What a GI Doctor Wants You to Know About Getting Pregnant With UC
Please see a doctor before starting or stopping a medication.
When it comes to family planning and pregnancy, people living with inflammatory bowel disease (IBD) may have a lot of questions and concerns about what’s safe and not safe. How should I deliver? Can I stay on my medication? Does my baby need to be tested? How often should I see my gastroenterologist? Do I need to get my regular colonoscopy? As someone living with ulcerative colitis (UC) and talking about family plans with my husband, I am one of those people who wonders about all of these topics.
I decided to sit down with my own gastroenterologist (GI), Dr. Gauree Konijeti at Scripps Health in San Diego, to ask for her thoughts on IBD, childbirth, family planning and disease management. “Dr. K” is the head of the Scripps IBD program and specializes in both Crohn’s disease and ulcerative colitis, and she’s been treating my UC for several years. I found her answers to be especially helpful. At the end of the day, every person is different, so it’s important to talk to your own GI about what’s best for you. I hope this conversation helps you start yours.
Caitlyn: When it comes to family planning, specifically as it relates to the person who will be giving birth, how do these conversations start in a GI’s office?
Dr. Konijeti: We always like to start even before conception happens, asking about what their plans are. Sometimes patients have never even had that discussion, and they may have some preconceived notions about what it would be like to conceive or carry a baby with Crohn’s disease or ulcerative colitis. So it’s nice to introduce the topic early and see where they’re at and what their plan is. While we may not be the ones to address all of that, at least we can sort of inform them about what the options are and how those might affect risks with IBD as well.
The goal before pregnancy is remission, both clinical and objective. Objective really means endoscopic remission, so trying to get the disease as controlled as possible on the inside. That leads to much better outcomes for both the parent and the baby. With the delivery, we have to think about what surgeries they’ve had in the past. We have to talk about medications, disease behavior — all aspects of their health. Then we can get into postpartum management.
There are also a lot of factors to discuss surrounding conception, even the route of conception, whether “natural” or IVF and so on.
Caitlyn: That’s a good point about talking about medications. I’ve heard that maybe some medications aren’t safe for breastfeeding, and I know some people have concerns about drugs used to manage inflammation. What can you share about medication safety and having a baby?
Dr. Konijeti: For the most part, most of the medications we use for IBD are considered safe during pregnancy and nursing. Anti-inflammatory drugs are fine to continue during pregnancy and nursing, but you might need to add some extra supplements. Be sure to speak with your doctor before starting or stopping any medication. Treatment plans just depends on the patient, with the whole goal being to keep the mother’s IBD under control. It has to be individualized for that patient, and we just make sure they understand any risks associated with medications.
Caitlyn: It sounds like as long as your IBD is managed well going into the pregnancy, it’s more or less safe to have a baby. But what if you do get pregnant during a flare? What would you do in that situation?
Dr. Konijeti: We’d really manage the flare much like we would if they weren’t pregnant. We’d evaluate potential triggers and assess how bad it is regarding symptoms and labs. If it’s more on the moderate-to-severe end, they might need a sigmoidoscopy to see what’s going on inside. That would usually be coordinated with their OB, too, just to make sure everyone remains safe during the pregnancy. Then we figure out how to manage it; sometimes it can mean a course of steroids to get it under control, or maybe the therapy they were on isn’t working anymore, and they need to switch. In that case, it’s OK to start new medications during pregnancy. We wouldn’t necessarily want to start a medication that could take a few months to work, when you don’t have that kind of time during pregnancy.
Caitlyn: You mentioned that they might have to get a sigmoidoscopy. Are those safe to do during pregnancy? If I had my regular checkup scheduled, do you still perform those, or do you wait until the baby is born?
Dr. Konijeti: Usually we avoid doing full colonoscopies on patients during pregnancy. If it’s for screening purposes, then we would defer that until after the baby is born, when they’re in a good place postpartum. I want to give women six months to adjust to that new life and the busyness of their schedule. A time that we would do procedures during pregnancy is when you’re going to change management; that’s a therapeutic decision, such as during a flare.
It’s also important to remember that flares look different for everyone. Some patients might have bleeding and diarrhea like in ulcerative colitis, but for patients with Crohn’s and something like a stricture, it can present as a bowel obstruction. While we do try to avoid x-ray-based imaging like CT scans or MRIs on pregnant women, we can do an x-ray if they’re in the hospital, then go from there. I have had women who have had those types of issues and have needed surgery during pregnancy, and they’ve done fine.
Caitlyn: That’s really good to know. Can a pregnancy itself cause a flare?
Dr. Konijeti: Most women who are in remission going into pregnancy remain in remission during pregnancy. If they’re not in remission, then they do have a higher chance of flaring. Probably one third of those women may continue to have the same amount of disease activity, then another third may actually feel better during pregnancy. It’s hard to predict who might flare, and there are a lot of factors. Sometimes women stop their medication because they’re pregnant, and that may cause a flare. Or the stress may be a factor. My best advice is to work with your doctor to get your IBD under control, then keep it under control the best you can during pregnancy. Pregnancy can actually have a protective effect for a lot of women with respect to inflammation. Many women report to me that they feel better than they ever have from a colitis perspective, and they wish they could be “perma pregnant,” sort of!
Caitlyn: I wouldn’t expect that about the inflammation, but that actually makes sense. I’ve also wondered about C sections versus vaginal delivery. Can you speak to the safety of one over the other in terms of women with IBD?
Dr. Konijeti: So we actually encourage vaginal delivery, unless there’s another reason the mother shouldn’t deliver that way. From a safety standpoint, we haven’t seen a higher rate of complications for women delivering vaginally versus C sections. Specifically with ulcerative colitis, I suppose if the patient has had prior surgery or is in a severe flare, those may be reasons to consider a C section. However, from an overall IBD standpoint, the only major contraindication to a vaginal delivery is having active perianal disease in the setting of Crohn’s, which affects the anal canal. But otherwise I don’t see any reason why they’d have to get a section.
If the baby is breech, or if the woman is having twins, then maybe that might make a C section safer, but that would be true regardless of IBD. Also, for those living with a j pouch, we do see an increase in bowel movement frequency during those pregnancies. However, they do not have to have a C section; they can also have a vaginal delivery. I would just encourage them to talk to their care team, especially their gynocologist, about their specific situation and see what’s best for them and the baby. I think it’s very reasonable to try doing vaginal first in most situations.
Caitlyn: This is all really helpful information! Obviously women who are pregnant have regular appointments with their OB/GYN to check on the baby. How often should those living with IBD also check in with their GI?
Dr. Konijeti: If a woman is thinking about having a baby, let your GI know! It’s about getting IBD under control but also making sure they’re on adequate supplements, navigating medications, improving nutrition and assessing for any vitamin deficiencies before conception. As a rule of thumb, I typically like to see patients every trimester, especially the first two and maybe the third. We can see how things are going, talk about fetal growth, monitor labs, change medication if needed and talk about nursing and delivery too.
Caitlyn: That all makes sense. Are there any tests you recommend for the baby after it’s born? I know there isn’t much data showing that IBD is genetic, but maybe that’s changing?
Dr. Konijeti: A routine assessment is fine. We don’t recommend any additional testing on the baby. We do recommend avoiding live vaccines for the first year. Then after that six months, it’s up to the mom and their pediatrician about if they want to do a live vaccine before one year. The ones you normally get around one year are fine to proceed with. And of course, bring in photos after they’re born! We love when patients share their good news with us.