Ulcerative Colitis Blog

A common question among female UC patients is how pregnancy may affect their disease course. Women with UC often wonder whether the hormonal changes associated with pregnancy will make their disease flare or if disease activity may change after delivery. Current studies indicate that the activity of a woman's colitis during pregnancy is dependent on the state of her disease at the time of conception. For women whose colitis is well-controlled at the time they become pregnant, 70-80% can expect their disease to remain quiet throughout the pregnancy. This is in contrast to those who have symptoms of active colitis at the time of conception, for whom disease relapse rates during pregnancy can be as high as 50-70%. There is no consistent evidence to suggest that different trimesters confer greater or lesser risks for flaring. Research has shown that the most common reason for relapse during pregnancy is the cessation of medical therapy for UC. As such, UC patients who are considering becoming pregnant should discuss with their physician the compatibility of their medication regimen with pregnancy. Women who have undergone colectomy with an ileoanal pouch generally do well during pregnancy, although 20-30% of patients may experience increasing numbers of bowel movements and fecal incontinence later in the gestation period. These symptoms generally resolve after delivery with resolution of pouch function.

Disease activity in the post-partum period seems to be dependent on the status of disease at the time of delivery. One study examining this issue found that only 13% of women with quiescent disease at delivery flared in the post-partum period, as compared to 53% of women who had active disease at delivery (Beniada, et al, Journal of Gynecology, Obstetrics, and Biological Reproduction 2995; 34:581-8). Furthermore, post-partum activities such a breastfeeding have not been shown to adversely affect disease activity. Similar to disease flares during pregnancy, it seems that flares post-partum are most likely attributable to discontinuation of UC medications.

Many UC patients have questions regarding the safety of their medications during pregnancy. It is important that women with UC who are considering pregnancy discuss appropriate therapy with their physician. Below is a brief review of the current safety information of UC medications in pregnancy.

Safe
1) Sulfasalazine - Women taking sulfasalazine should take 2mg of folate/day to diminish the risk of neural tube defects

2) 5-ASA medications - Both oral and topical formulations safe in pregnancy

3) Corticosteroids - Possible increased risk of cleft lip and palate deformities when used in the first trimester; otherwise safe and benefits felt to outweigh risks

Likely safe
1) Azathioprine/6-mercaptopurine - Data from use in humans does not show an increased risk of fetal malformations or spontaneous abortions

2) Budesonide - There is limited data regarding the use of budesonide in pregnant IBD patients, however, experience from use in women with asthma during pregnancy suggests it is likely to be safe

3) Infliximab - No difference in rates of fetal malformations, miscarriage, obstetric or neonatal complications between infliximab exposed women and the general population

4) Adalimumab - Preliminary data in animals does not show an increased risk of fetal malformations or obstetric complications - studies in humans are ongoing

5) Cyclosporine - Information from use in transplant patients suggests it is safe in pregnancy

6) Loperamide - Felt to be of low risk but prolonged use is best avoided

Unlikely to be safe
1) Diphenoxylate - Known to cause birth defects in animals

2) Cholestyramine - While cholestyramine does not cause birth defects, it may result in deficiencies of fat soluble vitamins in the fetus or mother

3) Tacrolimus - Possible risk of fetal malformations and premature delivery based on studies in transplant patients

Contraindicated
1) Mycophenolate mofetil - High rates of fetal malformations and miscarriage in animal studies and research in transplant patients

In response to a recent blog on disease activity and UC, Jennifer wrote in with a good question about whether the use of steroid enemas would decrease potential risks to the fetus compared to oral steroid therapy in active colitis. My base answer to this question is that it would depend on the individual characteristics of a patient's disease. Some important considerations are:

1) Extent of disease - For women with mild disease limited to the sigmoid and rectum (so-called "proctitis" or "proctosigmoiditis") steroid enemas may be viable and reasonable option. There is a paucity of data on how much of the topical steroid is absorbed through the GI tact and transferred across the placenta to the fetus. The scientific literature generally agrees that if placental transfer of steroids from the enemas occurs, it is likely low. In this respect, steroid enemas can be viewed at least equally as safe as oral steroids, and theoretically may transfer less steroid across the placenta. Note, however, that data to answer this precise question are not available.

2) Severity of disease activity - As discussed in prior blogs, the number one risk factor for complications to the fetus is active disease. It cannot be stressed enough how important it is for measures to be taken to ensure quiescent disease during pregnancy. That being said, for women with moderate to severe disease activity the use of oral steroids for flares is advised because the benefit to the fetus outweighs the risks. This principle holds true even for women with proctitis or proctosigmoiditis - if their disease does not appear to be controlled with topical steroids, then treatment with oral steroids is advised.

3) Pregnancy trimester - Rectal steroids are felt to be appropriate in mild, limited rectosigmoid disease during the first 2 trimesters of pregnancy. The use of rectal steroids is not recommended during the 3rd trimester.

As there are unique aspects to every patient, readers are encouraged to discuss information from the blog with their health care providers to better understand how these issues may impact their individual care.