Inflammatory bowel disease (IBD) is characterized by inflammation of the gastrointestinal tract. IBD includes Crohn’s disease (CD) and Ulcerative colitis (UC), and is often diagnosed in early adulthood. As a result, many women are faced with significant concerns regarding living with IBD and becoming mothers. A vast array of questions arise, including how will pregnancy affect IBD, can it be passed on to children, are the medications safe to take during pregnancy, is it safe to breastfeed, and how do you manage good control of disease with the new stress of raising children? These questions are important, and should be discussed at length with health care providers before starting a family to ensure a safe pregnancy, maintain good health and stable disease in the mother, and ensure good health of the child.
Fertility and preconception with IBD
Fertility is typically not affected in those with well-controlled IBD. However, there are a few circumstances in which patients can face issues with fertility. The use of methotrexate or sulfasalazine in men can cause reversible decrease in sperm production. Colonic surgery can also cause infertility in men and women, depending on the type of surgery performed and complications from surgery, such as scar tissue formation. Active IBD in women can result in inflammation of reproductive organs resulting in fertility issues.
Preconception counseling is imperative in ensuring safety and good health during pregnancy and delivery. Counseling offers the opportunity to discuss issues with all health care providers (dietician, nutritionist, gastroenterologist, and obstetrician), such as heredity, controlling disease throughout pregnancy, medication safety/use, and optimizing nutrition.
Children who have a parent with IBD are 3 to 20 times more likely to develop IBD compared to those without a family history of the disease. The best time to get pregnant is when disease is in remission. It is important that any medications that could negatively affect pregnancy be stopped, namely azathioprine and methotrexate. Such decisions regarding changes in medical therapy need to be made in the planning stages of pregnancy. Not only is a healthy diet essential, but pregnant women with IBD are encouraged to follow-up with a nutritionist and take nutritional supplements, such as folic acid, iron, and vitamin B12 to ensure adequate levels. Certain medications, and disease itself, can lower these levels.
Pregnancy and IBD
In general, about one-third of women with controlled disease at the start of pregnancy will maintain remission and one-third will experience a flare. Flares typically occur in the first trimester, however, once a flare is controlled, disease tends to remain in remission for the remainder of pregnancy.
Mothers with IBD are at increased risk for premature delivery, low birth weights in their babies, and bleeding before delivery. However, the risk for birth defects in children whose mothers have IBD is not affected, and it is comparable to those with mothers without IBD. Breastfeeding does not appear to affect disease activity. However, many women do not breastfeed due to physician recommendation, use of medications that can potentially transfer to the newborn through milk, or due to personal choice. Again, it is important to discuss and plan ahead with health care providers regarding newborn feeding.
Delivery and postpartum
Most women with IBD can deliver vaginally, with a few exceptions. Those with Crohn’s disease with perianal or rectal involvement should undergo cesarean delivery to avoid trauma to the area that could occur with vaginal delivery. Ultimately, the decision for mode of delivery is patient-dependent and left to health care professionals at the time of delivery. In the immediate postpartum period, few complications or flares occur. This is an important period when new mothers must be sure to take care of themselves and their IBD, as well as their newborn. New mothers are at risk for flares, which may require hospitalization, due to keeping their focus on their newborns and neglecting self-care.
Child rearing with IBD
During early motherhood and throughout the later years, the biggest challenge mothers face is balancing taking care of children and taking care of themselves. It is important to maintain consistent follow up with the multidisciplinary IBD team of health care providers, and also counselors and peer groups. Establishing a network of other women facing similar challenges helps significantly with coping with the stress of maintaining good health, rearing healthy children, avoiding hospitalization and not being present at home as a result, and the guilt of placing personal health at such a high priority. Mothers should be proactive and participate in open communication with their specialists and other available resources, especially peer groups, to help cope with the stresses of living with IBD.