or colitis, especially during flares. Though corticosteroids are usually effective for symptoms control, long-term use increases the risk of numerous side effects. When the potential benefit of putting your disease in remission outweighs the risks of the medication, your doctor may prescribe short-term use of corticosteroids. Prednisone, prednisolone and methylprednisolone are the corticosteroids of choice since they metabolize better for the developing fetus. The majority of studies do not show an increased risk of congenital abnormalities with use of corticosteroids. Some older studies show a possible association between corticosteroids and the development of cleft palate but this has not been shown in more recent studies. Breastfeeding while taking corticosteroids is considered safe.
Azathioprine (AZ) and 6-mercaptopurine (6-MP) are frequently used in combination to treat Crohn’s disease and ulcerative colitis. These immune system suppressants reduce inflammation by making the immune system less active. The current recommendation is to continue using AZ and 6-MP during pregnancy. Some animal studies have shown some malformations, but again, the animal subjects were given much higher doses of each medication than would be prescribed to humans. One study has shown trace levels of 6-MP in breast milk within the first four hours of taking the medication. Some physicians will recommend not using breast milk produced within the first four hours after taking the medication. But, overall the risk to nursing babies is very low.
Infliximab and adalimumab
Infliximab and adalimumab are biologics that are designed to block or protect the body from tumor necrosis factor (TNF), which is the inflammatory response that occurs in Crohn’s and colitis. There is no data to suggest that these medications could alter the development of the fetal immune system. However in order to reduce the possible risk, some experts have recommended that these drugs be stopped around 22 weeks into the pregnancy. This recommendation is based on the finding that these drugs are not transported across the placenta until 22 weeks into pregnancy. Alternatively, some experts also recommend continuing the drug throughout pregnancy as discontinuing use also increases the risk of disease flares and possible reactions to the drug when restarting the regimen after pregnancy.
Studies of infliximab and adalimumab (both before and after 22 weeks of gestation) have shown that there is no increase in congenital abnormalities when compared to those not taking these medications. Mothers on these biologics who are also taking azathioprine as a type of combination therapy have shown a tendency to deliver earlier than mothers not using combination therapy. However, we do not know if this is a drug effect or if this is due to the mother having more active disease. In addition, newborns exposed to infliximab and adalimumab during fetal development did not show a higher risk of infection during the first year of life. Passing these medications on to the infant through breastfeeding carries a very low risk as there is zero to minimal drug detectable in the breastmilk.
But, because infliximab and adalimumab can be detected in the infant, live vaccines such as Bacillus Calmette-Guerin (or BCG, for protection against tuberculosis), rotavirus (inflammation of the small intestine that leads to vomiting and severe diarrhea), mumps/measles/rubella and varicella zoster (chickenpox) should not be given during the first six months following delivery.
A recent addition to medications used to treat moderate to severe Crohn’s or colitis is golimumab. According to the manufacturer, there have been 47 reported cases of women who have received golimumab during pregnancy and no reported congenital abnormalities among the live births. To date, there are no published studies that have compared the use of golimumab with a control group that did not receive the drug. But, because golimumab is in the same family of biologics as infliximab and adalimumab, the drug can be transported across the placenta to the child.
Diagnostic and Surgical Procedures during Pregnancy
In certain situations there may be a need for diagnostic procedures, such as a colonoscopy or sigmoidoscopy during pregnancy. These can usually be performed safely during pregnancy. However, computerized tomography (CT) scans and standard X-rays should not be taken during pregnancy due to the radiation that is emitted during the procedure unless the potential benefits outweigh the associated risks of radiation. Magnetic resonance imaging (MRI) is considered safe for both mother and baby.
Surgery should be postponed until after delivery, unless your condition is serious and unresponsive to the medications you are taking. Any type of abdominal surgery during pregnancy can pose a risk to the fetus.
Nutritional Needs during Pregnancy
All pregnant women, especially those with Crohn’s disease or ulcerative colitis, should eat a balanced diet to get all the nutrients you need to stay healthy and to nourish your growing child. If you were taking vitamins before getting pregnant, you should continue those vitamins during pregnancy and ensure that this regimen includes at least 2 mg of Folic Acid a day, especially if you are taking sulfasalazine, which tends to inhibit folic acid absorption. Folic acid deficiencies are associated with spina bifida and other neural tube birth defects. Also, some vitamins may not be appropriate for pregnancy, so it’s always best to check with your doctor regarding your dietary supplements.
Most women can have a vaginal birth with the exception of those with Crohn’s disease who have developed fistulas (abnormal passages) or abscesses (pockets of pus) around the rectum and vagina. If these are active at the time of delivery, a Caesarean section will be ordered. In patients with a J pouch, the general recommendation is a Caesarean section but women should discuss this with their obstetrician and gastroenterologist because there may be situations where a vaginal delivery may be appropriate.
Passing Crohn’s or Colitis to Your Child
Though it is possible to pass ulcerative colitis or Crohn’s disease on to your child, the risk is relatively low. If one parent has the disease, the chance of your child developing the condition is approximately 2-9%. If both parents have Crohn’s or colitis, that risk jumps to as much as 36%. Even so, the odds are still in favor of your child not getting the disease.
Is Crohn’s Making Your Period Worse?
Online IBD forums are filled with questions from women who experience changes in their menstrual cycle. Anecdotally, it appears to be common for women with IBD to experience increased premenstrual and menstrual pain in addition to changes in period duration and flow.
Is it common for women with IBD to experience increased period pain, duration, and flow?
Although the relationship between IBD and the menstrual cycle hasn’t been fully explored, studies examining IBD and periods found common reports of painful menstruation, abnormal bleeding, and irregular periods.(2)
In a 2014 study published in Inflammatory Bowel Diseases, approximately 25% of participating women with IBD reported a change in period intervals in the year before being diagnosed with IBD. One fifth of women reported a change in their duration of flow, and almost one third of women said they experienced an increase in menstrual pain intensity and duration over the previous year.
The study found that, especially for women who already experience some degree of dysmenorrhea (period pain/cramps), it was common to experience intensified menstrual pain in the year prior to diagnosis.
What causes the increase in period pain for women with IBD?
For many, it is intuitive to believe that the inflammation associated with IBD is at the root of increased menstrual pain, but so far, there isn’t any research showing an objective increase in inflammation as it relates to menstruation.
Is it common for your period make your Crohn’s or UC symptoms worse? Do many women experience worse flares during their period?
Anecdotally, Crohn’s and colitis patients do have more IBD symptoms during their menses.
We also know that nsaids (aspirin, ibuprofen, naproxen) taken during time of menses can increase bowel symptoms.
There aren’t many studies examining how IBD symptoms are affected by the menstrual cycle, but the few that exist have found evidence that women with IBD experience increased gastrointestinal symptoms during or before their period. A 2013 study published in Gut and Liver referred to various studies that identified similar patterns:
- Increased prevalence of diarrhea in women with Crohn’s disease and ulcerative colitis during premenstrual and menstrual phases, compared to women without IBD.
- A pattern of gastrointestinal (GI) symptoms in women with IBD, with GI symptoms following the cyclic pattern of the menstrual cycle.
- Greater GI symptoms during menstruation in women with IBD independent of disease activity, when compared to healthy controls.
In their own study, the authors compared 47 IBD patients with 44 healthy controls who took notes on their daily symptoms. They found that IBD patients had significantly more frequent symptoms of nausea, flatulence, and abdominal pain. Altogether, these studies suggest that the hormonal fluctuations of the menstrual cycle affect gastrointestinal symptoms in women with IBD.
Many women seem to distinguish between normal abdominal pain associated with IBD and a new kind of abdominal pain that only occurs during periods. Any insight as to what this is caused by?
The studies that have been looked at the relationship between IBD and increase symptoms during menses have not been able to explain this observation.
What are the best ways for women with IBD to manage increased period pain?
At this time until there is research showing that the increase in symptoms are truly secondary to an increase in IBD related inflammation, we do not recommend any change in IBD medications.
Does going on birth control help to decrease period pain? What should women with IBD consider when they are thinking about using birth control to manage period pain? Mirena, seasonal birth control pills, etc?
We recommend patients discuss with their family doctor if they want to consider going on birth control to decrease period pain. Having IBD is not a contraindication to going on birth control pills.
Lim, S. M., Nam, C. M., Kim, Y. N., Lee, S. A., Kim, E. H., Hong, S. P., … Cheon, J. H. (2013). The Effect of the Menstrual Cycle on Inflammatory Bowel Disease: A Prospective Study. Gut and Liver, 7(1), 51–57. http://doi.org/10.5009/gnl.2013.7.1.51
Saha, S., Zhao, Y., Shah, S. A., Esposti, S. D., Lidofsky, S., Salih, S., … Sands, B. E. (2014). Menstrual Cycle Changes in Women with Inflammatory Bowel Disease: A Study from the Ocean State Crohn’s and Colitis Area Registry. Inflammatory Bowel Diseases, 20(3), 534–540. http://doi.org/10.1097/01.MIB.0000441347.94451.cf
Bernstein MT, Graff LA, Targownik LE, Downing K, Shafer LA, Rawsthorne P, Bernstein CN, Avery L. Gastrointestinal symptoms before and during menses in women with IBD Aliment Pharmacol Ther. 2012 Jul;36(2):135-44. doi: 10.1111/j.1365-2036.2012.05155.x. Epub 2012 May 24.PMID: 22621660