Young women who have inflammatory bowel disease are very concerned about their marriage and fertility. Female patients of childbearing age themselves, their husbands, and their families may also have insufficient understanding or even misunderstanding of the impact of the disease on pregnancy and childbirth, may have inappropriate dietary and nutritional concepts, and may have unreasonable concerns or fears about pregnancy and childbirth. Indeed, inflammatory bowel disease, especially Crohn’s disease, is likely to affect patients and their fetal development. On the other hand, inflammatory bowel disease is variable, recurrent and complicated, and requires a more specialized physician to accurately guide and manage the various problems that arise in pregnancy and childbirth in female patients. We have compiled the relevant questions here and provided them in a Q&A format for your reference. Of course, many of the questions are controversial and the answers provided may not be entirely accurate, so you will need to consult your doctor about your specific condition for a targeted discussion.
1. Does inflammatory bowel disease affect fertility?
It depends on the type of disease, condition and subjective will of the patient. Survey data show that the fertility rate of women of childbearing age with inflammatory bowel disease is not significantly different from that of the general female population overall. In ulcerative colitis, 85-90% of female patients of childbearing age can have normal pregnancies. In contrast, the fertility rate of young women with Crohn’s disease is somewhat reduced. There are various reasons for this here; the disease itself may lead to malnutrition, infection, complications of surgery, and reduced endocrine function in women. Large abdomen. Surgery such as partial or complete large bowel (colon) resection, small bowel-rectal anastomosis or ileostomy may have some effect on pregnancy and fertility. In fact, this effect is usually short-lived. Full recovery can occur within weeks or months. Second, many women with inflammatory bowel disease often avoid pregnancy for subjective reasons. They fear pregnancy and are often misled into believing that pregnancy will recur, worsen the disease, or affect the fetus, among other things. Moreover, these patients may prefer to use contraception for medical or psychological reasons. Therefore, there is a decrease in the fertility rate of female patients shown in the survey data, which may be mainly related to active contraception in some patients.
2. Does inflammatory bowel disease have a negative impact on the pregnancy process and fetal health?
Yes, but it is relatively small. In general, more than 85% of pregnant women with Crohn’s disease or ulcerative colitis behave normally, and the incidence of having a baby with congenital malformations is only 1%. This incidence is not dissimilar to that of healthy pregnant women. Inflammatory bowel disease can have an adverse effect on pregnancy compared to healthy women mainly related to whether the lesion is active or not. It has been investigated that active disease will increase the chance of obstructed labor. The effects of quiescent disease or mild inflammatory activity on pregnancy and fetus are minimal. Therefore, the risk of such neonatal malformations is not increased after pregnancy with inflammatory bowel disease. Of course, even in healthy women, pregnancies are not all normal. Therefore, if possible, couples can plan their pregnancies during the quiescent phase of the disease or during the mildly active phase of inflammation. If a pregnancy occurs during the active phase of the disease, be especially alert to the possibility of miscarriage, preterm labor and obstructed labor. In this case, the disease should be controlled as soon as possible. Any disease in the active phase should be treated aggressively. The disease is well controlled to ensure the safety of mother and baby.
Active inflammatory bowel disease during pregnancy has some adverse effects on the fetus. A survey of 756 deliveries of pregnant women with active inflammatory bowel disease showed that they were significantly more likely to deliver newborns with low birth weight and severe growth retardation than those delivered by healthy pregnant women; moreover, these adverse effects persisted even in pregnant women who were treated and whose disease activity index improved significantly. Some studies suggest that the risk of fetal growth retardation remains after the transition from active to quiescent inflammatory bowel disease during pregnancy. This is mainly seen in those pregnant women with ileal pathology and/or bowel resection surgery. It is clear that this is closely related to the impaired nutrientogenic absorption that occurs after ileal lesions and bowel resection. However, there is no evidence that pregnant women with inflammatory bowel disease have higher rates of miscarriage, stillbirth, or neonatal death than the normal population.
3. How is the safety of the planned pregnancy determined?
Married women with inflammatory bowel disease should be medically screened to assess the safety of pregnancy before planning a pregnancy. This needs to be discussed individually with the patient and her doctor. There is no fixed practice here. While nutritional status and the level of activity of the disease are certainly determining factors, an appointment with a senior physician for an abdominal examination and ultrasound may be necessary for an accurate evaluation, with detailed documentation of the findings. Sometimes the physician may also offer to perform a colonoscopy or radiological examination, as the information from these tests is important as a basis for an accurate evaluation, but not everyone needs them. However, the results of these tests are an important reference for subsequent pregnancies as well as for delivery. Some results may suggest that you need to increase your intake of certain vitamins and minerals such as vitamin B12, folic acid and iron. The absorption of folic acid in the small intestine may be reduced by the administration of salazosulfapyridine. Therefore, it is recommended that pregnant women take folic acid early in pregnancy. This is because folic acid can help prevent neurological defects during the growth and development of the fetus.
4. Can people who have had surgical procedures for inflammatory bowel disease get pregnant?
Generally speaking, abdominal surgery for inflammatory bowel disease has no effect on pregnancy. Even if you have had a major colectomy and a colostomy, you can still have a safe pregnancy. However. There should be sufficient interval between pregnancy and surgery for recovery, and it is important to ensure that the disease is well controlled and inactive after surgery. After major surgical procedures, pregnancy is usually considered after an interval of one year. People with colostomy should pay extra attention to the fact that the general nutritional status has recovered before pregnancy, otherwise, the incidence of preterm delivery after colectomy + colostomy increases.
Certain necessary surgical procedures may be performed during pregnancy due to certain special circumstances. This is without fear that the surgery will lead to preterm delivery and congenital malformations. Even slightly larger surgical procedures can still result in a safe pregnancy as long as they are managed properly.
5. Can pregnancy have a harmful effect on inflammatory bowel disease?
In most cases, pregnancy has no effect on the activity of inflammatory bowel disease and the maintenance of recovery. However, some cases of inflammatory bowel disease can be seen clinically to show large changes during pregnancy, ranging from significant improvement to significant worsening or even exacerbation of flare-ups. About 15% of women who become pregnant while in remission from Crohn’s disease experience an acute exacerbation of the disease. However, this rate is the same as the incidence in other non-pregnant female patients. It has been noted that if disease activity occurs in the first trimester, then 1/3 will have disease activity throughout pregnancy; in addition, they have an increased likelihood of disease activity or exacerbation of flare-ups during the puerperium. In pregnant women with ulcerative colitis, pregnancy has little to no effect on disease activity. Investigations have shown an increased frequency of acute exacerbations of inflammatory bowel disease during the sixth month of pregnancy and the puerperium. Most women who become pregnant during active Crohn’s disease have disease activity throughout pregnancy.
It is important to note that taking medication for inflammatory bowel disease during pregnancy can accelerate remission and improvement. Medication can also maintain the disease in a stable phase and reduce activity. Medication greatly ensures the safety of pregnancy, but some patients may still have activity. Patients who did not have inflammatory bowel disease in the past can present with the first episode of Crohn’s disease and ulcerative colitis in pregnancy. However, the condition is not made more severe by the combination of pregnancy. For accurate diagnosis and treatment, it is important to dispel the misconception that endoscopy does not pose a threat to pregnancy.
6. What is the treatment for inflammatory bowel disease during pregnancy?
It is well known that drug abuse should be avoided during pregnancy, even before planning a pregnancy. As a result, there are various questions about the pharmacological treatment of inflammatory bowel disease combined with pregnancy. In fact, doctors are even more concerned about the safety of medication for inflammatory bowel disease during pregnancy. The question of taking medication for treatment during pregnancy should be decided in consultation with your doctor and by his or her advice. Doctors prescribe medications is should also vary from person to person. Sometimes a specialist consultation is needed to decide to ensure the highest safety of the disease and the fetus.
The general rule for taking medication during pregnancy for inflammatory bowel disease is to choose only those medications that are absolutely necessary. Medication is in principle basically the same as in non-pregnant patients. On the other hand, it is important to pay due attention to the individual characteristics of the patient. Answering the question of the effect of medications taken for inflammatory bowel disease on the infant is more difficult, and there are no positive findings for some drugs. Therefore, the decision for the treatment of each patient with inflammatory bowel disease should be made by the obstetrician in consultation with an internal medicine specialist or a gastroenterologist. No damage to the unborn fetus has been found with conventional doses of corticosteroids (e.g. prednisolone, hydrocortisone) and salazosulfapyridine (SASP) or 5-aminosalicylic acid (5-ASA). Nevertheless, these drugs need to be administered with strict caution during the first trimester of pregnancy. Patients in remission who require 5-ASA or corticosteroid maintenance therapy should continue to take the medication according to their condition and medical advice or reduce the dosage. It is important to remember that the activity of the condition poses a greater risk to the fetus. If the inflammatory bowel disease is acute during pregnancy, adjust the medication to control the disease as soon as possible. Otherwise, the risk of inflammatory bowel disease to mother and child will go far beyond the medication itself.
Conventional treatment of inflammatory bowel disease is mainly 5-ASA or hormones. To date, this conventional treatment has been shown to have no adverse effects on the mother and child in early pregnancy. Unlike aspirin, the therapeutic dose of 5-ASA does not affect coagulation and does not inhibit platelet production. Therefore, there is no need to interrupt 5-ASA treatment before pregnancy. Moreover, the concentration of 5-ASA absorbed into the bloodstream is extremely low and the possibility of affecting the fetus is minimal. Other drugs such as antibiotics or immunomodulatory drugs such as azathioprine or 6-mercaptopurine require strict indications for their use and should be decided after consultation with an experienced specialist. Cyclosporine A, aminoglutethimide and tacrolimus are generally contraindicated. Infliximab is effective in the control of active inflammatory bowel disease, but is not currently recommended for use during pregnancy. If you are already using infliximab, delay contraception until at least three months after stopping the drug before pregnancy. Many mothers using infliximab deliver healthy infants, so there is no basis on which pregnant women using infliximab must terminate their pregnancies. The use of antibiotics such as metronidazole or ciprofloxacin during pregnancy for inflammatory bowel disease, for example, must be strictly indicated. These drugs are generally advocated as contraindicated. Antidiarrheal medications (e.g., Imodium or Atropine) must be used with caution in pregnant women. This is because there are reports of teratogenic risk to the fetus from the above drugs.
7. Is it safe to use corticosteroids in late pregnancy and during breastfeeding?
It is now generally accepted that there is no relationship between the dose of corticosteroids used to treat inflammatory bowel disease and the risk of miscarriage or fetal malformation. The use of high doses of corticosteroids in late pregnancy may reduce the production of adrenal corticosteroids in the newborn, resulting in lower blood cortisone levels in the newborn after birth. Therefore, any patient taking high doses of corticosteroids in late pregnancy should deliver a newborn who is closely monitored by an experienced specialist. If necessary, cortisone may be supplemented with alternative therapies based on the measured results. Moreover, continuous follow-up by a pediatrician is sometimes required. In practice, the chance of persistent hyperalgesia in newborns is very small. Most newborns normalize adrenal function soon after interruption of cortisone therapy.
8. Which diagnostic methods can be safely used during pregnancy?
Abdominal ultrasonography and rectal ultrasonography are not harmful to the mother or the baby. These examinations can provide important information about the activity of the disease and the course of the disease. Gastroscopy and colonoscopy are perfectly safe for women during pregnancy as long as they are well prepared and an experienced and skilled physician is the examiner. MRI is not harmful and can be performed with confidence. For radiological examinations, careful consideration should be given. They should be selected only if the condition is critical and the test must be performed. In general, the safety of radiological examination in the second trimester is relatively large.
9. Is there any special consideration for delivery of pregnant women with inflammatory bowel disease?
For pregnant women with inflammatory bowel disease, vaginal delivery is preferred. In patients who have already had a colostomy, the contractions of the uterus during delivery can cause the fistula to sag and the abdominal pressure to rise, so vaginal delivery is preferable. This is also not affected by any adhesions that may remain from previous surgery. However, many obstetricians prefer to perform a cesarean section. Cesarean delivery is beneficial for those pregnant women who have fistula formation in the rectopelvic region. Therefore, the exact choice of delivery method for patients with colostomy should be discussed with the obstetrician in advance and determined on a case-by-case basis.
10. Is a special diet during pregnancy beneficial for women with inflammatory bowel disease?
In general, patients with inflammatory bowel disease do not require a special diet. However, patients should follow the recommended balanced diet to ensure that the daily nutritional components required by the patient and the fetus are met.
11. Can women with inflammatory bowel disease breastfeed?
Corticosteroids (e.g. prednisone) or 5-ASA are no longer a problem for breastfeeding mothers. Although a small amount of the hormone may reach the infant through the breast milk, there is no permanent damage to the infant. Of course, the dose of corticosteroids should be reduced as soon as possible. If higher doses are needed, a pediatrician should be consulted. Breastfeeding is contraindicated if immunomodulatory drugs such as azathioprine, 6-mercaptopurine, methotrexate, cyclosporine A, tacrolimus, etc. are required during pregnancy or after delivery. This is because the above drugs may have long-term harmful effects on the infant, although the exact effects and extent of some are not known.