Learning points

1. Counsel women of child-bearing age about fertility and pregnancy with IBD
2. Control IBD tightly during pregnancy to achieve optimal maternal and fetal outcomes
3. Establish regular proactive communication with obstetrics to ensure joined-up care

Introduction

Management of inflammatory bowel disease (IBD) during pregnancy is crucial because patients are at increased risk of poor pregnancy outcomes. Cohort studies involving women with Crohn’s disease or ulcerative colitis have shown increased numbers of preterm births, babies small for gestational age, and caesarean deliveries.^1–5

Most patients who conceive while in remission will remain in remission during pregnancy. Of those who conceive during a period of active disease, in two-thirds the severity remains the same or worsens.^6,7 Assisting women to make complex and personal decisions on conception, pregnancy, breastfeeding, and the postnatal phase that are balanced against disease management is an important part of the IBD team’s role.

Effect of Active IBD on Pregnancy

Active inflammation from IBD poses a significant risk to mother and foetus. The data are strongest on the effects of Crohn’s disease.

Initial studies of ulcerative colitis have shown inconsistent results. However, population-based data on women requiring tumour necrosis factor inhibitors to control their ulcerative colitis have shown a clear link between disease activity and pregnancy outcomes. In one study of 461 pregnant women with IBD, increased risks of pregnancy-related complications were demonstrated, including spontaneous abortion, pre-eclampsia, eclampsia, prolonged premature rupture of membranes and placenta praevia, abruptio placentae, and venous thromboembolism.⁸ Women with IBD are also at increased risk of gestational diabetes, especially when steroid treatment is required during pregnancy.

Congenital Abnormalities

Congenital malformations are common in the general population, with 4–7% of neonates affected. In IBD, there is no convincing evidence for an increase in risk associated with either underlying disease or recommended medical therapy.

Principles of IBD Treatment during Pregnancy and Breastfeeding

The key aim of management during pregnancy in a woman with IBD is to keep the mother well, which in turn will create optimum and safe conditions for the foetus, and maximise the chance of a good pregnancy outcome.

In general, the balance swings towards treating active inflammation, as the benefits of most treatments far outweigh the risks (Table 1).⁹

Table 1: Safety of medications during pregnancy and breastfeeding

Data are mainly based on the European Crohn-Colitis Organisation 2015 guidelines.⁹

Delivery

Considering mode of delivery is an important part of any pregnancy. When possible, vaginal deliveries are preferred for women with IBD.⁹ A caesarean section is major abdominal surgery associated with a raised risk of venous thromboembolism, wound healing issues, and a 1:200 risk of stillbirth in subsequent pregnancies. However, in certain scenarios a caesarean-section is recommended, including active perianal disease (absolute indication) and in women with an ileoanal pouch or J-pouch (relative indication). The mode of delivery has no negative impact on the mother’s IBD, and there is no increase in risk of new perianal fistula or incontinence.⁹

Breastfeeding

Breastfeeding is beneficial for babies, as breastmilk has greater immunological and nutritional benefits than formula feeds. Evidence of the effect on infants of drugs that mothers may be taking during breastfeeding is limited. Often, the amount of drug transferred into breastmilk is low and insufficient to produce a discernible effect. When making recommendations about continued drug use and breastfeeding, consideration must be given to the amount of active metabolite or drug derived to the infant according to the drug pharmacokinetics, efficiency of absorption through the gut, and subsequent distribution elimination in the mother.

Aminosalicylates are excreted in low concentrations in breastmilk. Infants of mothers taking these drugs might develop diarrhoea, in which case the aminosalicylates should be stopped. Steroid usage during breastfeeding is deemed safe, as the concentrations that enter breastmilk are low. Thiopurines are detectable in breastmilk but at very low levels compared to those in plasma as early as 4 hours after ingestion. Their metabolites are almost undetectable in breastfed infants, and no increased risks of infection have been demonstrated. Ciclosporin is safe in breastfeeding, but the potential risk of immunosuppression of the baby should be discussed with the mother before initiation.

Methotrexate should not be used during breastfeeding. It is present in breastmilk and has been associated with immunosuppression and neutropenia in the infant.

Biologics

Few data are available about use of biologics during breastfeeding. However, evidence suggests that they do pass into the breast milk in small amounts, but that the subsequent oral absorption is minimal. Breastfed infants of mothers receiving infliximab, adalimumab, certolizumab, natalizumab, and ustekinumab have similar outcomes for 12-month development milestones and risks of infection to non-breastfed infants or breastfed infants not exposed to the drugs. The risks and benefits should be discussed with the mother.

Vaccinations in the infant

Vaccination schedules for infants should generally be followed routinely. However, for those exposed to biologics in utero, the rotavirus vaccination should be avoided, and the BCG vaccination delayed if offered.^9,10

IBD investigations during pregnancy

When cross-sectional imaging is required, ultrasound and MRI are preferable over ionizing radiation procedures. Endoscopy can be safely performed but should be limited to cases where management decisions are dependent on the results, and the least invasive approach (sigmoidoscopy rather than colonoscopy, if feasible) should be employed.⁹

Conclusions

Close management with the patient and obstetric team is essential for ensuring the best outcomes for the mother and baby. This requires regular communication with the obstetric team, and providing clear guidance to the patient and the obstetric team. ⁹

Author Biographies

Christian Selinger works as a Consultant Gastroenterologist with a special interest in inflammatory bowel disease in Leeds. He completed gastroenterology training in Manchester and advanced training in inflammatory bowel disease in Sydney, Australia. He was awarded an MD from the University of Manchester for his research on IBD in 2013 and an MSc with distinction in Gastroenterology from the University of Salford in 2011. His research expertise lies within gastroenterology and he is widely published especially in inflammatory bowel disease and endoscopy.

Dr Helen Steed is a consultant gastroenterologist at the Royal Wolverhampton NHS Trust and former IBD clinical lead. She is a serving member on the BSG IBD Section Committee and Food and Function Clinical Research Group.