Pregnancy and IBD

Women with IBD are always concerned about ensuring their pregnancies go smoothly. Two major concerns involve mode of delivery (vaginal delivery versus Cesarian section) and safety of drugs used to treat IBD for the baby.

Several years ago we reported that Manitobans with either Crohn’s disease or ulcerative colitis were significantly more likely to undergo Cesarian section than the general population. Since women with Crohn’s disease may have perianal fistulas, it was somewhat not surprising that more women with Crohn’s disease may have avoided a vaginal delivery where there can be potential trauma to the perianal area. However, it was surprising that women with ulcerative colitis were as likely as women with Crohn’s disease to have Cesarian sections. We wondered whether some doctors were attributing some of the potential risk of Crohn’s disease to ulcerative colitis.

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In another related study we assessed women with Crohn’s disease of childbearing age registered in our University of Manitoba IBD Research Registry for their prevalence of perianal disease and for their mode of delivery. We found that women without perianal disease or those with inactive perianal disease could safely undergo vaginal deliveries without risk of developing or flaring perianal fistulas. However, women with active perianal disease (active fistulas) should undergo a Cesarian section, because for those women a vagianl delivery can lead to worsened perianal fistulizing disease.

Ilnyckyj A, Blanchard JF, Rawsthorne P, Bernstein CN. Perianal Crohn’s disease and pregnancy: Role of the mode of delivery. American Journal of Gastroenterology 1999; 94: 3274-3278.

Breastfeeding Study

Moffatt D, Ilnyckyj A, Bernstein CN. A Population based study of breastfeeding in inflammatory bowel disease: Initiation, duration and effect on disease in the post partum period. American Journal of Gastroenterology 2009; 104: 2517-23.

We aimed to assess breastfeeding practices and the impact of breastfeeding on disease flare during the postpartum year in IBD. Women of childbearing age from 1985 to 2005 were identified from the University of Manitoba IBD Research Registry.

Questionnaires were completed regarding pregnancy and the postpartum period. Data for initiation and duration of breastfeeding were compared with regional data from Manitobans.

132 women responded to the survey, yielding information on 156 births. Breastfeeding was initiated in 83.3% of women with IBD, 81.9% of Crohn’s disease patients, and 84.2% of ulcerative colitis patients vs. 77.1 % in the general population. 56.1% of women with IBD, breastfed for >24 weeks vs. 44.4% of non-IBD controls.

The rate of disease flare in the postpartum year was not different in Crohn’s disease or UC among breastfeeders vs non breastfeeders. Risk of disease flare was not related to age at pregnancy, duration of disease, or socioeconomic status. We concluded that women with IBD are as likely as the general population to breastfeed their infants.

Further, breastfeeding was not associated with an increased risk of disease flare and may even provide a protective effect against disease flare in the postpartum year. Women should be encouraged to breastfeed but must review whether it is safe to do so with their doctors, in terms of whether the medications they use cross into breast milk.

Below are summary tables regarding drug safety in pregnancy and during breastfeeding

TABLE 1: Safety of IBD drugs in pregnancy

Known to be safe during pregnancy

Oral 5-ASA (Asacol, Pentasa, Salofalk)

Topical 5-ASA (Salofalk enemas or suppositories)

Sulfasalazine

*Corticosteroids

* An increase in some congenital abnormalities has been reported in newborns whose mothers used corticosteroids during pregnancy

Likely to be safe during pregnancy

Azathioprine (Immuran)

6-Mercaptopurine

Metronidazole (Flagyl)

Cyclosporine

Loperamide (Immodium)

Adalimumab (Humira)

Infliximab (Remicade)

Known to be UNSAFE during pregnancy

Diphenoxylate (Lomotil)

Cholestyramine

Tacrolimus

Methotrexate

Thalidomide

Mycophenolate Mofetil

 

TABLE 2: Safety of IBD medications during breastfeeding

Known to be safe during breastfeeding

Sulfasalazine

Topical 5-ASA (Salofalk enemas, suppositories)

Oral 5-ASA (Asacol, Pentasa, Salofalk)

Corticosteroids

Likely to be safe during breastfeeding

*Azathioprine (Immuran)

*6-Mercaptopurine

Budesonide (Entecort)

Cholestyramine

Infliximab (Remicade)

Adalimumab (Humira)

Metronidazole (Flagyl)

*A potential problem of using these agents if breastfeeding is that while a minimal amount may cross into breast milk if the baby does not metabolize these agents normally the baby can develop low white blood cell counts and hence may need intermittent blood testing

Known to be UNSAFE during breastfeeding

Diphenoxylate (Loperamide)

Methotrexate

Mycophenolate mofetil

Tacrolimus

Cyclosporine

Ciprofloxcin