Pregnancy in the IBD Pathway
Translating the concerns surrounding the care of patients with inflammatory bowel disease (IBD) who are or want to become pregnant into a clinical care pathway requires careful attention to disease management, medication choices, overall health maintenance, and the special concerns of conception, pregnancy, and postpartum care, Kim Isaacs, MD, said at the Advances in Inflammatory Bowel Disease (AIBD) virtual regional meeting on September 12.
Dr Isaacs is a professor of medicine in the division of gastroenterology and hepatology at the University of North Carolina, Chapel Hill.
She suggests that gastroenterologists consider restaging their patients’ disease prior to conception via colonoscopy and/or computed tomographic enterography, and evaluation of laboratory markers such as C-reactive protein and fecal calprotectin.
“Disease activity at conception predicts disease activity through pregnancy,” Dr Isaacs stated. Approximately 25% of patients who flare during pregnancy have preterm deliveries compared with 8% who do not have flares, and 30% deliver low-birth-weight neonates, compared with 3% who go through pregnancy without disease activity. “The goal should always be to attain remission prior to trying to conceive,” she said.
The biggest concern for most patients with IBD is the safety of their medications during pregnancy, Dr Isaacs said. She cited a study conducted in the French national health system from 2011 to 2014, which assessed disease, treatment, and pregnancy-related complications during pregnancy, and infections during the first year of life for infants born to women who remained on continuous treatment with biologics during pregnancy.
This study found more infections in patients with IBD exposed to biologics than to those who were not exposed, but there was no difference in the incidence of complications if the women were treated with anti-tumor necrosis factor (TNF) inhibitors beyond 24 weeks of pregnancy. However, there was a significant increase in the relapse rate among patients who stopped their biologic treatment at 24 weeks of pregnancy. “The study also found no increased risk of infections in children exposed to anti-TNF up to 1 year of life,” Dr Isaacs reported.
She recommended that patients treated with biologics should continue the same treatment after conceiving. With infliximab, “try to work out timing so that the last dose is given around week 32 or 33, then give a dose after delivery,” Dr Isaacs advised. For patients being treated with adalimumab or golimumab, “try to give the last dose at 36 to 38 weeks if the patient is on biweekly dosing, then dose after delivery.” Patients using certolizumab can maintain their normal dosing schedule.
Because there is limited data on the safety of usekinumab and vedolizumab in pregnancy, Dr Isaacs recommended that the final pregnancy dose be administered 6 to 10 weeks before delivery, and then regular dosing should resume postpartum. Tofacitinib should be avoided or used carefully due to lack of data on safety during pregnancy.
She said that aminosalicylates (5-ASAs) are safe to continue during pregnancy, but patients should increase folate supplementation to 2 mg/d if they are being treated with sulfasalazine. Thiopurines are generally safe at the doses used to treat IBD, but there is potential for increased infant infections with combination therapy. “In appropriate patients on combination therapy, consider stopping thiopurines,” Dr Isaacs said. Amoxicillin and metronidazole are preferred over ciprofloxacin when antibiotics are needed in pregnant patients, she added.
Methotrexate therapy should be stopped at least 3 months prior to conception, Dr Isaacs stated. Steroids should also be tapered prior to conceiving. “Steroids can be used for flares, but at the lowest amounts possible to control disease,” she said.
Patients who wish to conceive should optimize nutrition and maintain a healthy weight before becoming pregnant, Dr Isaacs added, noting that the PIANO study revealed that inadequate gestational weight gain predicts adverse pregnancy outcomes.
If a patient’s IBD is in remission when she becomes pregnant, Dr Isaacs said, she should visit her gastroenterologist during the first or second trimester and then as needed while receiving routine antepartum care with an obstetrician. Dr Isaacs recommended that complete blood cell count, liver panel, albumin, and regular obstetric lab testing should be done in each trimester.
The patient should also be examined for any active perineal fistulas and plan the mode of delivery with the gastroenterologist.
In the case of a pregnant patient with an IBD flare, Dr Isaacs said, “You should be doing visits every 2 weeks, monitor fecal calprotectin, and adjust medication as needed.” Fetal growth surveillance, antepartum surveillance for patients with active disease in the third trimester, and fetal assessment, including early glucose testing if the patient is taking steroids to control flares, are also indicated. Ultrasound cervical length screening and nutritional counseling are also important, she stated.
At 35 weeks, the gastroenterologist should do a group B strep culture and inspect the perineum as part of helping the patient plan for safe delivery, Dr Isaacs advised. For patients with a history of rectovaginal fistula or active perineal disease, the best option is cesarean section.
Patients without perineal disease can opt for vaginal delivery. A patient who has undergone ileal pouch/anal anastomosis may be able to deliver vaginally, “based on risk to the anal sphincter,” Dr Isaacs said.
Most therapeutics are safe to use while breastfeeding, with the exceptions of methotrexate and tofacitinb, she said. Neonates born to women who were treated throughout pregnancy with biologics should not receive live vaccines during the first 6 months, but by 1 year postpartum, they can safely receive the measles-mumps-rubella and varicella vaccines.
During the postpartum period, gastroenterologists should assess clinical disease activity and “talk about potential times that we see flares—after delivery, after stopping breast feeding.”
Dr Isaacs reported that one of her patients successfully conceived 2 months after ileal resection for medically refractory Crohn disease, did well during her pregnancy, and gave birth to a healthy son. “Pregnancy is safe in patients with IBD,” she said, “with appropriate planning and careful monitoring.”
—Rebecca Mashaw
Reference:
Isaacs K. Pregnancy in IBD Pathway. Talk presented at: Advances in Inflammatory Bowel Disease 2020 regional meeting; September 12, 2020; virtual.