Management of Crohn's Disease in Pregnancy

Preconception Planning

The American Gastroenterological Association recommends achieving clinical remission before conception to optimize pregnancy outcomes and reduce risks of preterm birth, low birth weight, and other complications 2, 3
The American College of Gastroenterology advises stopping methotrexate at least 3-6 months before attempting conception due to teratogenic risk 4, 2, 5
Patients taking sulfasalazine should supplement with 2 mg/day of folic acid starting 3 months before conception to prevent neural tube defects 1, 2
Conception during remission results in similar outcomes to non-pregnant patients with IBD 2

The American Gastroenterological Association recommends that all pregnant patients with Crohn's disease be managed by a gastroenterologist throughout pregnancy 4, 5
Consultation with a high-risk obstetrician is recommended for all pregnant patients with active or complicated disease 4, 5

The American Gastroenterological Association recommends continuing 5-aminosalicylates (5-ASA) maintenance therapy throughout pregnancy 1, 4, 5
Thiopurine maintenance therapy should be continued throughout pregnancy 1, 4, 5
Anti-TNF therapy should be continued throughout pregnancy, as discontinuation risks disease flare 1, 2, 4, 5
Systemic corticosteroids and budesonide are safe during pregnancy 1, 2

The American College of Gastroenterology recommends optimizing combination oral and rectal 5-ASA therapy first for mild to moderate flares 4, 5
Systemic corticosteroids or anti-TNF therapy should be used to induce remission in flares despite optimal 5-ASA or thiopurine therapy 4, 5, 6

Fecal calprotectin should be checked at preconception, during each trimester, and after delivery to screen for active disease 2
Flexible sigmoidoscopy or colonoscopy should be used if results will affect management decisions 4, 5, 6, 7

Radiologic investigations should be limited to ultrasound and MRI without gadolinium 4, 5, 6, 7
Gadolinium should be avoided during pregnancy 2, 8, 9

Anticoagulant thromboprophylaxis should be provided during hospitalization for all pregnant patients with Crohn's disease 4, 5, 6, 7

Cesarean delivery decisions should be based on obstetric indications, not Crohn's disease diagnosis alone 4, 6, 7
Anticoagulant thromboprophylaxis should be provided during hospitalization after cesarean delivery 4, 6, 7

The use of 5-ASA, systemic corticosteroids, thiopurines, or anti-TNF therapy should not influence the decision to breastfeed 4, 6
Methotrexate should be avoided during breastfeeding 6

Maintenance medications should not be discontinued due to pregnancy alone, as active disease poses far greater risks than medications 1, 2, 3
Methotrexate should not be used during pregnancy due to teratogenicity 4, 2, 5
Treatment of active disease should not be delayed, as flares during pregnancy carry high risk of adverse maternal and fetal outcomes 4, 3