Medications and pregnancy

  1. Women of Childbearing Age with IBD – Introduction
  2. Contraceptive Choices for Women with IBD
  3. Family Planning an IBD: Practical Considerations
  4. Fertility, Pregnancy and IBD
    1. Fertility and IBD (and vice versa)
    2. Pregnancy and IBD (and vice versa)
  5. Fertility, Pregnancy and IBD Therapies

 

1.0 Women of Childbearing Age with IBD – Introduction

Approximately 50% of IBD patients are younger than 35 years old when they are diagnosed with IBD, and 25% conceive for the first time after being diagnosed with IBD.1 When young women receive a diagnosis of IBD, they frequently have questions about the effects of the disease on childbearing – and vice versa.1-5 The following provides you with the bottom line based on what the experts have to say.

Most women with IBD can have a healthy pregnancy and a healthy baby.2,6 However, there are several factors that need to be considered. Ideally, women with IBD should be in remission for six months before becoming pregnant.1-5 For women in remission or with mild disease, pregnancy will almost be normal.  Talk with your doctors – OB/gyn and gastroenterologist about any concerns that you may have.  You and they need to have an open and honest discussion. 

Sources:

  1. Martin J, et al. Fertility and contraception in women with inflammatory bowel disease. Gastroenterology & Hepatology 2016:12:101-109.
  2. Crohn’s and Colitis Foundation Pregnancy Fact Sheet Jan 2015. Available at: http://

www.crohnscolitisfoundation.org/assets/pdfs/pregnancyfactsheet.pdf

  1. Hashash JG and Kane S. Pregnancy and inflammatory bowel disease. Gastroenterology & Hepatology 2015;11:96-102.
  2. Nguyen GC, et al. The Toronto consensus statement for the management of inflammatory bowel disease in pregnancy. Gastroenterology 2016;150:734-757.
  3. Vermeire S, et al. Management of inflammatory bowel disease in pregnancy. Journal of Crohn’s and Colitis 2012;6:811-823.
  4. Schulze H, et al. The management of Crohn’s disease and ulcerative colitis during pregnancy and lactation. Aliment Pharmacol Ther 2014;40:991-1008

2. Contraceptive Choices for Women with IBD

For women with IBD there is a lot to consider when thinking about choosing a contraception method. The most important thing is that women should be preventing pregnancy with an effective method of contraception until they have an OK from their gastroenterologist and their OB/Gyn.  As already noted, the ideal situation is for women with IBD to be in remission for six months before becoming pregnant.1-6  Aside from a woman’s own personal beliefs about contraception, she should also be informed about how these methods affect or relate to her IBD.  According to the experts, the bottom line is that women with IBD should be offered the same contraceptive choices as women without IBD.

All forms of contraceptives are acceptable in patients with IBD, although there are specific considerations.7  For example, women with CD who have small bowel involvement or malabsorption may find oral contraceptives to be less effective and may need to consider an alternate method of contraception in consultation with their doctors.7

            A major concern of many women with IBD is how do contraceptives affect the course of their IBD.  Specifically, women want to know if can contraceptives can cause  their IBD to flare?  The data to answer this question have been conflicting. However, as a whole the evidence suggests that oral contraceptive pills (OCPs) do not increase the risk of having a flare-up. 1,7

            Other issues for women with IBD who are considering contraceptive options include if the patient has any risk for venous thromboembolism (VTE) or the possibility of decreased bone density. Women with IBD at risk of VTE should avoid contraceptives containing an estrogen component and women with IBD at risk of decreased bone density should avoid Depot Medroxyprogesterone Acetate Injection (DMPA). Intrauterine Devices (IUDs) implants are safe and highly effective forms of contraception that can be recommended for first-line options in patients with IBD.1 Refer to the following table, which provides a quick reference to contraceptives for women with IBD.

Table: Quick Reference to Contraceptives for Women with IBD1,7

 

Contraceptive Method

 

Rate of Unintended Pregnancy

(based on 1 year of use)

 

 

Special Considerations & Discussion Points

 

No contraceptive method

 

 

85%

 

  • Patients with active OBD are likely to have worse pregnancy outcomes.

 

Barrier methods

(Condom or Diaphragm)

 

 

12-20%

 

  • No restrictions.
  • Failure rate may make them inappropriate alone in women taking cytotoxic medications.

 

 

Oral contraceptives

 

 

9%

 

  • Avoid in patients at risk of VTE or those with active IBD.
  • Avoid combined oral contraceptives if there is small bowel involvement or malabsorption.

 

 

DMPA injection

 

 

6%

 

  • Avoid in patients at risk of decreased bone density.

 

 

IUDs

 

 

<0.8%

 

  • No restrictions.

 

Implants

 

 

0.05%

 

  • No restrictions.

 

Sources:

  1. Martin J, et al. Fertility and contraception in women with inflammatory bowel disease. Gastroenterology & Hepatology 2016:12:101-109.
  2. Crohn’s and Colitis Foundation Pregnancy Fact Sheet Jan 2015. Available at:http://

www.crohnscolitisfoundation.org/assets/pdfs/pregnancyfactsheet.pdf

  1. Hashash JG and Kane S. Pregnancy and inflammatory bowel disease. Gastroenterology & Hepatology 2015;11:96-102.
  2. Nguyen GC, et al. The Toronto consensus statement for the management of inflammatory bowel disease in pregnancy. Gastroenterology 2016;150:734-757.
  3. Vermeire S, et al. Management of inflammatory bowel disease in pregnancy. Journal of Crohn’s and Colitis 2012;6:811-823.
  4. Schulze H, et al. The management of Crohn’s disease and ulcerative colitis during pregnancy and lactation. Aliment Pharmacol Ther 2014;40:991-1008
  5. Penney G, et al. Contraceptive Choices for women with inflammatory bowel disease.          J Fam Plann Reprod Health Care 2003;29:127-134.

 

3. Family Planning an IBD: Practical Considerations

Family planning is an important issue for any patient of reproductive age, but can be even more important in the setting of IBD. Young women with IBD frequently have significant concerns regarding family planning. Unfortunately, the available evidence suggests that patients with IBD typically have low levels of knowledge about their reproductive health. If you have a desire to start a family within the next six to twelve months, it is important to have discussions about your desire to become pregnant with both your gastroenterologist and OB/Gyn on a regular basis.1

It is widely agreed that best time for planning a pregnancy is while a patient’s IBD is in remission.2-7 In addition, it is important to recognize that women with IBD are over 50% less likely to have been prescribed any form of contraception.2 The importance of having both an understanding gastroenterologist and OB/Gyn to avoid an unplanned pregnancy cannot be stressed enough. 

Statistics show that by age 25 years, approximately half of all women in the USA have experienced at least 1 birth, and ~85% of all women in the USA have given birth by age 44. Approximately one-half of the 6.4 million pregnancies in 2001 (the most recent year for which adequate data are available) in the United States were unplanned.8 That is, one in two pregnancies – about 3 million were unplanned.  It is important to keep in mind as noted earlier in this section that women with IBD are at least 50% less likely to have been prescribed any form of contraception.2 Given these alarming figures regarding unplanned pregnancies, family planning for all women of reproductive age should be an ongoing discussion with your doctors.

What is the bottom line on having IBD and family planning?  You must be comfortable discussing whether or not you want to start a family.  It is up to you to initiate the conversation with your gastroenterologist and OB/GYN.  It will be easier for you if your two doctors are at the same center, or in the same referral network.  Do not be shy and do not forget to ask that your gastroenterologist and OB/Gyn communicate with each other.

 

Sources:

  1. Gaidos JK and Kane SV. Managing IBD Therapies in Pregnancy. Curr Treat Options Gastroenterol 2017;15:71-83.
  2. Martin J, et al. Fertility and contraception in women with inflammatory bowel disease. Gastroenterology & Hepatology 2016:12:101-109.
  3. Crohn’s and Colitis Foundation Pregnancy Fact Sheet Jan 2015. Available at:http://

www.crohnscolitisfoundation.org/assets/pdfs/pregnancyfactsheet.pdf

  1. Hashash JG and Kane S. Pregnancy and inflammatory bowel disease. Gastroenterology & Hepatology 2015;11:96-102.
  2. Nguyen GC, et al. The Toronto consensus statement for the management of inflammatory bowel disease in pregnancy. Gastroenterology 2016;150:734-757.
  3. Vermeire S, et al. Management of inflammatory bowel disease in pregnancy. Journal of Crohn’s and Colitis 2012;6:811-823.
  4. Schulze H, et al. The management of Crohn’s disease and ulcerative colitis during pregnancy and lactation. Aliment Pharmacol Ther 2014;40:991-1008
  5. The National Campaign to Prevent Teen and Unplanned Pregnancy. Unplanned pregnancy in the United States. May 2008. Available at: http://www.thenationalcampaign.org/resources/pdf/fast-facts-consequences-of-unplanned-pregnancy.pdf


4. Fertility, Pregnancy and IBD

 

When a young woman is told that they have IBD, they often have questions about the effects of the disease on their ability to have children and likewise how their pregnancy may affect their IBD.1

Fertility and IBD: How does fertility affect IBD and how does IBD affect fertility?

If IBD is active, conceiving a child may be more difficult and fertility may be affected.1,2 When IBD is in remission, women typically have normal fertility rates. Studies show that in women who have undergone ileanal J-pouch surgery that fertility rates are reduced by about one-third of normal.  This is most likely due to scaring and blockage of the fallopian tubes from inflammation and/or postoperative surgical scarring.2

Pregnancy and IBD: How does pregnancy affect IBD and how does IBD affect pregnancy?

When IBD is active at the time of conception and during pregnancy, the risk of complications, such as miscarriage, stillbirth, and developmental defects, is increased.2 However, for women in remission or with mild disease, pregnancy will almost be normal.2 As emphasized several times, the best situation for women with IBD is to be in remission for at least six months before becoming pregnant.1-6 

 

Sources:

  1. Crohn’s and Colitis Foundation Pregnancy Fact Sheet Jan 2015. Available at: http://

www.crohnscolitisfoundation.org/assets/pdfs/pregnancyfactsheet.pdf

  1. Martin J, et al. Fertility and contraception in women with inflammatory bowel disease. Gastroenterology & Hepatology 2016:12:101-109.
  2. Hashash JG and Kane S. Pregnancy and inflammatory bowel disease. Gastroenterology & Hepatology 2015;11:96-102.
  3. Nguyen GC, et al. The Toronto consensus statement for the management of inflammatory bowel disease in pregnancy. Gastroenterology 2016;150:734-757.
  4. Vermeire S, et al. Management of inflammatory bowel disease in pregnancy. Journal of Crohn’s and Colitis 2012;6:811-823.
  5. Schulze H, et al. The management of Crohn’s disease and ulcerative colitis during pregnancy and lactation. Aliment Pharmacol Ther 2014;40:991-1008

 

5. Fertility, Pregnancy and IBD Therapies

 

A significant patient concern that may lead to voluntary childlessness is the misbelief that medications may adversely affect conceptions and pregnancy.  However, let’s set the record straight.  Most of the drugs used to treat IBD are not associated with increased risk of birth defects, and therefore are considered to be combatable with pregnancy.  Guidelines recommend that medical treatment for CD, with an exception being methotrexate, should generally be continued during pregnancy, especially if there is a high disease activity.  The main concern should be to achieve remission prior to conception and to maintain it throughout pregnancy.1-4 The following table provides an overview of IBD drugs and the risk associated with their use on fertility and pregnancy.1,4

Table: Drug Treatment for IBD: Effects on Fertility and Pregnancy

 

 

Drug Class

 

 

Effect on Fertility

 

ECCO Pregnancy Rating

 

Recommendations/Observations

 

Corticosteroids

 

 

No effect in humans.

 

Safe

 

Use during 1st trimester associated with increased oral cleft in newborn.

 

 

Aminosalicylates

(5-ASAs)

 

 

No effect in animals.

 

Safe

 

No increased risk.

 

Antibiotics

 

 

No birth defects with metronidazole.  Musculoskeletal abnormalities in animal studies in animal studies but no birth defects in humans with quinolones.

 

 

Probably Safe

 

Avoid during the 1st trimester.

 

Azathioprine

 

 

No effect in humans.

 

Safe

 

Can be used to maintain remission during pregnancy.

 

 

Methotrexate

 

 

Contraindicated.

 

Contraindicated

 

Contraindicated

 

Anti-TNF

 

 

No effect in animals.

 

Probably Safe

 

Can be used in the first two trimesters of pregnancy.

 

 

Natalizumab

 

 

Negative effect in animals at high doses.

 

 

Unknown

 

Unknown

 

Vedolizumab

 

 

No effect in animals.

 

Unknown

 

Unknown

Sources:

  1. Martin J, et al. Fertility and contraception in women with inflammatory bowel disease. Gastroenterology & Hepatology 2016:12:101-109.
  2. Damas OM, et al. Treating Inflammatory Bowel Disease in Pregnancy: The Issues We Face Today. Journal of Crohn's and Colitis 2015;10:928–936.
  3. Gaidos JK and Kane SV. Managing IBD therapies in pregnancy. Curr Treat Options Gastroenterol 2017;15:71-8
  4. Vermeire S, et al. Management of inflammatory bowel disease in pregnancy. Journal of Crohn’s and Colitis 2012;6:811-823.