Learning Objectives:
- Identify risk factors for reduced fertility and adverse pregnancy outcomes
- Describe appropriate management of IBD through conception and pregnancy
- List medications appropriate for use during pregnancy and lactation
- Provide appropriate recommendations for lactation and vaccination in the infant of mothers with IBD
EPAs:
- EPA 1: Classify IBD phenotype, disease activity, and extraintestinal manifestations
- EPA 3: Prescribe and manage evidenced-based IBD therapies using clinical pharmacologic principles in clinical practice
- EPA 5: Manage hospitalized patients with IBD
- EPA 7: Manage IBD in special populations
- EPA 8: Recognize the importance of psychobehavioral health in IBD and implement
- psychosocial support strategies
- EPA 9: Evaluate and manage nutritional health status in patients with IBD
Discussion
Ideally women should be in endoscopic and symptomatic remission, free of steroids, for at least 3 months prior to considering conception. Mayo 1 disease in an asymptomatic patient is not, of itself, an indication for a biologic, so increasing the mesalamine was reasonable. Unfortunately, she never started it and experienced a flare. Women with UC tend to flare more often than women with Crohn’s disease during pregnancy. It is unclear if this is due to undertreatment (UC much less likely to be on a biologic than Crohn’s) or because pregnancy triggers UC more directly or both.
A pregnant patient with a flare is addressed similarly to the nonpregnant patient. Unsedated unprepped flexible sigmoidoscopy is low risk and can be performed, particularly if considering starting a biologic. Pregnant women are at increased risk of C. Difficile and this should always be checked. While it is reasonable to increase the mesalamine while completing the rest of the work up, this patient should be followed closely for worsening disease. Corticosteroids can be used if needed, but if biologics can be started quickly then going straight to them is preferred.
All current biologics approved for Crohn’s disease and UC are appropriate for use throughout pregnancy and lactation. Methotrexate, a known abortifacient and teratogen, should not be used during pregnancy, conception and lactation. Azathioprine/6-mercaptopurine can be continued throughout pregnancy and lactation, but generally should not be started for the first time in a pregnant patient given risks of leukopenia and pancreatitis, though rare. Jak inhibitors like tofacitinib have been associated with congenital anomalies in animals and should be avoided in pregnancy and lactation if possible.
References:
- Mahadevan U, et al. Inflammatory Bowel Disease in Pregnancy Clinical Care Pathway: A Report From the American Gastroenterological Association IBD Parenthood Project Working Group. Gastroenterology 2019;156:1508-1524.
- Mahadevan U, et al. Pregnancy and Neonatal Outcomes After Fetal Exposure to Biologics and Thiopurines Among Women With Inflammatory Bowel Disease. Gastroenterology 2020.
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