I have IBD, how does IBD affect delivery, postpartum, and breastfeeding?
DELIVERY: in general, having IBD does not affect delivery method
The decision about delivery method for an IBD patient should be made on an individual basis by the patient and her obstetric provider1,2. The decision should be based on obstetrical reasons, while also considering the patient’s IBD condition1,2. While some studies report higher rates of caesarean section among women with IBD compared to healthy women3, other studies report no significant difference in the rate of c-section4.
There are 2 IBD-related indications for recommending c-section over vaginal delivery:
- active perianal disease (disease located around the anus) in Crohn’s patients3.
- it is recommended to avoid vaginal delivery because of concerns of worsening perianal disease activity due to poor wound healing2.
- women who have significant scarring from prior perianal disease may also wish to discuss delivery method with their obstetrician.
- ileal pouch-anal anastomosis surgery
- although vaginal delivery may be safe for females with a pouch, a c-section may be recommended to prevent potential disruption of pouch function2,3,5.
- there is concern that vaginal delivery could disrupt the function of the anal sphincter (a ring of muscle that controls the anus opening) and lead to an increased risk of incontinence2,3,5.
POSTPARTUM: some women can flare postpartum even if they have been well during pregnancy
It is important for women to monitor their IBD during and after pregnancy, as physicians are currently unable to definitively predict which patients will flare postpartum. It has been reported that ulcerative colitis patients may be at increased risk for postpartum flares6. In general, the risk for postpartum flare depends on disease control during pregnancy, and on other factors that affect disease activity (eg. smoking in Crohn’s disease).
BREASTFEEDING: women with IBD can breastfeed
Breastfeeding is beneficial to the newborn as breast milk contains nutrients, immune proteins, and other beneficial factors. Some studies suggest that breastfeeding may have a protective effect against developing IBD7. It is thought that breastfeeding may help the newborn develop a healthy gut microbiome and immune system by helping newborns develop tolerance to certain bacteria, and thus prevent exaggerated immune responses to bacteria encountered later in life8,9.
BREASTFEEDING: most IBD medications can be continued
| Class of medication | Examples | Notes for breastfeeding |
| Mealamine (5-aminosalicylates) | Asacol ©, Pentasa ©, Salofalk ©, Mesavant ©, Sulfasalazine (Salazopyrin©) | Medications are excreted into the breast milk in very small amounts. Risk of toxicity to the child is very small2,10. |
| Corticosteroids | Prednisone (Deltasone ©), Budesonide (Entocort ©) | Steroids transfer into the breast milk in small amounts, with highest levels in the first 4 hours after taking the medication. Recommended to pump and dump the first 4 hours of breast milk after taking the medication2,11. |
| Immunosuppressant | Azathioprine (Imuran ©), 6-mercaptopurine (6-MP, Purinethol ©) | These can be continued while breastfeeding. To minimize the drug levels in the breast milk, mothers can pump and dump the first 4 hours of breast milk after taking the medication2,12. |
| Methotrexate (Rheumatrex ©) | MTX has teratogentic effects, and because it crosses into the breast milk, MTX is contraindicated while breast-feeding2,12. | |
| Biologics | Infliximab (Remicade ©), Adaliumumab (Humira ©) | These can be continued while breastfeeding. Although they cross into the breast milk, the levels are nil to minimal2,12. |
References
- Huang V W & Habal F M. From conception to delivery: Managing the pregnant inflammatory bowel disease patient. World J Gastroenterol. 2014;20(13).
- Ng S W & Mahadevan U. My Treatment Approach to Management of the Pregnant Patient With Inflammatory Bowel Disease. Mayo Clin Proc. 2014 Mar;89(3):355-360.
- Cornish J et al. A meta-analysis on the influence of inflammatory bowel disease on pregnancy. Gut. 2007;56:830-837.
- Bortoli A et al. Pregnancy outcomes in inflammatory bowel disease: prospective European case-control ECCO-EpiCom study, 2003-2006. Aliment Pharmacol Ther. 2011;34:724-734.
- Tulchinsky H et al. Restorative protocolectomy impairs fertility and pregnancy outcomes in women with ulcerative colitis. Colorectal Dis. 2013 July; 15(7):842-7.
- Pedersen N et al. The course of inflammatory bowel disease during pregnancy and post-partum: a prospective European ECCO-EpiCom Study of 209 pregnant women. Aliment Pharmacol Ther. 2013;38:501-512.
- Kane S & Lemieux N. The Role of Breastfeeding in Postpartum Disease Activity in Women with Inflammatory Bowel Disease. Am J Gastroenterol. 2005;100:102-105.
- Frolkis A et al. Environment and the Inflammatory Bowel Disease. CJG. 2013 Mar; 3:e18-e24.
- Belderbos M E et al. Breastfeeding modulates neonatal innate immune responses: a prospective birth cohort study. Pediatr Allergy Immunol. 2012 Feb;23(1):65-74.
- Silverman D A et al. Is mesalazine really safe for use in breastfeeding mothers? Gut. 2005;54:170-171
- Ost L et al. Prednisolone excretion in human milk. J Pediatr. 1985;26:45-51
- Saha S & Arnold W. Safety and efficacy of immunomodulators and biologics during pregnancy and lactation for the treatment of inflammatory bowel disease. Expert Opin. Drug Saf. 2012;11(6):947-957.