Preconception counseling offers an opportunity for the healthcare provider to address specific patient concerns regarding the risk of transmission of inflammatory bowel disease (IBD) to their offspring, to optimize control of disease activity and nutritional status, avoid inappropriate medication cessation and discontinue medications that may adversely affect pregnancy.
Care Before Pregnancy
Recommendations apply to any woman who is considering pregnancy.
- All women should take a supplement containing at least 400 mcg of folic acid. Taking folic acid can reduce the risk of a specific birth defect, 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. Patients with IBD are at risk for iron and vitamin B12 deficiency. Furthermore, iron requirements increase during pregnancy. Iron and B12 levels should therefore be checked in the first trimester and supplementation should be provided as needed.
- Women should stop smoking and consuming alcohol or any recreational drugs (eg,
marijuana) before trying to become pregnant.
- Women who take prescription or non-prescription medications should review these with a healthcare provider. Some medications are safe during pregnancy while others are not. In some cases, an alternate medication can be substituted for an unsafe drug.
- Caffeine intake should be limited to less than 250 mg per day while trying to become pregnant and during pregnancy.
- Blood testing for rubella (German measles), varicella (chicken pox), HIV, hepatitis B, and inherited genes (eg, cystic fibrosis) may be recommended before pregnancy.
- IBD therapy during pregnancy is most successful when a woman receives regular medical care and follows her treatment plan closely. Before becoming pregnant, women with IBD should discuss plans for their care with a healthcare provider. Women who discover that they are pregnant should continue their IBD medications until speaking to a healthcare provider. Having a medication plan in place prior to becoming pregnant is the best way to do it.
Care of women with IBD may be shared between a gastroenterologist and an obstetrical provider. Visits with the gastroenterologist are scheduled based upon the severity of disease during pregnancy. Women with IBD often require medications to control their disease. Some of these medications are probably safe during pregnancy and breastfeeding. In other cases, there is not enough information about the medication to determine if they are safe or not. Women who take one or more of these medications during pregnancy should discuss their concerns with a healthcare provider. They should also understand the risk to the pregnancy of stopping medications and having a significant flare.
- Sulfasalazine – Women 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 birth defects. Folic acid 2 mg/day should be taken with
- Antibiotics – Antibiotics are frequently required in the treatment of Crohn disease and are sometimes used for people with UC. The most common antibiotics used for treatment of IBD are ciprofloxacin and metronidazole. Short courses of metronidazole are probably safe for use during pregnancy, but metronidazole should be avoided in the first trimester. However, ciprofloxacin is not recommended for pregnant or breastfeeding women.
- 5-ASA – The safety of the 5-ASA drugs during pregnancy and breastfeeding is still being studied. Preliminary studies suggest that they are s afe when taken during pregnancy and that women should continue taking these drugs during pregnancy. However, women who take 5-ASA medications should speak to their clinician before trying to conceive. If 5-ASA medications are taken during breastfeeding, the American Academy of Pediatrics recommends monitoring the infant's stool consistency. There have been reports of diarrhoea in breastfeeding infants of women who took rectal 5-ASA.
- Steroids – Some studies have suggested that there may be a very small increased risk of cleft lip or cleft palate in the babies of mothers who took oral steroid medications during the first 13 weeks of pregnancy. Women 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. Steroids (eg, prednisone) are probably safe to take during breastfeeding.
- Azathioprine and 6-mercaptopurine – Azathioprine and 6-mercaptopurine can be continued during pregnancy if other types of treatment cannot be used. Women 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 is probably safe during pregnancy. There is no reported increase in the rate of birth defects with the use of any of the anti-tumor necrosis factor (TNF) medications (infliximab, adalimumab, certolizumab). However, infliximab and adalimumab can cross the placenta and be present in the baby for up to six months from birth. Therefore, these medications are often stopped in the third trimester if the disease is in remission. If you are on one of these medications, the 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 allowed on this drug. 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.
Antidiarrhoeal drugs – Antidiarrhoeal drugs should be avoided, especially early in pregnancy. Antidiarrhoeals should only be used for severe diarrhoea that cannot be controlled with dietary manipulation and bulking agents (eg, kaolin/pectin, Metamucil, psyllium).
In women with Crohn disease, the type of delivery (vaginal versus Cesarean)
depends upon the health of the tissues around the vagina and anus, the patient and clinician's preference, and the woman and baby's progress during labor. If Crohn’s disease affects the areas around the vagina or if a woman has an ileo-anal pouch (high risk for developing fistulas), a Cesarean delivery may be preferred to reduce the risk of developing fistulas. There does not appear to be any risk that IBD will worsen as a result of breastfeeding. Breastfeeding is strongly encouraged because there are a number of benefits for both women and infants.
Impact on Baby
Most women with IBD have a normal pregnancy and deliver a healthy baby. Some studies have suggested that there may be a very small increased risk of cleft lip or cleft palate in the babies of mothers who took oral steroid medications during the first 13 weeks of pregnancy. Women 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. If IBD affects the areas around the vagina or if it is indicated by the doctor, a Cesarean delivery may be preferred to reduce the risk of developing fistulas. Men and women 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