Dr Charabaty reviews her presentation from the Advances in Inflammatory Bowel Diseases regional meeting in Chicago on helping patients plan for conception, choose the right medications, and ensure a healthy mom and baby.

Aline Charabaty, MD, is the assistant clinical director of the division of gastroenterology and hepatology at Johns Hopkins School of Medicine in Baltimore, Maryland, and the clinical director of the IBD Center at Johns Hopkins Sibley Memorial Hospital in Washington, DC.

TRANSCRIPT:

Hi everyone. I'm Dr. Aline Charabaty. I'm the assistant clinical director of the Division of Gastroenterology and Hepatology at Johns Hopkins School of Medicine, and the clinical director of the IBD Center at Johns Hopkins Sibley Memorial Hospital in Washington, DC. We had amazing sessions at AIBD Chicago and I'm here to share with you some lessons that we learned together. So let's talk about inflammatory bowel disease and pregnancy.

As we know, IBD often affects women of childbearing age. So it's really important to be comfortable taking care of patients with IBD who are pregnant, and it's important to understand how we can optimize the mom’s and the baby's health during these times. The most important message that I want to leave you with is that a healthy mom means a healthy pregnancy, which also means a healthy baby. So this is the key concept. And based on that, I want to leave you with 3 messages.

One is that most inflammatory bowel disease medications are safe during pregnancy and during breastfeeding, and that includes mesalamine, thiopurine, and biologics. So it is very important to keep the patients on the medication that's keeping their disease in remission, and that is keeping them steroid-free during pregnancy and beyond. The second point is that it's important to initiate the discussion about pregnancy way before it happens. This is not a conversation you want to have once the patient is pregnant and maybe they stop the medication that they thought could harm their baby. So it's important to really talk to any of your patients that are of childbearing age, and start counseling them about the key principles of managing IBD before pregnancy, and during pregnancy, and during breastfeeding, etc.

Finally, when planning for a pregnancy, involve the right team for the right patient to optimize outcomes. So that could include an IBD specialist, a maternal-fetal medicine physician or an OBGYN who is comfortable in managing IBD, a nutritionist if needed, a primary care doctor to help with counseling, for example, to stop smoking, stop alcohol, etc. So involve the right team for your patient to optimize patient outcome.

Let's first talk about prepregnancy counseling. The best time for a patient to get pregnant is when the patient is in stable remission, both clinically and by endoscopy, off steroids, on a stable treatment regimen for at least 3 to 6 months. It is very important to confirm endoscopic remission, and make the necessary adjustments before conception, because we know that active disease during conception or during pregnancy increase the risk of negative pregnancy outcomes, including fetal loss and preterm birth. In addition, patients with active disease at conception have more than 65% risk of remaining active during their pregnancy or for their disease to get even worse during pregnancy. On the other hand, a patient whose disease is in remission at the time of conception has more than 75% chance of remaining in remission during pregnancy, and that is what we want.

So let's talk about medication. Like I mentioned, mesalamine, thiopurine, and biologics, including anti-TNFs, vedolizumab, and ustekinumab, are all safe therapies during pregnancy—which means they do not increase the risk of congenital malformation, and they do not increase the risk of negative pregnancy outcome. So it's very important to maintain these therapies during the entire pregnancy and not to stop them. We used to stop biologics during the third trimester, but what we see, the data that we have, is that it increases the risk of flares in mom and so it can increase the risk of negative pregnancy outcome, including premature birth. We know the consequences of premature birth on the infant health. It does not affect the overall health of the infant and their risk of infection during the first year of life. So continue your biologic and the mesalamine and thiopurine during the entire pregnancy to keep mom healthy and have a healthy pregnancy, delivery and healthy infant.

In terms of small molecule therapies, such as JAK1 inhibitors and ozanimod, we have very little data on small molecule therapies, and we know that they do cross the placenta during the first trimester. So at this point we don't have enough data to assess their safety during pregnancy, and they are not recommended during pregnancy. The other medication that needs to be stopped is methotrexate. Methotrexate is teratogenic and can cause spontaneous abortion, so methotrexate needs to be stopped at least 3 months before conception.

Now, in terms of delivery, having IBD does not necessarily mean you need a C-section. We do recommend C-section for particular circumstances—for patients with perianal Crohn's disease and for patients who had a colectomy and ileal pouch anal anastomosis—because the concern is, injury during vaginal delivery can lead to poor wound healing and an injury to the anal sphincter and stool incontinence.

Just to summarize: keeping IBD in remission during pregnancy will ensure a healthy pregnancy for mom, a healthy pregnancy outcome, and a healthy baby. So again, assess your patient, counsel your patient way before they are planning a pregnancy or having an unplanned pregnancy, make sure the disease is in remission. Review the medication, stop methotrexate. If they are on sulfasalazine, start them on two milligram of folic acid daily. Otherwise, mesalamine, thiopurines, and biologics are safe during pregnancy. Small molecule therapies, we don't have a recommendation yet, we don't have enough data. But overall, most medications are safe during conception, pregnancy, and breastfeeding. Let's make sure our pregnant patients are healthy so they can have a healthy pregnancy outcome and a healthy baby.