Considerations in Managing Pregnancy Among Patients with IMIDs

When talking about managing pregnancy among patients with immune mediated inflammatory diseases, we also need to consider women who have had miscarriages, and not just postpartum, Christopher Robinson, MD, said at the Interdisciplinary Autoimmune Summit (IAS) virtual session day 3. “We always talk about prepregnancy or postpartum, but seldom about the patient who has miscarried. They deserve a special mention too.”

Christopher Robinson, MD, is the chair of obstetrics and gynecology and the director of the maternal fetal medicine at Charleston Maternal Fetal Medicine in Mount Pleasant in South Carolina.

Pregnant women with immune-mediated inflammatory disease (IMID), either in the form of Crohn disease, ulcerative colitis, ankylosing spondylitis, rheumatoid arthritis, or psoriasis/psoriatic arthritis, are more prone to have disease flares after discontinuing biologics, Uma Mahadevan, MD, said. The appointment with your doctor or specialist discussing what’s ahead is usually used to advise patients on whether their medication should be adjusted and decide on the best time to conceive based on the status of their condition.

Dr Mahadevan is a professor of medicine and director of the Center for Colitis and Crohn’s Disease at the University of California San Francisco. She is also the recipient of the Sherman Emerging Leader Prize 2022 in honor of her work on the ongoing PIANO study of pregnancy in IBD.

Among pregnant women with IMIDs, those who continued biologics during pregnancy faced an increased risk of major infection, disease related hospital admission, glucocorticoid use, and disease flare within 6 months post-partum. However, these same patients did not face any significant change in maternal or neonatal outcomes. “One of the approaches that we take up is to maintain a steady medication course with the patient, without making any sudden changes or adjustments, to keep them in remission,” Dr Robinson said.

Dr Mahadevan also pointed out a common misconception that patients with IBD also face infertility issues. “That is far from the truth,” Dr Mahadevan said. “The infertility rate in large population-based studies of patients with IBD is similar to that in the general population and ranges from 5 to 14%. Women with IBD face fertility issues, in fact, from psychological problems and mechanical problems related to repeated surgery.”

Can IMID medications be continued through pregnancy? Can IMID medications be continued through lactation? The answers vary from individual to individual, but IMID medications are commonly known to be safe and used in the duration on pregnancy and post-partum. “In general, immunomodulating drugs that are not contraindicated in pregnancy are compatible with breastfeeding,” Dr Mahadevan noted.

Dr Mahadevan listed methotrexate and thalidomide as medications that are traditionally used to treat moderate to severe autoimmune conditions but are known to have safety concerns and monitoring requirements when used in lactation. Both methotrexate and thalidomide are considered contraindicated by most references.

Additionally, mesalamine with dibutyl phthalate, corticosteroids, ozanimod, tofacitinib, and upadacitinib are also medications to avoid during pregnancy and postpartum, in some cases due to lack of adequate experience with the drugs since their recent introduction.

Mesalamine/sulfasala, azathioprine/6 mercaptopurine, anti-TNF agents, interleukin-23 inhibitors such as ustekinumab and risankizumab, anti-integrins such as vedolizumab, and aspirin, however, are cleared for usage for pregnant and nursing mothers.

Mothers must be encouraged to make well-informed decisions based on the evidence available, Dr Mahadevan concluded. “Women require individualized and comprehensive support in managing both their medical conditions and their nursing relationships with their children, in order to ensure optimal maternal health and breastfeeding outcomes.”

“Usually when I meet pregnant patients, I ask them if they want a healthy placenta or a healthy baby; they look at me as if the answer is obvious — a healthy baby. That’s when I correct them that you should aim for a healthy placenta, because the placenta does 80-90% of the metabolic work of ensuring the baby remains healthy,” Dr Robinson said. “It is important to be careful and maintain a steady routine from the beginning of the pregnancy journey.”

—Priyam Vora

Reference:

Mahadevan U, Robinson C. Ask the expert: Managing IMIDs before, during and after pregnancy. Interdisciplinary Autoimmune Summit. April 26-28, 2023. Virtual.