Inflammatory Bowel Diseases and Pregnancy

Julita, BSN, RN

What is Inflammatory Bowel Disease?

Inflammatory bowel disease (IBD) is a chronic condition that results in swelling of the lining of the gastrointestinal (GI) tract. This condition should not be confused with irritable bowel syndrome (IBS) which is a collection of symptoms and does not cause any inflammation to the lining of the bowel. This definitely shows us that these two chronic conditions are different because one causes inflammation and the other doesn't. IBD is characterized by two common diseases namely Crohn's Disease (CD) and Ulcerative Colitis (UC). These two are considered chronic conditions because they are marked by periods of relapse and require long-term solutions to treat them. There are some clear differences between UC and CD but those will not be covered in this report.

Causes of IBD

There are many theories of how IBD develops including speculations about:

Autoimmune changes
Cigarette smoking
Environmental factors
Psychological stressors
Genetics

But today the actual causes of IBD are still unknown. The nature of these diseases is described as idiopathic which means that their origin is very spontaneous, with no clear indicators as to why some people develop these diseases. Some scholars believe that smokers are at a decreased risk of developing UC but are more at higher risk of developing CD.

How is IBD Diagnosed?

There are several ways to diagnose CD and UC in patients. Clinical investigations include:

Laboratory tests
Radiological tests
Diagnostic endoscopic procedures (colonoscopy, flexible sigmoidoscopy, gastroscopy)
Magnetic Resonance Imaging (MRI)
Computed Tomography (CT)

Surveillance methods are used to identify those patients at higher risk of developing complications from IBD. But they are not without their limitations and most patients try to avoid these screening procedures as much as they can.

Common Symptoms of UC and CD

Sometimes symptoms for patients with CD may develop very gradually but with harmful effects. Most patients with IBD present with various symptoms namely:

Frequent diarrhea
Severe abdominal pain
Rectal bleeding / bloody stools
Constipation
Cramping
Urgency to empty your bowels
Feeling like incomplete emptying of your bowels
Extreme fatigue
Excessive weight loss
Bloating

Severe IBD symptoms that are not adequately managed can even cause anemia and further damage to the GI tract. It is interesting to note that IBD symptoms are not just limited to the intestines. When symptoms are experienced elsewhere outside the GI tract they are often referred to as extraintestinal complications of IBD. Other body parts that can be affected are:

Joints
Skin
Eyes
Bones
Liver
Kidneys
Reproductive system

Further monitoring of these organs is required with scheduled regular health check-ups.

How Women are Affected by IBD?

IBD affects people between the ages of 15 and 35 but it is not rare for the disease to occur at any age even those between the ages 50 – 70¹. The prevalence of IBD is very diverse and affects all people in many regions globally. More numbers of people with IBD are now found in Black & Latin Americans within North America. It is widely accepted that IBD affects women differently than men. This could be attributed to some biological triggers that women with IBD experience. Common triggers can be pregnancy, menstruation, endometriosis and any hormonal imbalances. These causal factors can make IBD symptoms worse although many of the IBD symptoms are not necessarily caused by these triggers alone.

How Best to Treat IBD Symptoms in Pregnant Women?

Several treatment therapies can be implemented but it is important to note that there is currently no cure for IBD. Treatment therapies are mainly used to induce and maintain remission. During periods of remission, there are hardly any serious symptoms or flare-ups and this period can last for months or years depending on individual circumstances. To achieve this state of remission, physicians have to choose treatment methods that produce long-term results.

Some of the medications used in IBD have low risks and can be used during pregnancy but a lot are not yet well researched and should be given with caution. Some medications are well tolerated by pregnant women if they fall pregnant during remission. Most women are encouraged to have their symptoms in remission before deciding to get pregnant thereby giving them an added advantage of a healthy pregnancy.

Many researchers believe that a considerable number of women with IBD get worse during pregnancy. Statistics reports reveal 45% of patients who get pregnant during active UC get worse while 23% of them with active symptoms will continue to be active or remain stable and the rest will experience remission². During pregnancy women with IBD are usually monitored by a gastroenterologist and an obstetrician. This fosters a collective decision-making approach to achieve better outcomes for the mother and baby.

Most women of childbearing age with IBD have been concerned about the use of any medications during pregnancy. Pre-conception counseling with a responsible healthcare provider will address a lot of misconceptions about the available treatments. Below is a summary of four (4) treatment options relatively used:

1- Amino-salicylates

A step-up approach to treating IBD is used starting with oral medications in the early stages of the disease. Aminosalicylates are medications that contain 5-aminosalicylic acids also known as (5-ASA compounds). Examples are, asacol, sulfasalazine, mesalazine, etc. These groups of drugs work well within the large bowel but are less effective if there is a flare-up in the small intestine. That is why they are best given orally as slow-release pills or rectally as suppositories or enemas. Fortunately, these drugs are considered safe to use during pregnancy.

2- Corticosteroids

Steroid therapy with drugs like prednisone, methyl-prednisone or dexamethasone can be tolerated during pregnancy. Caution must be exercised with large dosages as these drugs are not recommended for maintenance in pregnant women. Unwanted side effects from steroid therapy in pregnancy include –pre-term gestational diabetes and hypertension. Pregnant women on such treatments must be regularly monitored to be able to detect the unpleasant side effects.

3- Immunomodulators

These drugs change the body's immune system to limit the flare-up periods in IBD patients. Examples are azathioprine and mercaptopurine. There are varied opinions and clinical findings regarding the use of immunomodulators among pregnant women with IBD. Some reports discourage the use of immunomodulators for IBD in pregnancy linking these drugs to birth defects, unwanted problems in the bone marrow and inflammation in the liver and pancreas³.

In contrast, other studies have discovered no substantial differences in pregnancy complications in patients with IBD. Currently, most clinicians agree that thiopurines are safe to use during pregnancy as long as they safely monitor the metabolite that can be passed on to the fetus⁴. Unfortunately, there is insufficient information about the safety of these drugs in pregnant women with active IBD.

4- Biologics

Biologics are drugs made from living organisms using biotechnology. They are very powerful drugs whose primary treatment was not necessarily for IBD but have proved beneficial in the treatment of IBD symptoms. Examples are infliximab, adalimumab and certolizumab and these do not have any traces in the breast milk however they must be avoided late in pregnancy. If biologics are used late in pregnancy they may cause low birth weight, stillbirths, and congenital malformations⁵.

However, a meta-analysis review discovered no significant differences between pregnant and non-pregnant women with IBD who were treated with biologics⁶. These authors allude to the safety of biologics during all trimesters but nevertheless, they also propose that supplementary studies are needed.

Although a lot of medications are not well researched in this population group the goal here is not to exclude the women from therapies that could be beneficial to them. The majority of treatments implemented today help to alleviate symptoms of IBD and most patients may experience remission for months or years. Medications used in IBD require careful monitoring of the patient, in regards to reducing/increasing the dosage. The main goal is to maintain a balance between the risks and benefits of the treatment both to the mother and the baby.

Conclusion

IBD patients need to be reassured and supported during their treatment by using a multi-disciplinary approach. Healthcare professionals can support their patients by encouraging them to discuss any symptom changes openly. Supportive care may include helping patients to choose their diet carefully, how to minimize stress levels and how to comply with treatments. The lack of clear and concise information makes the management of pregnant women with IBD somewhat challenging to healthcare professionals. Clear communication methods are paramount in achieving measurable goals. The fight to get the cure for pregnant women with IBD is ongoing and it certainly is one that is worth fighting for. There are very few studies that address this issue extensively and definitely further studies are needed to inform practice. Every pregnant woman with IBD deserves a chance to live a healthy and symptom-free life.

Let us continue supporting pregnant IBD patients by delivering care that will make their healthcare experience positive.

References and Resources

¹Overview of Inflammatory Bowel Disease

²Pregnancy and Inflammatory Bowel Disease

^3,5Crohns & Colitis Foundation: Understanding IBD Medications and Side Effects

⁴Inflammatory bowel disease and pregnancy: fertility, complications and treatment

⁶Biologics for Inflammatory Bowel Disease and Their Safety in Pregnancy: A Systematic Review and Meta-Analysis

What is inflammatory bowel disease (IBD)?

Crohn's Disease in Females

Inflammatory bowel disease

Update on the Management of Inflammatory Bowel Disease in Pregnancy and Breastfeeding

Fast Facts: What You Need To Know About Inflammatory Bowel Disease