Crohn's Disease And Pregnancy: Symptoms, Diagnosis & Treatment

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Crohn’s disease is commonly diagnosed in adolescents and adults from ages 15 to 30, and both men and women are equally susceptible (1). The condition, complications, tests, and interventions can impact fertility and pregnancy in women of childbearing age. Pregnant women with Crohn’s disease require special care to minimize the possible risks and complications.

Most women can have a normal pregnancy and healthy baby if Crohn’s condition is under control. Also, having a baby does not worsen Crohn’s. Maintaining remission with prescribed medications and a well-balanced diet, including prenatal supplements and regular physical activity, might increase the likelihood of having a healthy baby (2).

Read on to know more about the effects, safety, diagnosis, and treatments for Crohn’s disease in pregnancy.

What Is Crohn’s Disease?

Inflammatory bowel disease

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Crohn’s disease is an inflammatory bowel disease (IBD) that can affect any part of the digestive tract from mouth to anus. It also affects the small intestine and former parts of the large intestine. Fever, blood in stool, mouth sores, diarrhea, and abdominal pain are some possible symptoms of the condition.

The exact cause is yet unknown. There can be autoimmune or genetic etiologies, and Crohn’s may run in families. Smoking, a high-fat diet, NSAIDs, and certain antibiotics can increase the risk of Crohn’s disease. Although there is no cure, medications help manage symptoms during the flare. Bowel obstruction, malnutrition, reactive arthritis, the increased risk of cancer, and fistula formation are possible complications of Crohn’s disease (3).

How Will Pregnancy Affect Crohn’s Disease Symptoms?

The effect of pregnancy on Crohn’s disease symptoms vary in each woman. Those in a flare or active stage of disease at the time of conception tend to have the symptoms throughout the pregnancy. Some may experience no symptoms or improvement of symptoms if conceived during remission. However, a few women reported having worsening Crohn’s symptoms during pregnancy.

Stopping Crohn’s medications can increase the risk of worsening the symptoms during pregnancy. You may stick to the treatment regimes and avoid triggers to reduce the severity of symptoms during pregnancy (4).

Is It Safe To Get Pregnant With Crohn’s Disease?

You can have a healthy pregnancy under the supervision of a gastroenterologist

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Women with Crohn’s disease can conceive and have a healthy pregnancy under the supervision of a gastroenterologist and obstetrician. You may inform your doctor about the plans for pregnancy to make necessary changes in medication doses and begin with prenatal supplementations to reduce the baby’s risk of developing congenital disabilities.

It is also advised to treat malnutrition related to Crohn’s before consumption. Healthy weight and nutritional status are essential for optimal growth and development of the baby and maternal immunity. Due to safety concerns, some diagnostic tests and medications need to be delayed during pregnancy. Although women with Crohn’s can have healthy pregnancies and babies, they are considered high-risk OB patients due to the chances of pregnancy complications (5).

When Is The Best Time To Get Pregnant If You Have Crohn’s Disease?

The best time is to conceive during the remission for three to six months and when you are not on steroid medications. Usually, women with IBD have equal chances of conception during the remission period unless they have any complications (5).

Dr. Jacqueline Wolf, a physician in the Division of Gastroenterology, Hepatology, and Nutrition at Beth Israel Deaconess Medical Center says, “Because it affects them in their childbearing years, women need to know when it is safe to get pregnant,

Women with IBD have equal chances of conception

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Twenty years ago, women with this disease would be told that they shouldn’t have children or that this would affect their ability to have children,” adds Wolf. “Now most women can have a safe pregnancy and delivery if they go into pregnancy without the active disease (2).”

Most women conceiving in remission may continue to have the remission period throughout their pregnancy. It is not advisable to conceive in flares since the Crohns can be active during all trimesters, and there is a higher risk for adverse outcomes. Pregnancy in the active phase of the disease can also worsen symptoms and require more medications (5).

What Are Possible Pregnancy Complications With Crohn’s Disease?

According to a population-based study, Crohn’s disease increases the chances of poor pregnancy outcomes than other inflammatory bowel diseases such as ulcerative colitis. Some women may experience pregnancy complications due to Crohn’s disease. Inadequate management of the disease and pregnancy in a flare can be the reason for complications.

The following pregnancy complications are possible in women with IBD, including Crohn’s disease (5):

  • Preterm birth
  • Small for gestational age newborns
  • Cesarean section deliveries
Cesarean is a common pregnancy complication in women with Crohn disease

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  • Miscarriage or pregnancy loss
Things to know
If one parent has IBD, the child’s risk of developing the condition is approximately 2 to 9%. The risk may increase to 36% if both parents have the condition (5).

Pregnant women with IBD also tend to have an increased risk for other pregnancy and delivery complications. In most studies, congenital disabilities are not shown to be directly associated with IBD. Crohn’s disease can increase the risk of fistulas (passages) and the collection of pus (abscesses) around the rectum and vagina. Cesarean-section deliveries are recommended if a woman has an active fistula or abscess around the vagina or rectum near the due date (5).

How Is Crohn’s Diagnosis And Monitoring Done During Pregnancy?

Inform the healthcare provider before undergoing investigations or tests to check the status of IBD. Although you have Crohn’s flare-up, some investigations are delayed until after childbirth.

The following factors are considered for Crohn’s diagnosis in pregnancy (6):

  • MRI imaging is not done in the first trimester when the baby’s organs and organ systems develop.
  • Colonoscopy, gastroscopy, and sigmoidoscopy are safe anytime during pregnancy.
  • X-rays, barium X-rays, CT scans, and PET scans are not usually recommended during pregnancy unless there is an unavoidable need since these tests involve radiation.
  • Regular prenatal blood testing and ultrasounds are done at scheduled intervals.

The clinical guidelines recommend that healthcare providers order diagnostic evaluations for Crohn’s when it is needed during pregnancy. However, the tests are delayed to the second trimester or postpartum from the first or last trimesters to avoid risks.

Can You Continue Crohn’s Disease Treatment During Pregnancy?

Corticosteroids are less risky in pregnancy

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Pregnancy and Crohn’s treatment should be well managed under the guidance of experts to avoid complications. There are some considerations and exceptions for drugs and their dosage during pregnancy. According to the Canadian Society of Intestinal Research, there are no drugs with no risks to the fetus; they can be low, moderate, or high risk (7).

The following medications are often prescribed for Crohn’s flares in pregnancy (8):

  • Aminosalicylates such as sulfasalazine and mesalamine do not directly harm the fetus.
  • Corticosteroids such as prednisone are low risk in pregnancy. However, it is recommended to conceive after a few months of stopping the steroids. Doses are reduced if a woman becomes pregnant during steroid therapy.
  • Antibiotics are given if necessary. Quinolone antibiotics are not suggested due to their risks.
  • Biologics such as infliximab and certolizumab are low risk and can be used in pregnancy and lactation. Vaccinations for infants can be delayed if the mother receives biologics during pregnancy due to the possible risk of infections after live vaccines (2).
  • Immunomodulators such as azathioprine (Imuran) are low-risk drugs given in standard doses.

Most medications for inflammatory bowel disease are safe during pregnancy, except for two (8):

  • Methotrexate
  • Thalidomide (Celgene, Thalomid)

These medications are teratogenic and come under pregnancy category X. This means they have the potential to affect the embryo or fetal development negatively. These medications are used cautiously in women of childbearing age and are often discontinued months before pregnancy. Surgical treatments are recommended in pregnancy if the benefits outweigh the risks.

Experts advice
Both men and women should stop taking Methotrexate three to six months before conception (5).

What Is The Effect Of Surgery For Crohn’s Disease On Pregnancy?

Past bowel resections (removal surgery) for Crohn’s disease do not cause adverse effects on pregnancy. However, the outcomes may vary in each woman and depending on the type of resection. Some procedures may reduce the chance of conception, so women of childbearing age with Crohn’s should make informed decisions and delay or choose surgical procedures when it is an absolute requirement (5).

The following bowel resections are known to slightly decrease the fertility rates and adverse outcomes in pregnancy (5):

  • Colostomies involve colon incisions to create an opening in the abdominal wall.
  • Ileostomies, where damaged ileum is removed and connected to an artificial opening on the abdomen wall.
  • J pouches (pelvic pouch or ileal pouch) is a type of ileoanal anastomosis (connection) made by two loops of the small intestine.
Quick fact
Women with IBD who have undergone proctocolectomy with ileal-pouch anal anastomosis (IPAA) have a success rate for in vitro fertilization comparable to those without IBD or with IBD but no surgery (11).

Although modern abdominal surgeries and anesthesia pose minimal risks to the fetus, they are not safe. There is also an increased risk of prolapse or obstruction of ileostomy during pregnancy when the growing uterus exerts more pressure on the abdominal organs. Unless there is a risk to maternal health or unresponsiveness to medications, surgeries are postponed to postpartum.

Frequently Asked Questions

1. Should pregnant women be tested for Crohn’s disease?

Not all pregnant women need to be tested for Crohn’s disease during pregnancy. Doctors may recommend the tests if symptoms and tests are required. Pregnant women with Crohn’s disease flares may require diagnostic tests during pregnancy. Those in remission or who do not have the disease will not require tests or screening during pregnancy. Always inform your doctor about the disease and pregnancy to make safe decisions. Doctors may plan the tests based on the gestational week if needed.

2.Does Crohn’s get worse in pregnancy?

The severity of Crohn’s in pregnancy may vary in each woman. Studies show fewer relapses during pregnancy, or there were no significant differences. More evidence is needed to know the effects of pregnancy on Crohn’s disease (9).

3. Can I take folic acid with Crohn’s disease?

You should take folic acid as per your doctor’s recommendations from the preconception period throughout the pregnancy. Doctors may prescribe 2mg of folic acid daily for women taking sulfasalazine since it may interfere with folic acid absorption (10). In your regular diet, you may also consider including folic acid-rich foods, such as rice, fortified breakfast cereals, meat, avocado, and orange juice. These supplements are essential to prevent congenital anomalies in babies.

Crohn’s disease is not a contraindication for childbearing. However, the right plan and wise decisions can help you have better control of pregnancy outcomes. It is vital to get all prenatal and gastroenterologist visits on schedule since doctors may change or adjust the doses of medications depending on the gestational age and other factors. Pay attention to the nutrition status if you are experiencing diarrhea and other symptoms. Never hesitate to seek help from a counselor or support group when dealing with Crohn’s and pregnancy.

Key Pointers

  • Women with Crohn’s disease should discuss with healthcare providers and delay certain medications and surgery until childbirth.
  • It is better to plan pregnancy when Crohn’s disease is in remission to have a pregnancy with minimal risks.
  • It is ideal to seek preconception care to improve pregnancy outcomes and reduce the risk to the baby.

References:

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