Antonia Repollet, Psy.D.
Licensed Clinical Psychologist
Certified School Psychologist
Ellen Joseph, PhD
Licensed Clinical Health Psychologist
Managing a chronic illness like Inflammatory Bowel Disease (IBD) can be overwhelming and challenging. This, coupled with the beautiful yet also overwhelming journey of planning for, becoming, and navigating pregnancy, can feel even more daunting for individuals with IBD.
What is IBD?
IBD is a life-long disease that causes inflammation of the gastrointestinal (GI) tract and includes both Crohn’s Disease and Ulcerative Colitis. More specifically, Crohn’s Disease most commonly impacts an individual’s small bowel (ileum) and large intestine (colon); however, any part of the GI tract can be affected (Crohn’s & Colitis Foundation, n.d.). Like Crohn’s Disease, Ulcerative Colitis also causes inflammation of the GI tract, although this inflammation is localized to the colon. Despite these differences, both conditions cause similar symptoms, including but not limited to diarrhea, abdominal pain, and fatigue (Crohn’s & Colitis Foundation, n.d..).
Prenatal Planning, Managing Flares, & IBD
IBD is most often diagnosed between the ages of 15 and 30 (Yale Medicine, n.d.), which largely encompasses one’s reproductive years; thus, many individuals navigating initial diagnosis of and adjustment to IBD may also be in a developmental period when planning for pregnancy is a more common consideration. First and foremost, when thinking about becoming pregnant, it is important for individuals to explore with their gastroenterologist whether their IBD is well-controlled. Open discussions with a gastroenterologist about the desire to conceive are essential for ensuring that IBD is well-managed before pregnancy, which can help reduce the risks for both the parent and baby. Additionally, these conversations can help guide delivery planning based on prior surgeries or complications and determine the safest medication regimen to maintain remission while minimizing risks to the fetus.
Experiencing active inflammation (i.e., an IBD “flare-up”) during conception or pregnancy could cause fertility issues and significant complications for both the parent and baby. Research has found that an IBD patient’s fertility (whether the patient has male or female reproductive organs) can decrease during flare-ups (Caballero-Mateos et al., 2023). Some individuals with female reproductive organs can also experience reduced fertility if they have a history of undergoing IBD surgeries, such as colectomies with J-pouches, which could reduce fertility (Peifer, 2024).
Beyond fertility considerations, active disease during pregnancy increases the risk of complications, including miscarriages, low maternal weight gain, pre-eclampsia, pre-term births, and low birth weight infants (Boyd et al., 2015). In terms of delivery, most individuals with IBD can safely have vaginal births; however, cesarean section may be recommended for cases involving active perianal disease or history of ileal pouch surgery (Liu et al., 2024). Given that Crohn’s Disease can lead to perianal fistulas or abscesses, vaginal delivery could increase the risk of perianal injury (Cheng et al., 2014). These risks highlight the importance of working closely with a gastroenterologist and obstetrician to make informed decisions during pregnancy.
Managing Flares
Research has demonstrated that remission is the ideal disease state for pregnancy. Patients whose IBD was well controlled at the time of conception are more likely to remain in remission throughout pregnancy and postpartum (Mogadam et al., 1981). Hashash & Kane (2015) found that approximately 66% of IBD patients who conceive when their disease is active experience continuing or worsening symptoms.
Diagnostic & Treatment Consideration:
Gastroenterologists can safely diagnose and manage IBD flares during pregnancy. Diagnostic procedures, including colonoscopy, sigmoidoscopy, upper endoscopy, rectal biopsy, and abdominal ultrasound, can all be safely conducted on pregnant individuals (Crohn’s & Colitis Foundation, 2015). While CT scans and X-rays are typically avoided, MRIs (without contrast if administered during the first trimester) can be performed (Crohn’s & Colitis Foundation, 2015).
IBD medications play a crucial role in controlling flares. Many IBD medications, including infliximab, adalimumab, certolizumab pegol, golimumab, and biosimilars, are safe and recommended during pregnancy to prevent flares. Further, newer medications, such as vedolizumab and ustekinumab, are also showing promising results in pregnant individuals. However, some medications may need to be discontinued before conception due to risks, such as methotrexate and steroids. Methotrexate should be stopped 3 to 6 months before conception for individuals with male or female reproductive organs (Peifer, 2024). Gaidos (2020) notes that steroids should be avoided during pregnancy unless necessary for flare management, as they can increase the risk of gestational diabetes and low birth weight.
The Role of Stress & Mental Health
The link between maternal mental health and IBD is also important to explore. For instance, research has found that having IBD is often inaccurately viewed as a potential threat to fertility and reproductive health, thus causing increased anxieties and worries in pregnant patients (Homer-Perry et al., 2024). This concern is compounded by the high prevalence of perinatal mood and anxiety disorders (PMADs), which impact approximately 15% to 21% of pregnant and postpartum individuals (Byrnes, 2018). The intersectionality between PMADs and stress related to managing a chronic health condition like IBD can result in profound effects. More generally speaking, stress can impact a patient’s IBD symptoms given the strong connection between the brain and the gut. Stress is linked to increased inflammation due to the release of stress hormones in the body, causing more frequent or severe GI upset (Osso & Riehl, 2024). This, in turn, could then potentially increase the risk IBD flare and result in harm to the patient and/or fetus. Because of this, it is vital that IBD patients who are considering pregnancy or are pregnant receive the appropriate support and interdisciplinary collaboration needed to navigate this delicate time.
The profound impact of IBD on maternal mental health extends beyond pregnancy-related anxieties, influencing daily functioning and contributing to broader emotional and social challenges. A study exploring the impact of IBD on everyday life found that more than half of the study’s participants experienced a significant impact on daily life functioning, including work, education, and social relationships (Kim et al., 2017). Understandably, these challenges and persistent problems can begin to take a toll on one’s mental health and general well-being. Patients with IBD have also been found to experience mental health issues at a higher rate than those without. Studies have shown that IBD patients are two to three times more likely to develop depression and anxiety (Neuendorf, Harding, Stello, Hanes, & Wahbeh, 2016), particularly if they identify as women (Fracas et al., 2023). These intersecting challenges are more pronounced during pregnancy when the physical and emotional demands of managing IBD are compounded by the unique needs and concerns associated with maternal health. Consequently, the need for comprehensive prenatal planning and care that addresses all areas of managing IBD and ensures optimal outcomes for both the parent and baby is imperative.
Partnering with a Multidisciplinary Team
Prenatal:
As mentioned, early conversations with one’s GI provider can help ensure that medications are appropriately adjusted, disease remission is maintained, and potential risks are managed ahead of time. Furthermore, a collaborative approach between the GI provider and obstetrician is key to optimizing both maternal and fetal health. It is also often recommended that IBD patients see a maternal fetal medicine (MFM) specialist. These physicians, who are obstetricians with advanced training in high-risk pregnancies, can provide recommendations regarding fetal monitoring and prenatal care (American Gastroenterology Association, n.d.). A colorectal surgeon may also be necessary for patients with a surgical history (e.g., for ostomy management) (Mahadevan et al., 2019).
Other Multidisciplinary Providers
IBD patients may also consider seeing other professionals during the pre- and postnatal periods. For instance, dietitians can address vitamin deficiencies and challenges regarding food absorption associated with active disease. Patients with IBD may benefit from consulting with lactation specialists who are knowledgeable about working with individuals with IBD and/or chronic health issues. Given the additional stressors pregnancy naturally brings, it is important for IBD patients to receive adequate mental health care during the prenatal period. A gut-brain therapist and/or therapist specializing in IBD can be particularly helpful, as they are experts in managing the emotional and psychological challenges faced by IBD patients. Mental health therapies such as Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), Mindfulness-Based Stress Reduction (MBSR), and gut-directed hypnotherapy have been found to effectively address these challenges and support emotional well-being during pregnancy.
Steps for Providers:
To further support individuals with IBD during pregnancy, healthcare providers can take several proactive steps, such as:
- Encourage Open Communication – Patients should be encouraged to maintain regular communication with their gastroenterologist and obstetrician before conception and throughout pregnancy to optimize care and minimize potential risks.
- Facilitate Provider Collaboration – Utilizing Release of Information (ROI) forms can enable seamless communication between the GI provider, obstetrician, MFM doctor, primary care physician, and any other specialists involved in the patient’s care. This interdisciplinary collaboration ensures informed decision-making and comprehensive management of IBD during pregnancy.
- Support Stress Management – Given the bidirectional relationship between stress and IBD symptoms, it is crucial to provide resources for stress reduction and mental health support.
By fostering communication, provider collaboration, and stress management strategies, healthcare teams can empower individuals with IBD to navigate pregnancy with confidence and improve health outcomes for both the parent and baby.
If you’re looking to gain further insight and support on managing IBD in pregnancy, please see the resources below:
- GI Psychology
- CC&F: Pregnancy & IBD
- IBD & Pregnancy Discussion Guide
- American Gastroenterological Organization: IBD & Healthy Pregnancies
References
American Gastroenterological Association. (n.d.). Thinking about becoming pregnant? My IBD Life. Retrieved January 21, 2025, from https://myibdlife.gastro.org/scenarios/thinking-about-becoming-pregnant/
Boyd, H. A., Basit, S., Harpsøe, M. C., Wohlfahrt, J., & Jess, T. (2015). Inflammatory bowel disease and risk of adverse pregnancy outcomes. PloS One, 10(6), e0129567. https://doi.org/10.1371/journal.pone.0129567
Byrnes, L. (2018). Perinatal mood and anxiety disorders. The Journal of Nurse Practitioners, 14(7), 507–513.
Caballero-Mateos, A. M., Quesada-Caballero, M., Cañadas-De la Fuente, G. A., Caballero-Vázquez, A., & Contreras-Chova, F. (2023). IBD and motherhood: A journey through conception, pregnancy and beyond. Journal of Clinical Medicine, 12(19), 6192. https://doi.org/10.3390/jcm12196192
Cheng, A. G., Oxford, E. C., Sauk, J., Nguyen, D. D., Yajnik, V., Friedman, S., & Ananthakrishnan, A. N. (2014). Impact of mode of delivery on outcomes in patients with perianal Crohn’s disease. Inflammatory Bowel Diseases, 20(8), 1391–1398. https://doi.org/10.1097/MIB.0000000000000093
Crohn’s & Colitis Foundation. (n.d.). Overview of Crohn’s Disease. https://www.crohnscolitisfoundation.org/patientsandcaregivers/what-is-crohns-disease/overview
Crohn’s & Colitis Foundation (2015). Pregnancy fact sheet. https://www.crohnscolitisfoundation.org/sites/default/files/legacy/assets/pdfs/pregnancyfactsheet.pdf
Fracas, E., Costantino, A., Vecchi, M., & Buoli, M. (2023). Depressive and anxiety disorders in patients with inflammatory bowel diseases: Are there any gender differences?. International Journal of Environmental Research and Public Health, 20(13), 6255. https://doi.org/10.3390/ijerph20136255
Gaidos, J. K. J. (2020, June). Medication during pregnancy. Crohn’s & Colitis Foundation. https://www.crohnscolitisfoundation.org/clinical-pearls/medication-during-pregnancy?
Hashash, J. G., & Kane, S. (2015). Pregnancy and inflammatory bowel disease. Gastroenterology & Hepatology, 11(2), 96–102.
Homer-Perry, R., Czuber-Dochan, W., Wade, T., Purewal, S., Chapman, S. C.E., Brookes, M., Selinger, C. P., & Steed, H. (2024). Full title: “hopes, worries and expectations” experiences of pregnancy with inflammatory bowel disease: An interpretative phenomenological analysis study. Heliyon, 10(11). https://doi.org/10.1016/j.heliyon.2024.e31954
Kim, Y. S., Jung, S. A., Lee, K. M., Park, S. J., Kim, T. O., Choi, C. H., Kim, H. G., Moon, W., Moon, C. M., Song, H. K., Na, S. Y., Yang, S. K., & Korean Association for the Study of Intestinal Diseases (KASID) (2017). Impact of inflammatory bowel disease on daily life: An online survey by the Korean Association for the Study of Intestinal Diseases. Intestinal Research, 15(3), 338–344. https://doi.org/10.5217/ir.2017.15.3.338
Liu, E., Chatten, K., & Limdi, J. K. (2024). Conception, pregnancy and inflammatory bowel disease—current concepts for the practising clinician. Indian Journal of Gastroenterology. https://doi.org/10.1007/s12664-024-01563-9
Mahadevan, U., Robinson, C., Bernasko, N., Boland, B., Chambers, C., Dubinsky, M., … & Kane, S. (2019). Inflammatory bowel disease in pregnancy clinical care pathway: A report from the American Gastroenterological Association IBD Parenthood Project Working Group. Gastroenterology, 156(5), 1508–1524. https://doi.org/10.1053/j.gastro.2018.12.022
Mogadam, M., Korelitz, B. I., Ahmed, S. W., Dobbins, W. O., 3rd, & Baiocco, P. J. (1981). The course of inflammatory bowel disease during pregnancy and postpartum. The American Journal of Gastroenterology, 75(4), 265–269.
Neuendorf, R., Harding, A., Stello, N., Hanes, D., & Wahbeh, H. (2016). Depression and anxiety in patients with Inflammatory Bowel Disease: A systematic review. Journal of Psychosomatic Research, 87, 70–80. https://doi.org/10.1016/j.jpsychores.2016.06.001
Osso, M., & Riehl, M. (2024, August 7). Stress and IBD: Breaking the vicious cycle. crohnscolitisfoundation.org. https://www.crohnscolitisfoundation.org/blog/stress-and-ibd-breaking-the-vicious-cycle
Peifer, R. (2024, January 26). IBD and pregnancy: What you need to know. Crohn’s & Colitis Foundation. https://www.crohnscolitisfoundation.org/blog/ibd-and-pregnancy-what-you-need-to-know
Yale Medicine. (n.d.). Inflammatory bowel disease. https://www.yalemedicine.org/conditions/inflammatory-bowel-disease