Uma Mahadevan, MD, on Managing IBD During Pregnancy

Appropriate interdisciplinary care is of crucial importance in treating pregnant women who also suffer from inflammatory bowel diseases, Uma Mahadevan, MD, said during her presentation at the Advances in Inflammatory Bowel Disease annual meeting in Orlando, Florida, on December 6.

Dr Mahadevan is a gastroenterologist and a professor of medicine and director of the center for colitis and Crohn’s disease at the University of California in San Francisco. She specializes in IBD particularly related to pregnancy and fertility and is involved in trials of new drugs and dietary therapies.

She also was awarded the Sherman Prize 2022 at the conference.

Women with IBD who are considering having children face a number of questions about how to ensure a safe pregnancy and a healthy baby. In her presentation, Dr Mahadevan used case studies to discuss appropriate medication and managing flares and active inflammation.

Women with IBD have higher rates of pregnancy complications, Dr Mahadevan said, which may manifest as spontaneous abortion, preterm birth, low birth weight or complications of labor and delivery. Active disease and surgical history may increase the likelihood of adverse events.    Malnutrition due to food avoidance by the mother, breastfeeding difficulties, emotional and mental health, and concerns about administering live vaccines to the infant during its first 6 months are all issues that should be considered and discussed.

“Getting the obstetricians, gastroenterologists, colorectal surgeons, nutritionists, psychologists, lactation consultants, and pediatricians to work closely together, we could provide effective multidisciplinary care to pregnant woman who are starting an important chapter in their lives,” she said.

While all women face some challenges in their reproductive health, women with IBD face an even larger number of barriers. Pregnant women are often excluded clinical trials even if drug classes have known safety or low risks. Women of child-bearing age may be prevented from receiving JAK inhibitors, even if they do not plan to become pregnant. Approximately 68% of women are advised by their obstetricians to discontinue anti-TNFs if they become pregnant. If the mother is breastfeeding and also treated with infliximab, live vaccines are not advised for infants until after they reach 6 months of age.

Dr Mahadevan spoke in detail about the Pregnancy Inflammatory Bowel Disease And Neonatal Outcomes (PIANO) study that focuses on short- and long-term outcomes of IBD medications on pregnancy and children. The study revealed that among the 1,431 live births registered, “corticosteroid use was associated with increased risk of preterm birth, smaller gestational age, low birth weight, intrauterine growth restriction, and neonatal intensive care unit (NICU) admission.” Results from the PIANO registry “emphasized the importance of controlling disease activity before and during pregnancy with steroid-sparing therapy,” she said.

Another study by Mahadevan et al found that “biologic, thiopurine, or combination therapy exposure during pregnancy was not associated with increased adverse maternal or fetal outcomes at birth or in the first year of life.” Of the 1431 live births, exposure to thiopurines (n = 242), biologics (n = 642), both (n = 227), and unexposed (n = 379) were recorded. The drug exposures did not increase the rate of congenital malformations, spontaneous abortions, or infections in the first year of life. Meanwhile, “higher disease activity was associated with risk of spontaneous abortion (HR 3.41; 95% CI, 1.51-7.69) and preterm birth with increased infant infection (odds ratio, 1.73; 95% CI, 1.19-2.51).”

A systematic review and meta-analysis of the safety of vedolizumab and ustekinumab during pregnancy in patients with IBD found that the drugs were safe, with favorable outcomes. Out of the 54 pregnancies exposed to ustekinumab and 39 to vedolizumab, there were no negative safety signals in the postnatal outcome of exposed children regarding growth, psychomotor development, and risk of allergy/atopy or infectious complications. In the ustekinumab group, 43 (79.9%) resulted in live births, and 11 (20.4%) led to spontaneous abortion. In the vedolizumab group, 35 (89.7%) resulted in live births, 2 (5.1%) in spontaneous abortion, and 2 (5.1%) in therapeutic abortion.

Dr Mahadevan encouraged physicians and patients to have a thoughtful discussion about counseling, monitoring, and medication adherence, to minimize the risks to both mom and baby.

—Priyam Vora

Reference:
Mahadevan U. Rick MacDermott lecture in advanced and multidisciplinary care in IBD: Management of IBD in pregnancy. Presented at: Advances in Inflammatory Bowel Disease Annual Meeting; December 6, 2022. Orlando, Florida.