Pregnancy and IBD

May 27, 2025

Introduction

The objectives of this presentation were to describe the impact of inflammatory bowel disease (IBD) on pregnancy outcomes and the impact of pregnancy on IBD, to consider how best to assess IBD activity and provide optimal management preconception and during pregnancy, and to evaluate the safety of IBD medications during pregnancy and breastfeeding.

It is important to keep in mind that treatment strategies in IBD for pregnant women are very similar to that in non-pregnant individuals. Furthermore, the treat-to-target paradigm applies to all ages and stages from young adulthood to preconception and pregnancy. This is pertinent given the increasing pediatric onset of IBD.¹ Guidance on the management of IBD during pregnancy continues to evolve. Recently, the Global Consensus Statement on the Management of Pregnancy in Inflammatory Bowel Disease brought together 39 IBD and global content global experts from gastroenterology, obstetrics, surgery, pharmacy, placental physiology and pharmacology, along with 7 patient advocates from 6 continents. The global experts reviewed and assessed current data and developed a document on best practices,² which will replace pre-existing international guidelines.^3-5

Impact of IBD on Pregnancy

When considering the impact of IBD on pregnancy, control of active IBD is the most important goal. The evidence has clearly demonstrated that IBD activity increases the risk of adverse materno-fetal outcomes, including spontaneous abortion, stillbirth, preterm birth, and newborns that are small for gestational age.^6-8 Given these risks, the role of preconception counselling, including encouraging adherence to medication, is important to help improve patient outcomes, as ultimately the health of the infant is dependent on the health of the mother. Beyond improving medication adherence, preconception care has been demonstrated to improve folic acid intake and smoking cessation.⁹ Pregnant individuals tend to be most concerned with the impact of IBD medications rather than the IBD activity itself, highlighting the need to counsel patients on the importance of medically optimizing IBD management prior to elective conception, including the allowance of adequate time for treatment optimization before pregnancy whenever possible. Furthermore, women with IBD who are less educated on disease and pregnancy outcomes are more likely to choose to be voluntarily childless.¹⁰

In terms of identifying what else can be done to prevent IBD in infants, genetics and early life exposures including diet, infections, judicious exposure to antibiotics and breastfeeding can play a role through modulating the microbiome.^11,12

Impact of Pregnancy on IBD

Studies have shown that women with ulcerative colitis (UC) are 3–4 times more likely to experience a disease flare in pregnancy than women with Crohn’s disease (CD).¹³ Regardless, for both UC and CD, it is recommended to monitor disease before and during pregnancy, similar to non-pregnant patients. This includes a full evaluation pre-conception, including blood markers, fecal calprotectin, bowel ultrasound, and endoscopic evaluation, in an effort to identify and treat active IBD before pregnancy. During pregnancy, it is recommended to continue noninvasive disease monitoring including fecal calprotectin and bowel ultrasound (up to week 24, beyond which bowel views may be obscured), with endoscopic evaluation only in more acute settings when non-invasive assessment is inadequate, and the endoscopic results will directly change management plans.^14-17

IBD Medications in Pregnancy

Active disease (inflammation) is a teratogen, while the majority of IBD therapies are safe during pregnancy and breastfeeding. Therefore, women should be more concerned about active disease than active therapy. Guidance on IBD medication use during pregnancy is a large focus of upcoming guidelines,² representing 11/39 GRADE statements and 9/35 consensus statements, with key evidence summarized in Table 1.

To summarize the impact of IBD treatment during pregnancy, it is crucial to treat flares aggressively and continue therapy for both stable and unstable IBD. Shared decision-making is imperative for all patients, and when electively switching therapies, make sure to incorporate adequate time to transition. Since the totality of data supports stringent disease control, it is recommended to continue the current IBD therapy if there is no effective alternative therapy to maintain maternal health.

Obstetric, Post-Partum Care & Breastfeeding

Pregnant patients with IBD should be referred to obstetrics as they are all considered high-risk pregnancies. Aspirin can be used for the prevention of preterm pre-eclampsia (ASPRE Study), a decision usually made by the obstetrician or family physician based on individual risk assessment. This strategy is acceptable in women with IBD and does not increase the risk of flare.^18,19 Most women with IBD can proceed with a vaginal delivery unless there are specific IBD-based indications for Caesarean delivery including active perianal CD, ileo-anal pouch, or recto-vaginal fistula.²⁰ Women with IBD are at increased risk of thromboembolic events due to the contribution of disease activity, the pregnancy state, and surgery. Women who undergo Caesarean delivery should be considered for venous thromboembolism (VTE) prophylaxis postpartum.^21,22

With respect to breastfeeding, a relative infant dose (the metric comparing the infant with maternal drug dose) of ≤10% is considered safe. Biologic therapies are present in breast milk at much lower concentrations and therefore mothers on these medications can breastfeed.²³ However, discussion regarding avoidance of breastfeeding for individuals on oral small molecules is required since these cross into breast milk and there is limited data on safety.²⁴

Preventive care

It is important to protect mothers and infants with vaccinations. Evidence has shown that inactive vaccines maintain their efficacy and safety despite exposure to maternal IBD therapy. With respect to live vaccines, it is recommended to avoid the Bacillus Calmette-Guerin (BCG) vaccine in the first 6 months.^25,26 The live oral rotavirus vaccination is permissible in anti-TNF-exposed infants as per existing data, however, exposure to other agents may still require assessment by pediatric immunology prior to vaccine administration.^27,28 Other preventive care measures such as nutrition, cancer surveillance, and mental health monitoring are also important to put into place in pregnant individuals with IBD.^29,30

Conclusions

In conclusion, consider both the impact of IBD on pregnancy as well as the impact of pregnancy on IBD when treating patients with IBD that are pregnant or may become pregnant. There is accumulating data and guidance on the safety of IBD medications in pregnancy and breastfeeding. Preventive care, including vaccines, are important as part of a holistic approach to the management of pregnancy in IBD as, ultimately, maternal health directly impacts infant health.

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Clinical Case

Jenna is a 31-year-old, postdoctoral associate in a biomedical company specializing in artificial intelligence. She has CD (Montreal classification A1 L1 B2p) and has been on infliximab 5mg/kg and azathioprine since her diagnosis of complex fistulizing CD. Her last surgical intervention for her perianal disease was 3 years ago.

She has no nausea, no post-prandial discomfort, 2–4 semi-formed bowel movements a day, and uses a bile acid sequestrant on an as-needed basis. Jenna states, “This is the best I have felt for years” and apologizes that she hasn’t seen you for two years. She and her partner have been trying to conceive for 18 months. Her partner has rheumatoid arthritis and is on subcutaneous methotrexate therapy. Jenna is on a multivitamin.

Commentary

• Most gastroenterologists would restage her CD.

Case Evolution

You ask her partner to see his rheumatologist, and in the interim, commence restaging her disease. Her symptoms are as stated above with no post-prandial abdominal discomfort or bloating. Her abdomen is soft, non-tender, with laparoscopic scars. Incidentally you note moderate atopic dermatitis.

You are quite concerned that she has downplayed her symptoms as she has 4 external perianal tracts, 3 setons, and some drainage from one tract. Her fecal calprotectin is 837 ug/g, C-reactive protein (CRP) is 1.7 mg/L, and infliximab drug concentration is 3.4 ug/mL. A bowel ultrasound demonstrates 4mm wall thickness in the neoterminal ileum with mild hyperemia but no stricture.

You decide to proceed with ileocolonoscopy anyway, and this reveals findings consistent with a Rutgeerts i2b score, and no colonic disease. MRI confirms complex perianal fistulizing disease with enhancement of at least 3 intersphincteric fistulae and a small inflammatory mass.

Commentary

• Most gastroenterologists would optimize her infliximab and continue combination therapy with azathioprine.
• The pending updated Global Consensus document² will provide important guidance on the safety of IBD treatment during pregnancy for the range of new agents brought to market since the 2016 Toronto consensus statements for the Management of IBD in Pregnancy were developed.³
• In the absence of current guidance for small molecules, in this case, if she was already exposed, many gastroenterologists would consider continuing treatment given the short half-life and monitor closely.
  • Recent data from clinical trial and post-marketing studies identified 128 cases of in utero exposure to upadacitinib and showed comparable rates of adverse pregnancy outcomes to the general population or individuals with autoimmune inflammatory diseases.³¹

Case Evolution

You optimize her infliximab dosing and stop her azathioprine as she has an abnormal Pap smear and tell her it is best to wait 6–12 months before she attempts to conceive to ensure her disease is responding to therapy. Five months later, Jenna remains asymptomatic from her luminal disease. However, her perianal disease remains unchanged.

Perianal examination reveals some drainage around one remaining seton and some erythema and adjacent fluctuance. Her ‘dermatitis’ has progressed. Jenna excitedly tells you she is 8 weeks pregnant.

Commentary

• Most gastroenterologists would refer to surgery for attempted drainage.
• Some gastroenterologists would arrange for an MRI.

Case Evolution

Fortunately, Jenna recovers well from the incision and drainage, completes a short course of oral antibiotics, and continues on optimized maintenance infliximab. She is commenced on low dose aspirin for the prevention of preterm pre-eclampsia by her family doctor and is referred to materno-fetal medicine.

Jenna is monitored non-invasively with fecal calprotectin tests and a second trimester bowel and perianal ultrasound. Her baby is delivered at term, 38 weeks 3 days, by elective Caesarean section. She chooses to exclusively breastfeed the baby.

Commentary

• More recent data demonstrate that infants born to mothers exposed to a range of biologics show normal immunologic assessments and no adverse effects following live rotavirus vaccination. The authors thus recommend provision of the live oral rotavirus vaccine in the setting of anti-TNF exposure.²⁸
• Regarding aspirin prophylaxis, there is no contraindication in IBD, as it does not increase the risk of IBD flare, but this decision is generally left to the family physician or obstetrician.

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References

1. 1. Crohn’s Colitis Canada. The 2023 Impact of Inflammatory Bowel Disease in Canada Report: Epidemiology of IBD. Available at: https://crohnsandcolitis.ca/Crohns_and_Colitis/documents/reports/2023-IBD-Report-English-LR.pdf
   2. Mahadevan U, Seow CH, Barnes E, et al. The Helmsley PIANO Global Consensus and GRADE Statement: The Management of Pregnancy in Inflammatory Bowel Disease (In Press, Clinical Gastroenterology and Hepatology); https://pianostudy.org/conference.php
   3. Nguyen GC, Seow CH, Maxwell C, et al; IBD in Pregnancy Consensus Group; Canadian Association of Gastroenterology. The Toronto Consensus Statements for the Management of Inflammatory Bowel Disease in Pregnancy. Gastroenterology. 2016;150(3):734–57.e1.
   4. Torres J, Chaparro M, Julsgaard M, et al. European Crohn’s and Colitis Guidelines on Sexuality, Fertility, Pregnancy, and Lactation. J Crohns Colitis. 2023;17(1):1–27.
   5. Laube R, Selinger CP, Seow CH, et al. Australian inflammatory bowel disease consensus statements for preconception, pregnancy and breast feeding. Gut. 2023;72(6):1040–53.
   6. Vestergaard T, Julsgaard M, Røsok JF, et al. Predictors of disease activity during pregnancy in women with inflammatory bowel disease-a Danish cohort study. Aliment Pharmacol Ther. 2023;57(3):335–44.
   7. Meyer A, Drouin J, Weill A, et al. Pregnancy in women with inflammatory bowel disease: a French nationwide study 2010–2018. Aliment Pharmacol Ther. 2020 Nov;52(9):1480–90.
   8. Kim MA, Kim YH, Chun J, et al. The influence of disease activity on pregnancy outcomes in women with inflammatory bowel disease: A systematic review and meta-analysis. J Crohns Colitis. 2021;15(5):719–32.
   9. De Lima A, Zelinkova Z, Mulders AG, et al. Preconception care reduces relapse of inflammatory bowel disease during pregnancy. Clin Gastroenterol Hepatol. 2016;14(9):1285–92.
   10. Laube R, Yau Y, Selinger CP, et al. Knowledge and attitudes towards pregnancy in females with inflammatory bowel disease: An international, multi-centre study. J Crohns Colitis. 2020;14(9):1248–55.
   11. Agrawal M, Sabino J, Frias-Gomes C, et al. Early life exposures and the risk of inflammatory bowel disease: Systematic review and meta-analyses. EClinicalMedicine. 2021;36:100884.
   12. Torres J, Jianzhong H, Akihiro S, et al. Infants born to mothers with IBD present with altered gut microbiome that transfers abnormalities of the adaptive immune system to germ-free mice. Gut. 2020;69(1):42–51.
   13. Kammerlander H, Nielson J, Kjelsen J, et al. The effect of disease activity on birth outcomes in a nationwide cohort of women with moderate to severe inflammatory bowel disease. Inflamm Bowel Dis. 2017;23(6):1011–18.
   14. Prentice RE, Flanagan EK, Wright EK, et al. Active inflammatory bowel disease on intestinal ultrasound during pregnancy is associated with an increased risk of adverse pregnancy and neonatal outcomes independent of clinical and biochemical disease activity. Gastroenterology. 2025 25:S0016-5085(25)00537-2. Epub ahead of print.
   15. Leung Y, Shim HH, Wilkens R, et al. The role of bowel ultrasound in detecting subclinical inflammation in pregnant women with Crohn’s disease. J Can Assoc Gastroenterol. 2019;2(4):153–60.
   16. Tandon P, Leung K, Yusuf A, et al. Noninvasive methods for assessing inflammatory bowel disease activity in pregnancy: a systematic review. J Clin Gastroenterol. 2019;53(8):574–81.
   17. Ko MS, Rudrapatna VA, Avila Pet al. Safety of flexible sigmoidoscopy in pregnant patients with known or suspected inflammatory bowel disease. Dig Dis Sci. 2020;65(10):2979–85.
   18. Rolnik DL, Wright D, Poon LC, et al. Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. N Engl J Med. 2017;377(7):613–22.
   19. DeBolt CA, Gottlieb ZS, Manasa GR, et al. Low-dose aspirin use does not increase disease activity in pregnant patients with inflammatory bowel disease. Dig Dis Sci. 2024;69(5):1803–07.
   20. Foulon A, Dupas J-L, Sabbagh C, et al. Defining the most appropriate delivery mode in women with inflammatory bowel disease: a systematic review. Inflamm Bowel Dis. 2017;23(5):712–20.
   21. Hansen AT, Erichsen R, Horváth-Puhó E, et al. Inflammatory bowel disease and venous thromboembolism during pregnancy and the postpartum period. Thromb Haemost. 2017;15(4):702–08.
   22. Kim YH, Pfaller B, Marson A, et al. The risk of venous thromboembolism in women with inflammatory bowel disease during pregnancy and the postpartum period: A systematic review and meta-analysis. Medicine (Baltimore). 2019;98(38):e17309.
   23. LaHue SC, Anderson A, Krysko KM, et al. Transfer of monoclonal antibodies into breastmilk in neurologic and non-neurologic diseases. Neurol Neuroimmunol Neuroinflamm. 2020;7(4):e769.
   24. Julsgaard M, Mahadevan U, Vestergaard T, et al. Tofacitinib concentrations in plasma and breastmilk of a lactating woman with ulcerative colitis. Lancet Gastroenterol Hepatol. 2023; 8(8):695–7.
   25. Goulden B, Chua N, Parker E, et al. A systematic review of live vaccine outcomes in infants exposed to biologic disease modifying anti-rheumatic drugs in utero. Rheumatology (Oxford). 2022;61(10):3902–06.
   26. Cheent K, Nolan J, Shariq S, et al. Case Report: Fatal case of disseminated BCG infection in an infant born to a mother taking infliximab for Crohn’s disease. J Crohns Colitis. 2010;4(5):603–5.
   27. Fitzpatrick T, Alsager K, Sadarangani M, et al. Immunological effects and safety of live rotavirus vaccination after antenatal exposure to immunomodulatory biologic agents: a prospective cohort study from the Canadian Immunization Research Network. Lancet Child Adolesc Health. 2023;7(9):648–56.
   28. Ernest-Suarez K, Murguía-Favela LE, Constantinescu C, et al. Live rotavirus vaccination appears low-risk in infants born to mothers with inflammatory bowel disease on biologics. Clin Gastroenterol Hepatol. 2025;23(5):835–45.
   29. Vigod SN, Kurdyak P, Brown HK, et al. Inflammatory bowel disease and new-onset psychiatric disorders in pregnancy and post partum: a population-based cohort study. Gut. 2019;68(9):1597–1605.
   30. Crohn’s & Colitis Canada. IBD During Preconception or Pregnancy Checklist. April 1, 2024. Available at: https://crohnetcolite.ca/Crohns_and_Colitis/documents/Support/Clinical_Care_Pathways/2024-04_IBD-and-Pregnancy_vA.pdf
   31. Mahadevan U, Levy G, Gensler L, et al. Pregnancy outcomes in patients treated with upadacitinib: analysis of data from clinical trials and postmarketing reports. Drug Saf. 2024;47(10):1039–49.

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Editor-in-Chief

John K. Marshall, MD MSc FRCPC CAGF AGAF
Professor, Department of Medicine
Director, Division of Gastroenterology
McMaster University
Hamilton, ON

Contributing Author

Cynthia Seow, MBBS (Hons) MSc FRACP
Professor of Medicine
Division of Gastroenterology and Hepatology
Departments of Medicine and Community Health Sciences
University of Calgary
Calgary, AB

Mentoring in IBD Curriculum Steering Committee

Alain Bitton, MD FRCPC, McGill University, Montreal, QC
Karen I. Kroeker, MD MSc FRCPC, University of Alberta, Edmonton, AB
Cynthia Seow, MBBS (Hons) MSc FRACP, University of Calgary, Calgary, AB
Jennifer Stretton, ACNP MN BScN, St. Joseph’s Healthcare, Hamilton, ON
Eytan Wine, MD PhD FRCPC, University of Alberta, Edmonton, AB

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