According to available data, the risk of ulcerative colitis in a child, if one of the parents is sick is about 1.6%, in the case of Crohn’s disease – about 5%. If both parents have the disease, the probability of inheritance increases to 35%. Thus, these risks are not high and the likelihood of a child inheriting the disease is extremely low. In general, the inheritance of ulcerative colitis and Crohn’s disease is multifactorial under the influence of not yet recognized environmental factors, so the presence of the disease in parents is not a reason for refusal of pregnancy.
In general, the ability to conceive in the presence of ulcerative colitis or Crohn’s disease does not differ from a healthy population. Decrease in the ability to conceive may be a consequence of surgical operations on the intestine, and in the presence of fistula forms of Crohn’s disease — a consequence of the development of adhesions in the pelvis and violations of the patency of the fallopian tubes. In addition, with severe exacerbations of ulcerative colitis and Crohn’s disease, weight loss, impaired absorption of vitamins and minerals and the use of high doses of glucocorticoid, hormones can lead to menstrual disorders and a temporary decrease in the possibility of pregnancy.
In the presence of factors that prevent the natural onset of pregnancy, it is possible to use methods of assisted reproductive technologies. Contraindications to ART programs are exacerbations and severe complications of ulcerative colitis and Crohn’s disease.
In patients with remission of the disease during pregnancy complications develop as often as in women who do not have these diseases. The high activity of the inflammatory process in the intestine at the time of conception and during pregnancy increases the risk of miscarriage, premature birth and birth of a child with low body weight. In this regard, it is very important to plan pregnancy for the period of remission of the disease, and with the development of exacerbations to provide adequate treatment for the early achievement of remission.
According to the results of numerous studies and observations, the risk of congenital malformations in children born to women with IBD is not increased.
How the disease will occur during pregnancy depends largely on its activity at the time of conception. In the presence of remission at the time of conception, in most cases, the disease remains inactive during pregnancy. Exacerbation developing only in 1/3 of cases. And only in 1/3 of cases exacerbation develops. Often, the development of exacerbations during pregnancy is provoked by the termination of drug therapy. If at the time of pregnancy there is an exacerbation of IBD, the disease in 2/3 of cases remains active or the severity of the inflammatory process increases. This indicates the need to plan pregnancy for the period of persistent remission of IBD.
The presence of an exacerbation during one of the pregnancies does not mean that it will occur during subsequent pregnancies.
Of course, the main principle during pregnancy is the desire to reduce the drug load on the expectant mother and growing fetus. However, in some situations, the use of drug therapy during pregnancy is a prerequisite for its successful course and the birth of a full-term and healthy child. It should be clearly understood that with ulcerative colitis and Crohn’s disease, a great danger for pregnancy and normal fetal development is the high activity of the disease, but not a drug therapy.
The outcomes of pregnancy in women who take most of the medicals for the treatment of IBD, in the presence of good control of the disease, do not differ from the outcomes in healthy women.
Mesalazine preparations are safe during pregnancy and are not associated with toxic effects on the developing fetus.
At the same time, the use of sulfasalazine may affect the metabolism of folic acid, and therefore during pregnancy it is recommended to use folic acid in an increased dose of 2 mg per day.
With the development of exacerbations of IBD during pregnancy, it may be necessary to use glucocorticoid hormones.
To date, sufficient data has been accumulated on the safety of glucocorticoids during pregnancy in women who have taken these drugs for the treatment of bronchial asthma, autoimmune diseases and IBD. In early studies, there was a slight increase in the risk of cleft palate when taking glucocorticoid hormones in high doses in the first trimester of pregnancy. However, more recent studies have not confirmed this.
Glucocorticoids do not contribute to miscarriage, complications of the fetus and, if indicated, can be used by pregnant women.
Immunomodulators (azathioprine, 6-mercaptopurine, methotrexate)
The safety of azathioprine and 6-mercaptopurine during pregnancy has been well studied in women with autoimmune diseases, inflammatory bowel diseases and in patients undergoing organ transplantation. Taking these drugs does not increase the risk of congenital malformations of the fetus, miscarriage and other undesirable effects. It is believed that azathioprine and 6-mercaptopurine may be safely continued during pregnancy.
Methotrexate is absolutely contraindicated during pregnancy due to the high risk of malformations in the fetus and spontaneous miscarriages. Pregnancy may be planned no earlier than 3 months after discontinuation of methotrexate.
Metronidazole and ciprofloxacin are most often used in the treatment of IBD. The use of metronidazole in small courses is not associated with side effects on the fetus, but its long-term use, especially in the first trimester of pregnancy in the absence of strict indications, should be avoided. Pregnancy is a limitation for the use of ciprofloxacin because of its impact on the development of bone and cartilage tissue of the fetus. Safe during pregnancy is Amoxiclav, which can be used as an alternative.
Biological therapy is one of the new directions in the treatment of IBD. Biological therapy drugs are prescribed in cases of severe ulcerative colitis and Crohn’s disease, when standard treatments are ineffective or ineffective. In this regard, the cessation of biological therapy before or during pregnancy is associated with a high probability of severe exacerbation. Global data indicates the safety of these drugs during pregnancy and the absence of risks of congenital malformations, miscarriage and other complications. Of course, when planning a pregnancy, it is necessary to weigh the possible risks associated with treatment and the risks associated with active disease, and discuss with the attending physician the possibility of stopping or continuing treatment.
The use of rectal forms of drugs during pregnancy is safe and does not affect the tone of the uterus. Even though a certain amount of the drug is absorbed from the intestine into the general bloodstream, these concentrations are minimal and do not have harmful effects on the fetus.
Mesalazine, or 5-aminosalicylic acid, does not affect the blood clotting ability and, accordingly, does not increase the likelihood of postpartum bleeding. Therefore, there is no need to cancel mesalazine before childbirth.
Indeed, the first manifestations of ulcerative colitis and Crohn’s disease can develop during pregnancy or shortly after birth. However, the onset of diseases in this period does not affect the severity of their course. A certain difficulty may be the rapid diagnosis due to limitations of diagnostic capabilities during pregnancy.
The optimal time for planning a pregnancy is a stable remission of the disease. This minimizes the probability of exacerbation of the disease during pregnancy, and the risk of complications of pregnancy. A favorable time for conception should be discussed with your doctor. To confirm remission of the disease, in addition to the absence of symptoms and well-being, it may be necessary to make a laboratory examination and, in some cases, endoscopy. If signs of inflammation are detected, treatment should be corrected, and pregnancy postponed until remission of the disease is achieved. It is also necessary to assess the levels of vitamins, macro – and microelements and fill their deficit before pregnancy (total protein, albumin, folic acid, B-vitamins, vitamin D, calcium, iron, zinc, etc.).
During pregnancy, the use of radiation examination methods associated with x-rays, including computed tomography, is contraindicated. These methods of examination can be used only for the diagnosis of complications or severe exacerbations of IBD, when the risk of complications for the mother exceeds the possible adverse effects of radiation on the fetus.
For diagnostic purposes and to monitor the effectiveness of treatment safe during pregnancy ultrasound, laboratory tests, and MRI (without contrast) are considered safe. Endoscopy (colonoscopy, sigmoidoscopy) can be carried out in the presence of strict indications.
The presence in the past of operations for ulcerative colitis and Crohn’s disease in most cases does not affect the course of future pregnancies.
In most cases, natural childbirth is possible if there are no obstetric indications for cesarean section.
In cases where past surgical treatment for complications in the perineum (abscesses, perianal fistulas) was carried out, cesarean section is the preferred method of childbirth.
Subsequent damage occuring to the perineum in childbirth or episiotomy results in a high probability of tissue healing disorders in women with prior surgical treatment.
In the presence of an intestinal reservoir (ileoanal anastomosis with a reservoir), cesarean delivery is recommended. This avoids damage to the tank in childbirth and further disruption of its function.
In the presence of ileo – or colostomy, natural childbirth is possible.
Undoubtedly, the issue of delivery should be discussed individually in each case jointly by an obstetrician-gynecologist, gastroenterologist or coloproctologist.
In most cases, in the presence of ulcerative colitis and Crohn’s disease, natural childbirth is preferred, if there are no other obstetric reasons for cesarean section.
In the presence of perianal manifestations (fistulas, infiltrates, etc.) or intestinal reservoir, delivery by cesarean section is recommended.
The successful course and completion of pregnancy is largely determined by the presence of remission of ulcerative colitis and Crohn’s disease in this period. Without a doubt, inflammatory bowel disease in each patient can occur in different ways, and to decide on the continuation or change of therapy before pregnancy should be assessed individually in each case. However, if you have previously had severe exacerbations, and are currently taking biological or immunosuppressive therapy to maintain remission, withdrawal of drugs before or during pregnancy is associated with a high probability of disease activation. Therefore, when planning a pregnancy, it is necessary to discuss in advance with your doctor what medicines are safe during pregnancy and at conception. In most cases, the drug therapy used to maintain remission can be continued during pregnancy. According to studies in recent years, the potential benefits of taking drugs for the treatment of ulcerative colitis and Crohn’s disease during pregnancy far outweighs the possible associated adverse effects. Taking a course of drugs at the time of conception, or during pregnancy, for the treatment of IBD, even the most effective, is associated with a low risk of undesirable effects on the fetus.
In cases where taking drugs can have dangerous effects during pregnancy, you should discuss with your doctor the possibility of replacing them with alternative medication.
It is known that women with ulcerative colitis and Crohn’s disease breast-feed more rare and shorter. At the same time, breastfeeding has a protective effect on the development of inflammatory bowel diseases, asthma and allergic diseases at an early age. Refusal to breastfeed is often associated with the fear of the mother’s medication getting into breast milk. However, most of the drugs are found in breast milk are in virtually undetectable amounts and do not have adverse effects on the child. The possibility and mode of breastfeeding when taking medication should be discussed with your doctor.
Pregnant women with IBD, like all pregnant women, are advised to follow a balanced diet. In the presence of remission of the disease there is no need to limit the diet. As an additional micronutrient support for the prevention of nervous system defects, folic acid is recommended for all pregnant women. When a deficiency is detected, the deficiency of iron, calcium, vitamin D, zinc, protein is replenished. In violation of the absorption of nutrients, patients may use enteral mixtures. Enteral mixtures are special balanced “cocktails” of proteins, carbohydrates and fats that are easily absorbed in the intestine, even in the presence of acute diseases.
During periods of exacerbation of the disease, the following products should be excluded from the diet in order to prevent worsening symptoms. These include foods rich in fiber (fruits with thick skin, dried fruits, vegetables, whole grains), legumes, nuts, seeds, milk (in the presence of lactose intolerance), coffee, spicy, fatty, fried food, carbonated drinks.
During exacerbations, it is advised to eat foods that are easier to digest, such as foods that are steamed, boiled, baked, or cooked on the grill.
Multivitamins allow you to fill the increased need for vitamins and micronutrients during pregnancy. Even in healthy people, there may be poor tolerability and the appearance of symptoms from the gastrointestinal tract. To avoid possible side symptoms when taking multivitamins, it is advisable not to take them on an empty stomach. You should carefully study the composition of multivitamins and avoid those that contain lactose, food colors and preservatives. In persons with lactose intolerance or hypersensitivity to food additives, symptoms from the intestine may occur when these substances are used even in small quantities.
One of the manifestations of IBD is the release of blood from the intestine. Prolonged or significant release of blood leads to depletion of iron stores in the body and the development of anemia. In itself, pregnancy is accompanied by an increased need and expenditure of iron, insufficient intake of which through diet, can also contribute to the emergence of iron deficiency anemia.
Not all patients with IBD tolerate oral forms of iron-containing drugs well, especially in the presence of exacerbations. On the one hand, iron preparations can cause or enhance intestinal symptoms (constipation, diarrhea, bloating, colic), on the other hand – poorly absorbed due to the presence of inflammation in the gut. Liquid forms of iron preparations have less side effects on the intestine. In case of intolerance to any oral dosage forms of iron preparations or for rapid replenishment of the iron depot, intravenous preparations are used in the body.