Learning Objectives: At the end of this blog, you should feel confident in talking with women on various aspects of care related to pregnancy and IBD. Your discussion needs to provide reassurance that for most women, pregnancy is possible and does not need to be avoided because of IBD.
THE LINK BETWEEN PREGNANCY AND WOMEN WITH IBD
Pregnancy for women is typically a time of anticipation and excitement about the life to come. For women with IBD, this joy is often overshadowed by fears, uncertainty, and misconceptions of their IBD and the medications that they take. Unfortunately, this misconception often keeps women from pursuing their family planning goals.
A systematic review looked at 11 studies in non-surgical IBD patients and women with Crohn's disease. They saw a 17 to 44 percent reduction in fertility, but this was linked to voluntary childlessness. Furthermore, studies have shown that the rate of voluntary childlessness is on the rise among women with IBD.
WHAT TO KNOW WHEN TREATING PREGNANT WOMEN WITH IBD
It's important to set clear goals with your women. Help them understand that establishing remission prior to pregnancy and maintaining that remission helps minimize the risk of flare during pregnancy. Moms in remission at conception are likely to maintain remission. A third of those patients will relapse, but most do not.
How pregnancy impacts IBD is largely dependent on disease activity at the time of conception. If mom has active disease, you can follow the rule of thirds:
- A third of patients will continue to have active disease.
- A third of patients will have worsened disease.
- And a third of patients will have lessened disease.
Active IBD and pregnancy lead to increased risk of adverse pregnancy outcomes, such as miscarriage, small for gestational age infants, premature delivery, and complications of labor and delivery. However, there's been no noted increased risk of congenital abnormalities. I do encourage patients to establish care with maternal-fetal medicine. If that is not available in their area, many times I will contact their local obstetrician to discuss a plan of care.
WHAT TO KEEP IN MIND WHEN EVALUATING AND TESTING YOUR PREGNANT IBD PATIENT
There are some considerations to keep in mind when you're evaluating a pregnant IBD patient. We need to consider the accuracy of the tests to be performed and also the safety for mom and baby. For example, we know that CRP is falsely elevated in pregnancy, but trends may still be helpful. Albumin may be low during pregnancy, and mild anemia may be present. For patients who are symptomatic with diarrhea, it's still important to rule out infectious etiologies, including C. diff and CMV colitis. Keep in mind that a fecal calprotectin can be a helpful, non-invasive test that is as accurate in the pregnant patient as in the non-pregnant patient.
HOW DO ENDOSCOPY AND IMAGING FACTOR INTO PREGNANCY AND IBD?
What about endoscopy and imaging? A nationwide population-based cohort study from the Swedish Medical Birth Registry looked at the exposure of 3,000 pregnancies to endoscopy, and what they noted is that endoscopy is associated with an increased risk of preterm birth or small for gestational age infants, but not an increased risk of congenital malformations or stillbirth. Lower endoscopies, therefore, should be avoided for weak indications during pregnancy and deferred until after the first trimester.
If endoscopy is needed, fetal monitoring should be implemented. And keep in mind that a flexible sigmoidoscopy without sedation could be a safe alternative. With regards to imaging, MR enterography with an adapted protocol for pregnancy is a reliable modality to manage the pregnant woman with known or suspected Crohn's disease. This MR enterography should be performed without IV gadolinium.
One of the most common concerns I hear in my practice from women considering conception is how their medications will affect their baby. Thanks to the data and information collected in the PIANO registry, we are able to reassure moms regarding most medications.
MEDICATIONS FOR IBD IN PREGNANCY
On this slide, you will see a summary of the medical management of IBD in pregnancy. There are a few things I would like to highlight. If mom is on sulfasalazine, it's important to increase folic acid supplementation to two milligrams daily in pregnancy. If mom is on a thiopurine, it is safe to continue the thiopurine. However, thiopurine should never be started during pregnancy due to the risk of pancreatitis. Metronidazole should be avoided in the first trimester. With regards to anti-TNF therapy, these are safe to continue during pregnancy.
If mom is on infliximab, infliximab should be dosed at the pre-pregnancy weight throughout the pregnancy. Anti-TNF therapy should be continued through the third trimesters. Studies have shown that there's no increased risk of infection in babies who are exposed to anti-TNF therapy in the third trimester. Furthermore, studies report that if the anti-TNF therapy is discontinued, there's an increased risk of relapse among moms, which could potentially lead to further complications of the pregnancy.
I'd like to touch a little bit on ozanimod. Ozonimod is a S1P signaling blocker. S1P signaling is found in placental and uterine tissue. There are animal studies that suggest blocking this could cause fetal harm. Therefore, currently in the MS population, ozanimod is not recommended to continue during pregnancy.
PREGNANT WOMEN WITH IBD CAN STILL HAVE A VAGINAL DELIVERY
Another misconception among women with IBD is they will have to have a C-section. Women with IBD do have a one and a half to two-fold greater risk of a C-section. However, most women with inflammatory bowel disease can have a vaginal delivery. Exceptions to this include women who have an active or recent perianal disease or have a history of a rectovaginal fistula. Special considerations on a patient-to-patient basis include patients with a J pouch or an ostomy. Those patients should be reviewed with a colorectal surgeon to discuss the mode of delivery.
POSTNATAL CARE AND RARE INFANT RISKS FOR PREGNANT WOMEN WITH IBD
It's also important to talk to your patients about postnatal care. I often ask my patients what their goals are regarding breastfeeding. We know that most medications can be continued during breastfeeding, but there are a few considerations to keep in mind. First, women breastfeeding should avoid methotrexate, metronidazole, rifaximin, and tofacitinib. Ozanimod at this time is unknown. If the mom is on an aminosalicylate, you should choose mesalamine over sulfasalazine.
Also, you should discuss with mom the rare risk of diarrhea in the infant. Additional follow-up considerations include recommending that if the baby was exposed to a biologic in the third trimester, that live vaccine be avoided for at least six months. However, it is OK to give at one year, even if the baby is being breastfed.
Also for mom, it's important to schedule postpartum follow-up visits, including a complete repeat evaluation three months after delivery.
I'd like to close this lecture with a case. McKenna is a 23 year old female diagnosed with ileocolonic Crohn's disease at 17 years old. She's been in endoscopic and clinical remission for two years on infliximab, five milligrams per kg every eight weeks, and azathioprine 1.5 milligrams per kg per day. In the past, she flared with an attempted taper of her azathioprine. She comes in for a routine six-month visit and continues to feel well. She is excited to share with you that she is engaged.
What recommendations would you have for McKenna?
A) have her call you if she decides to become pregnant so you can stop her azathioprine
B) reassure her that her medications are safe during pregnancy and breastfeeding
C) Discourage pregnancy because it could make her IBD worse
D) hold her infliximab starting in the second trimester.
(Answer is below).
The answer to this question is B. You can reassure her that her medications, infliximab and azathioprine, are safe during pregnancy and breastfeeding.