The American Gastroenterological Association (AGA) has issued a new report designed to standardize the management of inflammatory bowel disease (IBD) in pregnancy.
Published in Gastroenterology, the guide, “Inflammatory Bowel Disease (IBD) Clinical Practice Pathway,” is intended as a practice resource addressing the continuum of care from preconception to the postpartum period for IBD patients. The report is also scheduled for publication in Inflammatory Bowel Diseases and the American Journal of Obstetrics and Gynecology.
Whereas pregnancy and IBD were once considered a risky combination, the proliferation of therapeutic options in the past 15 years has given hope to IBD patients who wish to bear children. There is still lingering fear, however, about the impact of IBD and its therapies on pregnancy and infant outcomes, and conversely, about the impact of pregnancy on IBD on maternal health.
“Oftentimes, the default is to stop all therapies through pregnancy and lactation despite the significant risk of worsening disease activity, which is the greatest known risk to pregnancy outcome,” wrote Uma Mahadevan, MD, of the University of California San Francisco, and co-authors.
“With so many different new medications, 70% to 80% of patients and general practitioners were worried they didn’t have the correct information,” Sonia Friedman, MD, of Brigham and Women’s Hospital in Boston told MedPage Today. “People will be relieved to have a standardized approach to managing IBD in pregnancy and especially to know that biologics are safe.”
Added Manreet Kaur, MD, of Baylor College of Medicine in Houston, who was not involved with the report: “This will be a very useful clinical tool. It is very relevant since so many women are diagnosed during their reproductive years and so much of the decision-making has been mired in fear and uncertainty. But this provides comprehensive evidence-based information so women can make the right decisions from before conception to the postpartum period.”
Controlling Maternal Disease
The primary focus of the clinical pathway outlined in the report is controlling maternal disease. “Control of the inflammation of the mother will improve outcomes for the child,” study co-author Marla Dubinsky, MD, of the Icahn School of Medicine at Mount Sinai in New York City, told MedPage Today. “Often the emphasis has been on the baby and how the mother’s systemic inflammation may impact the pregnancy, but if we control the mother’s disease, outcomes such as preterm birth, low birth weight, and possibly pre-eclampsia may actually be reduced.”
“That means that if a woman has needed anti-TNF therapy, then she should keep to the same medication schedule in pregnancy. The risk from flare is greater than any risk to the baby from the drugs,” said Dubinsky, who along with Friedman is a member of the AGA’s IBD Parenthood Project Working Group.
Another focal point of the guide is preconception counseling to ensure disease control in advance of pregnancy. “The most important part of care is to get the IBD into deep remission, since even subtle, subclinical disease can impact everything from getting pregnant to the postpartum period,” Dubinsky said.
Among the resource’s many detailed recommendations are the following:
Fertility Concerns. Women in remission from IBD and UC who have never had surgery should be reassured that fertility rates are equal to those in the general population. Those, however, who have had ileal pouch-anal anastomosis, proctectomy, and permanent ostomy have reduced fertility. IBD medical therapies, including all biologics, steroids, thiopurines, methotrexate, and 5-aminosalicylic acid, do not decrease fertility.
Genetic risk. Patients should be reassured that the risk of having an IBD-affected child is often overestimated. The absolute risk of a child’s developing Crohn’s disease (CD) in the setting of maternal CD is 2.7%; the risk of ulcerative colitis (UC) in the setting of maternal UC is 1.6%.
Preconception counseling. This should include a recommendation for a remission of 3 to 6 months before conception to reduce the risk of flaring along the spectrum from conception to gestation and postpartum; preconception care should optimize nutritional status, maintain iron and folic acid supplementation, and the achievement, if possible, of an ideal weight.
Multidisciplinary care. The pregnant IBD patient should ideally be monitored by a gastroenterologist and a specialist in maternal-fetal medicine and may need consultation with a nutritionist.
Disease management. Care providers must check laboratory values and correct any abnormalities as well as supplement with folic acid; corticosteroids may increase the risk of gestational diabetes and adverse pregnancy outcomes, and are not recommended as maintenance therapy.
Medications. Methotrexate must be stopped at least 3 months before conception owing to its teratogenicity; thiopurines and biologics are considered low-risk during pregnancy and breastfeeding; serum drug levels of biologics should be measured and escalated or de-escalated as necessary, before conception.
Delivery. Vaginal delivery is safe in most cases, unless active perineal disease is present around the time of delivery; cesarean section is recommended for women with previous rectovaginal fistulas since avoiding perineal trauma may prevent recurrent damage or incontinence.
Postpartum care. Biologics may be resumed 24 hours after vaginal delivery and 48 hours after cesarean delivery; methotrexate again excepted, other IBD medications should be continued in the postpartum period.
Ostomy management. In patients with ostomy, stomal problems such as displacement, enlargement, retraction, stenosis, and prolapse may occur because of the stretching of the abdominal wall. Patients should work with a nutritionist if needed to avoid excessive weight gain.
Breastfeeding. Most IBD medications are either undetectable in breast milk or present in concentrations too low to the infant. The Pregnancy in Inflammatory Bowel Disease and Neonatal Outcomes registry found that infants exposed to immunomodulators, biologics, or combination therapy had similar milestone achievement and were no more susceptible to infections in the first 12 months of life than unexposed infants. No IBD treatments are known to suppress lactation. The galactagogue fenugreek is not recommended as it may cause diarrhea and bleeding.
Developmental milestones. No evidence suggests that babies born to mothers with IBD, regardless of medication exposure, have any developmental delays. Pro-inflammatory mediators, however, have been shown to negatively influence brain development, further underscoring the need for good inflammatory control during pregnancy.
The report was prepared for the AGA by the IBD Parenthood Project Working Group.
Mahadevan disclosed ties to Janssen, Abbvie, Pfizer, Takeda, Celgene, Lilly, and Samsung; several other co-authors reported relationships with companies including Pfizer, Takeda, AbbVie, Prometheus Labs, Amgen, AstraZeneca, Apotex, Barr Laboratories, Bristol-Myers Squibb, Celgene, Gerber Foundation, GlaxoSmithKline, Janssen, Kali Laboratories, Hoffman La Roche-Genentech, Sandoz, Genzyme Sanofi-Aventis, Regeneron, Sequirus, Teva, UCB, Boehringer Ingelheim, Prometheus, Salix, Shire, Spherix Health, Seres, and Gilead.
Kaur disclosed no competing interests relevant to her comments.