INFORMATION FOR WOMEN WHO HAVE CROHN’S DISEASE DURING PREGNANCY OR BREASTFEEDING
What is Crohn’s disease?
Crohn’s disease is an inflammatory bowel disease that is chronic (persistent for many years) and relapsing. It can affect any part of the gastrointestinal tract, from mouth to anus, but usually, it affects the terminal ileum (the last part of the small intestine) and colon, and typically leaves the rectum intact. Symptoms, which may come and go, include diarrhea (sometimes with blood), nausea, and vomiting. Often the diarrhea comes at night and there is often melena (black stool, resulting from blood mixing into the feces).
Crohn’s disease often affects women and often begins at a young age, with onset typically between ages 15-30, so it can coexist with pregnancy, in which case the pregnancy is considered complicated.
How common is Crohn’s disease during pregnancy?
Overall, inflammatory bowel disease (of which Crohn’s disease is one of the main forms) occurs in about 31 per 10,000 pregnant women, according to a recent study in Australia. The prevalence of such disease probably varies throughout the world, but this study result implies that Crohn’s disease is fairly common during pregnancy. There are particular risk factors that make Crohn’s disease likely. Having a first degree relative (parent, sibling, or child) with an inflammatory bowel disease, for instance, increases the risk of developing Crohn’s disease, compared with the general population. The disease is most common in Ashkenazi Jews. Smoking also increases the risk of developing Crohn’s disease, as does long-term use of non-steroidal anti-inflammatory drugs.
How is Crohn’s disease diagnosed?
Diagnosis begins with a suspicion for Crohn’s based on the patients history. Usually, there is a gradual onset of the following symptoms, which get worse as time goes on:
- Anorexia (you are severely underweight)
- Diarrhea, which may be bloody and may happen at night
- Melena (dark stools due to the presence of blood)
- Abdominal pain, typically in the central or right part of the lower abdomen. In Crohn’s disease, the pain can be dull or crampy and its severity varies.
You may also have a history of bone fractures, which could give the doctor another clue. You may also experience modest fevers and on physical examination, the doctor may find that your liver and spleen are enlarged. Having family members with IBD can raise the level of suspicion. If you are an Ashkenazi Jew, Crohn’s disease also becomes more likely.
Once Crohn’s disease is thought to be a possibility, various tests will be conducted on blood samples for signs of anemia, vitamin deficiencies, parasitic infections, iron deficiency, and evidence that the immune system is attacking the body. Doctors will also order a complete metabolic panel that reveals various aspects of your blood chemistry and your kidney function. Samples of stool will be taken to look for bacterial and parasitic infections, blood, and signs of inflammation. Various genetic tests will be performed to determine whether you carry any genetic sequences that are particularly associated with Crohn’s disease. Finally, imaging studies will be conducted. These will include either something called computed tomography (CT) enterography or a similar test called magnetic resonance (MR) enterography. You may also be given either an MRI of your abdomen or a CT scan of your abdomen. If you are already pregnant, the MRI will almost always be chosen over an abdominal CT.
Most importantly, the inside of your colon and part of your small intestine will be examined with colonoscopy, in which a tube-like instrument is inserted through the anus. This will provide your doctors with video footage of the inner lining of the parts of the gastrointestinal tract that are scanned, plus they will be able to take biopsies of selected areas. If you are suspected of having Crohn’s disease that involves higher parts of the gastrointestinal tract, such as the stomach and esophagus or the part of the small intestine thats near the stomach, you also will be tested with an instrument that enters through the mouth in order to view areas that colonoscopy cannot reach. Another test may be done, called capsule endoscopy, in which you swallow a wireless camera that is enclosed in a pill-sized capsule, which progresses through the gastrointestinal tract collecting and sending data to a recording belt on your waist. Eventually, you excrete the capsule.
Does Crohn’s disease cause problems during pregnancy?
Crohn’s disease will put you at risk for nutritional deficiencies and gastrointestinal tract bleeding that can get worse during pregnancy. It also will make it more likely that you will have to give birth by cesarean section. If your disease becomes very severe during pregnancy such that you require surgery on your colon, it is possible that the surgery can trigger premature labor. Various complications can develop, such as an abscess (a collection of pus), perforations in the gastrointestinal tract, connections between parts of the intestines and between parts the intestines and other organs, and nutritional deficiencies due to problems absorbing nutrients from food. Your colon also can produce toxins in severe cases.
Does Crohn’s during pregnancy cause problems for the baby?
Loss of nutrients and blood through the gastrointestinal tract can lead to reduced growth in the developing baby. If folic acid intake is inadequate, this can also put your child at risk for neural tube defects, in which parts of the brain or spinal cord are left without a bony covering. IBD puts your developing baby at risk for various poor outcomes, such as low birth weight, congenital abnormalities, and even stillbirth.
What to consider about taking medications when you are pregnant:
- The risks to yourself and your baby if you do not treat the Crohn’s disease
- The risks and benefits of each medication you use when you are pregnant
- The risks and benefits of each medication you use when you are breastfeeding
What should I know about using medication to treat Crohn’s disease during pregnancy?
Several medications are given to control Crohn’s disease. Most of the drugs are thought to be safe during pregnancy, but some have raised concern. In particular, anti-tumor drugs, which are given in Crohn’s disease to oppose the inflammatory process, are potentially dangerous during pregnancy. One common example is the drug methotrexate.
5-aminosalicylic acid (5-ASA, mesalamine) is a common treatment and appears to be fairly safe in pregnancy with the exception of one brand, called Asacol HD, although the preparation is being adjusted to make it safer.
Various antibiotics can be given to control gastrointestinal infections without harm to the developing baby. Metronidazole and amoxicillin-clavulanic acid both are considered to be low risk. Another class of drugs is steroids, the safety of which is a subject of debate, but since they are very effective they are always on
the list of medications that can be given during pregnancy if needed. If given for long periods, however, steroids may provoke gestational diabetes and also raise your blood pressure, but these are things that can be monitored.
There is some concern about various drugs known as biological agents (most of which are antibodies that end with the suffix mab), but studies have been very limited. Two other commonly used drugs are called azathioprine and 6-mercaptopurine. Evidence has shown azathioprine may cause fetal harm, and its use should be avoided in pregnant or breastfeeding women (the potential benefit should be weighed against potential risks under certain conditions). Small studies did not show adverse events in infants exposed to azathioprine in the breastmilk, but benefits must be weighed against risks and additional steps may be taken such as increasing breastfeeding intervals after taking a dose and monitoring infant blood count. Patients that are pregnant or breastfeeding should stop taking 6-mercaptopurine or discontinue breastfeeding while on therapy due to potential fetal loss and risk of adverse events. The excretion of 6-mercaptopurine into breastmilk is unknown.
Who should NOT stop taking medication for Crohn’s disease during pregnancy?
If you have active Crohn’s disease (meaning not in remission) at the onset of pregnancy, you need to continue your treatment. However, it is possible to switch from one drug treatment to another. Work with your doctors to select the optimal treatment strategy that keeps the disease in check while minimizing risk.
What should I know about choosing a medication for my Crohn’s during pregnancy?
You may find Pregistrys expert reports about the individual medications to treat Crohn’s disease here. Additional information can also be found in the sources listed at the end of this report.
What should I know about taking a medication for my Crohn’s disease when I am breastfeeding?
5-ASA appears to be fairly safe in breastfeeding with the exception of one brand, called Asacol HD, although the preparation is being adjusted to make it safe. Corticosteroids, such as prednisone, are considered safe in those who breastfeed. Only a small amount of corticosteroids are excreted into breastmilk though levels may be increased if higher doses of medication are taken. Being prescribed smaller doses or increasing the breastfeeding interval after taking a dose can help minimize excretion into the breast milk and infant exposure to the medication.
What alternative therapies besides medications can I use to treat my Crohn’s disease during pregnancy?
There are no viable alternatives to medications for severe Crohn’s disease. However, smoking cessation programs can possibly reduce the amount and severity of flareups if you are a smoker. Regular exercise also may be helpful. Various surgical treatments may become necessary in cases when particular parts of the gastrointestinal tract are affected severely.
What can I do for myself and my baby when I have Crohn’s disease during pregnancy?
Help to keep your Crohn’s disease in check by working with your doctors to optimize treatment and minimize risks to you and the baby.
Resources for Crohn’s disease in pregnancy:
For more information about Crohn’s disease during and after pregnancy, contact http://www.womenshealth.gov/ (800-994-9662 [TDD: 888-220-5446]) or read the following articles: