What is Crohn’s disease?
Crohn’s disease is a chronic disease that can affect the intestines, rectum and anus. It is a form of inflammatory bowel disease (IBD). The exact cause is not known, but it is likely a combination of genetic, environmental and immunologic factors. The heart of the disease is inflammation, and it is thought that certain risk factors lead the immune system to inappropriately attack areas of intestinal tract.
Who gets Crohn's?
Anyone can get Crohn’s disease at any age. However, Crohn's is slightly more common in women than men; and more common in persons of Caucasian and Ashkenazi Jewish origins. The average age of onset is 15-30. Approximately 1 in 500 adults has Crohn’s. Crohn’s is seen more commonly in Westernized countries and in urban settings.
Will my baby have Crohn’s? Most children of mom’s with Crohn’s do NOT develop Crohn’s. If the mom has Crohn’s, there is a 2-9 percent chance that the child will develop Crohn’s. If both parents have Crohn’s there is 1 out of 3, or 36 percent chance s/he will develop Crohn’s.
How is Crohn’s prevented or treated? There currently is no way to prevent Crohn’s, as there is not a good way to predict who is going to get Crohn’s. There is no genetic test for Crohn’s at this time. It is recommended that persons who have a strong family history of IBD see a gastrointestinal specialist to discuss the best strategy for screening in their particular case.
Crohn’s is treated both with medications and with surgery. Historically, approximately 75 percent of persons with Crohn’s will require surgery at some point. These numbers may decrease with the advent of new and better medications to treat Crohn’s.
Can I get pregnant with Crohn’s?
Most women with Crohn’s disease that is in remission can get pregnant and get pregnant as easily as women without the disease. This is good news, but also means that women with Crohn’s who are not actively trying to conceive need to use reliable contraception to avoid an unexpected pregnancy. There is a subset of women with Crohn’s who have had to have a pelvic surgery, such as a J-pouch or colectomy, that may have additional pelvic scaring that can lead to decrease fecundity (difficulty getting pregnant) as a result of scaring involving the tubes. If you have had pelvic surgery, your obstetrician may want to do a test called a hysterosalginogram (HSG) to make sure that your tubes open so sperm and egg can unite and form an embryo.
There are certain medications that women should not be on while trying to get pregnant such as methotrexate, as it can be toxic to the fetus. Methotrexate should be stopped three-six month before trying to get pregnant.
Steroids in early pregnancy can slightly increase the risk of cleft palate and the dose may be lowered; but do not abruptly stop steroids as this can place you at risk for significant acute medical complications. If you are not using contraception, or are trying to get pregnant, check with your doctor that all of your medications are safe in early pregnancy.
Do not stop your Crohn’s medications because you want to get pregnant or find out you are pregnant without talking to your doctors first. This increases your chances of a Crohn’s flare, and it is very important that your Crohn’s be under excellent control at the time of conception to maximize the health of the pregnancy.
How will my Crohn’s do in pregnancy? The most important predictor of how your Crohn’s will do in pregnancy is how well controlled your disease is at the time of conception. In some pregnancies, we actually see Crohn’s improve, probably because your immune response is a little slowed down in pregnancy as a protective mechanism for the fetus. However, it is not a good idea to get pregnant during a Crohn’s flare or if you are just starting a new treatment regimen. Women who have quiescent disease (inactive) at the time of conception have only a 30 percent risk of disease relapse in pregnancy. Women who have active disease at the time of conception have a 70 percent chance of continued or worsening disease symptoms in the pregnancy. Once the disease flares in pregnancy, it is often hard to get back under control, highlighting the importance of coordinating your medical care with your obstetrician and your gastroenterologist so that there is no treatment gap that might increase your risk of antepartum flares.
What if I need surgery during my pregnancy? Patients with active disease at the onset of pregnancy are most likely to require surgery during pregnancy. Complications that may arise during pregnancy that require surgery are refractory colitis, strictures (narrowing of the intestinal lumen) causing obstruction, abscesses or perforation of the intestine. If surgery is anticipated to be needed, it is best to time it before 24 weeks of pregnancy if possible. Most of the time, surgery for complications of Crohn’s disease is safe during pregnancy and the decision for surgery is best made by coordination between your GI doctor and obstetrician to minimize any risks. Any surgery in pregnancy should be done at a facility where the anesthesia team is familiar with caring for pregnant patients during surgery and there is a pediatric team available to care for the infant should the pregnancy be beyond 24 weeks and the need for emergent cesarean delivery arises. Often, the obstetrician will operate with the colorectal surgeon to help reduce any risks to the uterus or pregnancy.
Sometimes patients need non-surgical procedures in pregnancy such as a colonoscopy, sigmoidoscopy, or a perianal/anal exam to better evaluate uncontrolled symptoms or pain, bleeding or diarrhea. The risks versus benefits of these procedures varies depending on the gestational age of the pregnancy and individual situation. Your obstetrician and gastroenterologist will work together to determine if such procedures are warranted at any given time in pregnancy.
Are my Crohn’s medications going to harm my baby? There are many medications that can be used in Crohn’s; some have been used for decades like methotrexate, 6MP/Azathioprine and steroids and some are newer biologic agents like anti-TNF agents[ Certolizumab (Cimzia), Adalimumab (Humira), and Infliximab(Remicaid)] and anti-integrin antibodies [Vedolizumab(Entyvio) and Natalizumab (Tysabari)]. The good news is that most of the medications used for Crohn’s are safe in pregnancy. There are six basic classes of medications used in treating Crohn’s: antibiotics, steroids, aminosalicylates, immune suppressive, biologics and thalidomide (not used in pregnancy).
Steroids: We often try to avoid or minimize steroid exposure in the first trimester due to a three-fold risk of cleft palate seen with early exposure before 12 weeks when the palate is closed. Although it is an increased risk, the absolute risk remains small at 0.4 percent or less with first trimester exposure. Chronic steroids exposure can also increase the risk for hypertension in pregnancy, diabetes of pregnancy and premature rupture of the membranes (watering break too early). Although budesonide (Entecort and Uceris) is a safer steroid option because of decrease active steroid metabolites, there is still some steroid exposure. Steroid enemas and suppositories also have some steroid absorption systemically, although less than oral prednisone. Minimizing steroid exposure is recommended.
Amino salicylates: Asacol HD is the only mesalamine that is not recommended in women trying to conceive or pregnant. One of the ingredients (phenophthalates) is associates with a decrease ano-genital length. With sulfasalazine, we recommend 2mg a day of folic acid to reduce the risk for spina bifida due to the metabolic effects of this medication.
Antibiotics: Certain antibiotics like Ciprofloxacin are avoided in pregnancy due to the risk of cartilage deformation in the fetus. Many antibiotics life flagyl and ertepenem are considered to have greater benefits in pregnancy than risks and are often used in Crohn’s patients during pregnancy. Every antibiotic’s compatibility with pregnancy will be evaluated by your team of doctors and the pharmacy prior to administering it.
Immunosuppressive: Medications such as azathioprine (Imuran) and 6MP (6 Mecaptopurine) are general considered safe in pregnancy.
Biologics: AntiTNFs is the class of drugs with the most recent advances that shows good success with getting Crohn’s into longstanding remission and are generally considered safe in pregnancy. Some of the biologics cross the placenta more easily than others and your doctor may choose to hold your doses near the end of the pregnancy. This is not necessary with certolizumab (Cimzia) because this antibody’s structure reduces its ability to cross the placenta and get to the baby Anti-integrin antibodies (Vedolizumab and Natalizumab) have very limited safety data in pregnancy and are not recommended during conception or pregnancy.
Will I have to have a cesarean delivery? Most pregnant women with Crohn’s do not require a cesarean because of their Crohn’s. Women who have perianal or rectal involvement with their disease are advised to avoid vaginal delivery and deliver via a scheduled cesarean. In the absence of perianal or rectal disease, the need for a cesarean should be based on standard obstetric indications. For women planning a vaginal delivery, the delivery can be routine and does not require extensive interventions just because they have Crohn’s. Just like any other woman, those with Crohn’s may avoid an epidural, remain mobile, push in whatever position is most effective and comfortable for them, and welcome their baby into the world in calm and welcoming setting. Episiotomies, if necessary, are encouraged laterally instead vertically.
What can I expect after delivery? Most medications used in Crohn’s in pregnancy are compatible with breastfeeding, and the baby can breastfeed right away after birth. Assuming the baby is full-term and otherwise healthy, s/he can stay in the room with you and nurse and snuggle skin-to-skin just like babies of moms who do not have Crohn’s.
It is important to make the pediatrician aware, at the baby’s first visit, of the medications you are taking. Although anti-TNFs are secreted in the breast milk, they are not absorbed from the baby’s intestines. Azathioprine/6MP is secreted in the breast milk and a baby’s blood count or liver function tests may need to be checked by the pediatrician within the first few months.
For more information, Dr. Rosanna Gray-Swain is available at West End Ob/Gyn. Her phone number is 314.286.2620.