How Should Crohn's Disease Be Managed in Pregnancy
How Should Crohn's Disease Be Managed in Pregnancy
When a woman has Crohn's disease, what special considerations are needed during pregnancy?
There are several factors to keep in mind when managing Crohn's disease in a pregnant woman. Ideally there has been a conversation prior to conception regarding issues surrounding pregnancy. The state of a woman's disease at the time of conception is the strongest determinant of the pregnancy course and outcome. If a woman is in remission at the time of conception, she has no greater risk for a disease flare than a woman who is not pregnant. A woman with active disease at the time of conception has a one-third chance of going into remission, a one-third chance of staying at the same disease activity level, and a one-third chance of getting worse during pregnancy.
During pregnancy, disease activity must be minimized. Most medications used to treat Crohn's disease are considered low risk during pregnancy. Active disease poses more risk to the fetus than most Crohn's medications, so the benefits of treatment clearly outweigh the risks. Whatever medications helped maintain remission before pregnancy should be continued during pregnancy, except methotrexate or antibiotics.
If a woman with Crohn's disease experiences a disease flare during pregnancy, she should be treated aggressively to get the disease under control. This may require hospitalization earlier than in a non-pregnant patient, predominantly for nutritional support and closer fetal monitoring. Supplementation with extra iron, folate, and protein during pregnancy is encouraged because maternal loss of these nutrients can occur quickly.
For a patient on a biologic agent, therapy should continue through the first and second trimesters and stopped in the third, because in the third trimester, IgG is actively transported across the placenta and fetal exposure is at its highest. Infants born to mothers on immunosuppressant therapies should not receive live virus vaccines in the first 8-12 months of life (rotavirus vaccine) until more is known about the immunologic environment of these children.
Disease assessment during pregnancy includes endoscopy when indicated. Flexible sigmoidoscopy with a tap water enema prep and no sedation is adequate for obtaining biopsy specimens to rule out cytomegalovirus infection. Imaging studies can be performed if clinically necessary; magnetic resonance imaging without contrast provides abdominal images without radiation and can help rule out abscess or obstruction.
Vaginal delivery is recommended except in instances of active perianal disease or a history of fistulas. Breast-feeding should not be discouraged as most medications are considered safe for nursing.
Question
When a woman has Crohn's disease, what special considerations are needed during pregnancy?
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Response from Sunanda V. Kane, MD, MSPH, FACG Miles and Shirley Fitterman Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota |
There are several factors to keep in mind when managing Crohn's disease in a pregnant woman. Ideally there has been a conversation prior to conception regarding issues surrounding pregnancy. The state of a woman's disease at the time of conception is the strongest determinant of the pregnancy course and outcome. If a woman is in remission at the time of conception, she has no greater risk for a disease flare than a woman who is not pregnant. A woman with active disease at the time of conception has a one-third chance of going into remission, a one-third chance of staying at the same disease activity level, and a one-third chance of getting worse during pregnancy.
During pregnancy, disease activity must be minimized. Most medications used to treat Crohn's disease are considered low risk during pregnancy. Active disease poses more risk to the fetus than most Crohn's medications, so the benefits of treatment clearly outweigh the risks. Whatever medications helped maintain remission before pregnancy should be continued during pregnancy, except methotrexate or antibiotics.
If a woman with Crohn's disease experiences a disease flare during pregnancy, she should be treated aggressively to get the disease under control. This may require hospitalization earlier than in a non-pregnant patient, predominantly for nutritional support and closer fetal monitoring. Supplementation with extra iron, folate, and protein during pregnancy is encouraged because maternal loss of these nutrients can occur quickly.
For a patient on a biologic agent, therapy should continue through the first and second trimesters and stopped in the third, because in the third trimester, IgG is actively transported across the placenta and fetal exposure is at its highest. Infants born to mothers on immunosuppressant therapies should not receive live virus vaccines in the first 8-12 months of life (rotavirus vaccine) until more is known about the immunologic environment of these children.
Disease assessment during pregnancy includes endoscopy when indicated. Flexible sigmoidoscopy with a tap water enema prep and no sedation is adequate for obtaining biopsy specimens to rule out cytomegalovirus infection. Imaging studies can be performed if clinically necessary; magnetic resonance imaging without contrast provides abdominal images without radiation and can help rule out abscess or obstruction.
Vaginal delivery is recommended except in instances of active perianal disease or a history of fistulas. Breast-feeding should not be discouraged as most medications are considered safe for nursing.
