A high percentage of patients diagnosed with inflammatory bowel disease (IBD) are of childbearing age, as these diagnoses usually occur between the ages of 15 and 35. Therefore, there is a need for the doctor to assess whether the disease or treatment may influence pregnancy and vice versa: how pregnancy may affect IBD.

Below are some issues that patients with IBD should consider during pregnancy and breastfeeding:

1. Can I get pregnant?

In general, patients with IBD have the same fertility rates as the rest of the population, especially if the disease is inactive or in remission. However, there are some factors that reduce fertility, such as intestinal surgery or decreased libido.

In any case, it is important to plan your pregnancy when the disease is in remission in order to reduce obstetric complications such as low birth weight. It is also advisable to have a consultation prior to conception in order to address any potential risk factors on an individual basis and to advise the patient on the necessary vitamins and supplements.

2. What should I do when my pregnancy is confirmed?

The first thing the patient should do when she finds out she is pregnant is to contact her doctor and midwife, as well as the IBD unit, in order to schedule visits to the gynaecologist and gastroenterologist during pregnancy. This follow-up should be coordinated by both specialists, and under no circumstances should the medication be suspended or modified on her own.

3. Can IBD affect my pregnancy?

When the disease is in remission, there is no evidence to suggest increased obstetric risks such as a higher risk of miscarriage, fetal death or congenital malformations. Only in a third of cases does a flare-up of the disease usually occur, normally in the first trimester of pregnancy.

However, in patients with active inflammatory bowel disease during pregnancy, there has been evidence of increased premature births, fetal growth retardation and low birth weight.

Surgery for complications associated with IBD (e.g. fistulas, abscesses, intestinal obstruction, etc.) increases the risk of premature birth and miscarriage. Despite this, if doctors suggest this option, it is because the benefits are significant.

4. Does pregnancy affect IBD activity?

The progression of IBD during pregnancy is more closely related to the state of the disease at the time of conception. This means that if conception occurred while the disease was in remission, the pregnancy will proceed normally, although there is a possibility of a flare-up in the first trimester.

If, on the other hand, if conception took place at a time when IBD was active, it will be more difficult to control. 70% of women continue to experience or worsen their symptoms during pregnancy, thus increasing possible complications for both the mother and the baby. Hence the importance of planning conception during a period of remission of the disease.

5. Can I take my IBD treatment if I want to become pregnant, am pregnant or want to breastfeed?

In most cases, IBD treatments can be continued during pregnancy and breastfeeding because they are safe. In fact, it is not the treatment that poses the greatest risk to pregnancy, but rather the active disease. That is why it is important to inform your IBD specialist before trying to conceive so that they can review your treatment, ensure that the disease is under control, and assess whether your medication needs to be adjusted. The goal will always be to maintain remission of IBD with the safest regimen for you and your baby.

During pregnancy, you should avoid stopping your medication without consulting your doctor, due to the risk of a new flare-up.

So, in general, it is safer to continue treatment than to interrupt it

In summary, most treatments can be continued, and in the few cases where this is not possible, there are safe alternatives.Planning, medical support and disease control are the keys to a peaceful and complication-free pregnancy, both for you and your baby.

6. Necessary check-ups during pregnancy

During pregnancy, general pregnancy check-ups will be carried out:

• one visit per month to the midwife until week 28, at which point these check-ups will become more frequent, depending on the progress of the pregnancy and the IBD. It is common for vitamin supplements such as folic acid, iron and vitamin D to be recommended during the pre-conception consultation.
• The first visit to the gynecologist should take place before week 12 of pregnancy, at which point an ultrasound scan will be performed. In the case of patients with IBD, it is necessary to correctly date the week of pregnancy.
• After week 20, check-ups are carried out every 4 weeks to assess fetal growth, especially in women with active disease or undergoing treatment with corticosteroids.
• As for the gastroenterologist, the consultation should be made as soon as possible in case the medication needs to be adjusted or modified. Subsequent visits will depend on the severity of the disease and whether it is in the active phase or in remission.

Maintain the hygiene and dietary measures recommended for any pregnant woman (avoid alcohol and tobacco, engage in regular physical activity whenever possible, and get plenty of rest…).

In case of complications with IBD, your doctor will recommend endoscopies or imaging tests, always attempting to perform them after the second trimester.

7. Can I have a vaginal delivery?

As with any other delivery, whether it is vaginal or by caesarean section depends on the obstetric conditions of each woman.

However, some patients with active perianal disease or activity in the rectum, in Crohn’s disease (due to the risk of damage to the perineal area); or ileo-rectal anastomosis or in patients with ileo-anal reservoir (due to the likelihood of developing or worsening incontinence problems after delivery), an elective caesarean section should be considered in each individual case.

In women with an ileostomy or colostomy, vaginal delivery is not contraindicated, as it is not associated with an increase in complications. It is also advisable not to perform an episiotomy due to the risk of perianal involvement.

8. Is there a risk of transmitting the disease?

The causes of inflammatory bowel disease are not fully understood. The current hypothesis is that IBD develops in genetically predisposed individuals, where environmental factors interact with the gut microbiota and the immune system.

That said, the risk of developing IBD is higher for those with a family history of the disease. In Crohn’s disease, for example, if one parent suffers from it, the risk of transmission to their offspring is 5%. In ulcerative colitis, the risk is 2%, and if both parents suffer from one of these two conditions, the possibility of transmission increases to 30%.

9. Can I breastfeed?

Breastfeeding is recommended in all pregnancies because of the benefits it brings to both the mother and the newborn. Furthermore, there is no evidence to suggest that breastfeeding has a negative effect on IBD, provided that the disease is under control and the treatment is compatible (as is the case in most instances). In the case of the newborn, breast milk promotes beneficial intestinal microbiota, with regard to the risks associated with the mother’s IBD treatment, the dose can be adjusted to avoid any impact on the baby.

Medications used during pregnancy are also safe during breastfeeding, as the doses of medication that reach the fetus through the placenta are higher than those that reach it through breast milk.

It should be noted that if the mother has received biological treatment (except certolizumab) during the third trimester of pregnancy (i.e. from week 27 of gestation onwards), it is recommended to avoid administering vaccines with live attenuated microorganisms during the first 6 months of the baby’s life (usually the oral rotavirus vaccine). However, other vaccines with live attenuated viruses, such as the MMR (measles, mumps and rubella) or chickenpox vaccines, which are administered around the first year of life, can be given as normal.

In any case, mothers with IBD who wish to breastfeed their babies should follow the general recommendations for nutrition:

• Caloric intake should be 450 to 500 additional kcal per day.
• Add 200 to 300 mg of omega-3 fatty acids.
• Hydration is very important, which can be difficult for mothers with IBD, especially those with an ostomy or active disease. If this is the case, the mother should receive nutritional advice.

References

• Brondfield, M.N., Mahadevan, U. Inflammatory bowel disease in pregnancy and breastfeeding. Nat Rev Gastroenterol Hepatol 20, 504–523 (2023). https://doi.org/10.1038/s41575-023-00758-3 /
• Pregnancy and birth. Crohn’s & Colitis UK Pregnancy and birth with Crohn’s Disease or Ulcerative Colitis (IBD)