IBD can behave differently, and presents different management challenges, at different stages of life. In this chapter, we outline, in separate sections, features of IBD and its care relating to fertility, pregnancy and lactation, childhood and old age.
Fertility
Female fertility is not impaired except in active IBD. Because of the risk of inadequate absorption, women with diarrhea due to small-bowel Crohn’s should not rely exclusively on the oral contraceptive pill to prevent pregnancy. Fertility is reduced as a result of azoospermia in male patients taking sulfasalazine, but this can be reversed within a few weeks by switching to an alternative aminosalicylate (see Tables 5.2 and 5.3).
There is an increased risk of infertility in women with an ileo-anal pouch after a colectomy (see Chapter 9), probably due to Fallopian tube adhesions. Women should consider deferring pouch construction until they have completed their family.
Pregnancy and lactation
Outcome of pregnancy is normal in women with quiescent IBD at the time of conception, but there is an increased rate of spontaneous abortion, premature delivery and stillbirth in those with persistently active disease. As in other contexts, a multidisciplinary approach to the care of IBD patients who are pregnant is advised, with close liaison between gastroenterologist and the obstetric team.
Pregnancy itself has no consistent effect on the activity of IBD, although the disease occasionally flares early in the puerperium.
Treatment. Corticosteroids and aminosalicylates can be used safely during pregnancy and lactation; withholding them exposes the mother and fetus unnecessarily to the adverse consequences of active disease. Azathioprine and mercaptopurine (MP) appear to be safe in pregnancy and do not seem to adversely affect immune function in offspring; mothers taking thiopurines should not be discouraged from breastfeeding. Other immunomodulatory drugs and metronidazole are contraindicated in pregnancy.
Use of anti-TNFα drugs during pregnancy has not been associated with an adverse outcome; but where the clinical setting permits they should be withheld in the last trimester to avoid placental transfer to the newborn. Trace amounts of anti-TNFα agents may enter breast milk but a significant risk to the neonate is unlikely: mothers taking these drugs can therefore breastfeed.
Surgery is occasionally necessary in very sick women, for example those with non-responsive acute severe ulcerative colitis or sepsis complicating Crohn’s disease; it is associated with a high rate of fetal loss.
Vaginal delivery appears safe for women without perianal disease or with quiescent perianal disease. The optimal mode of delivery for those with active perianal disease is uncertain but many clinicians favor Cesarean section. Each instance should be discussed between the patient and her obstetrician and gastroenterologist.
Key points – IBD in pregnancy and lactation
• Fertility is not significantly impaired by well-controlled IBD.
• Women should be encouraged to achieve disease remission before attempting conception.
• Pregnancy does not increase the risk of disease exacerbation.
• The well-being of the mother is the single most important factor influencing the outcome of pregnancy; theoretical risks of commonly used drugs for the unborn are outweighed by the benefit of health maintenance in the mother.
• Thiopurines do not appear to increase the risk of complications during pregnancy or lactation, but methotrexate, other immunomodulatory drugs and metronidazole are contraindicated.
• Anti-TNFα biologics can cross the placenta in the third trimester but any risk to the fetus appears to be low. Many clinicians recommend discontinuation of anti-TNFα therapy at the start of the third trimester.
• Vaginal delivery is safe for women without perianal disease or with quiescent perianal disease. For those with active perianal disease, Cesarean section is often advised.
Key references – IBD in pregnancy and lactation
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Ilnyckyj A. Surgical treatment of inflammatory bowel disease and pregnancy. Best Practice & Res Clin Gastroenterol 2007;21:819–34.
Mahadevan U, Matro R. Care of the pregnant patient with inflammatory bowel disease. Obstet Gynecol 2015;126:401–12.
Manosa M, Navarro-Llavat M, Marin L et al. Fecundity, pregnancy outcomes, and breastfeeding in patients with inflammatory bowel disease: a large cohort survey. Scand J Gastroenterol 2013;48:427–32.
Marchioni RM, Lichtenstein GR. Tumor necrosis factor-α inhibitor therapy and fetal risk: a systematic literature review. World J Gastroenterol 2013;19:2591–602.
Nielsen OH, Maxwell C, Hendel J. IBD medications during pregnancy and lactation. Nat Rev Gastroenterol Hepatol 2014;11:116–27.
Pedersen N, Bortoli A, Duricova D et al. The course of inflammatory bowel disease during pregnancy and postpartum: a prospective European ECCO-EpiCom study of 209 pregnant women. Aliment Pharmacol Ther 2013;38:501–12.
Van der Woude CJ, Metselaar HJ, Danese S. Management of gastrointestinal and liver diseases during pregnancy. Gut 2014;63:1014–23.
van der Woude CJ, Ardizzone S, Bengtson MB et al.; European Crohn’s and Colitis Organisation. The second European evidence-based consensus on reproduction and pregnancy in inflammatory bowel disease. J Crohns Colitis 2015;9:107–24.
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