Sara Horst, MD, on Postpartum Flares Among Patients With IBD

In this video, Dr Horst discusses the risks of flares of inflammatory bowel disease following childbirth, and the safety of medications among pregnant women with IBD.

Sara Horst, MD, is an associate professor and gastroenterologist at Vanderbilt University Medical Center in Nashville, Tennessee, and a Section Editor for Inflammatory Bowel Disease on the Gastroenterology Learning Network.

TRANSCRIPT:

Hi, I'm Sarah Horst, a physician at Vanderbilt University Medical Center, who specializes in the care of patients with inflammatory bowel disease. Today, I'm going to talk about postpartum care for women with inflammatory bowel disease.

Over the past 15 years, there have been many researchers and experts in IBD who have given us so much information about care of pregnant patients who have IBD. We've learned through prospective studies such as the PIANO registry led by Dr. Mahadevan that most medicines that pregnant patients are on are safe in pregnancy including biologic medication.

Just this year, there was data published from the PIANO registry looking at over a thousand patients with IBD going through pregnancy, and this showed that biologic therapy, thiopurine therapy, or combination therapy, did not increase the risk of fetal adverse events.

Increased disease activity did increase the risk of spontaneous abortion or preterm birth, which to me again solidifies the importance of disease control prior and during pregnancy and continuing meds that work for the mom.

However, postpartum pregnancy outcomes for mothers who have had IBD has been a little less well delineated. Increasingly over the past year, however, there have been new studies looking at this question, and I thought I'd go through some of that data today.

In late 2020, a large retrospective data study looking at a group of patients from the Boston area hospitals was published. They looked at about 200 patients with IBD and about a half of those had Crohn's disease and the risk of postpartum flare. About 30% of those patients did experience a postpartum flare. In this group, risk of postpartum flare was having a flare in your third trimester of pregnancy or de-escalation of therapy during or after pregnancy. I think it's important to note that in this group only about 30% of the patients are on biologic therapy.

This year, we looked at our experience of patients with Crohn's disease only in risk of postpartum flare. We did a retrospective study, and we looked at about a hundred patients with IBD who had babies and were cared for in our tertiary care center.

Now, a little bit differently than that prior study, about 70% of our patients were on biologics during therapy and most of these patients maintained regular dosing into their third trimester and continued in their postpartum period, so basically didn't miss any doses. Interestingly, 28% of these patients also experienced a postpartum flare.

We couldn't identify any risk factors for flare other than smoking in pregnancy, but that was a very small number of patients. Now, the good news is most of these flares were very mild and they were managed with alterations of biologic dosing, budesonide , or supportive care. Only 5% of the patients were hospitalized and 4 required prednisone.

As I noted, most of these were on biologic therapy, noting that they had moderate to severe disease. Being able to manage these patients in an outpatient setting without large alterations in their therapy to me is good news.

There was another really interesting study published this year that looked at a large database of about a hundred patients with IBD who delivered within 3 large hospital systems in the New York area. They specifically looked to see if having IBD or being on certain meds could affect peripartum infections; 72% of these patients were on biologic therapy at delivery, with most having therapy in their third trimester or very soon after delivery.

Again, good news. Only 7 infections occurred in 5 patients, all of who underwent C-section delivery, and this is the similar infection risk to the general population. Biologic therapy did not increase the likelihood of infection in the peripartum period.

There was another group that looks this year at a national readmissions database to look at the risk of hospitalization for IBD flare in the postpartum period. Reassuringly, and looking at over 7,000 new mothers with IBD, only 5% were hospitalized in the 9-month period after delivery, and 30% of those were six months after delivery. Risk factors for hospitalization for those patients, including Crohn's disease, Medicare insurance status, multiple comorbidities, and younger age. That study was limited by the ability to evaluate what medicines patients were on.

Looking at this data, what have I learned? Increasingly, we understand that continuing medications that work for our patients with IBD who are pregnant through their entire pregnancy is extremely important. This includes biologic therapy into the third trimester if needed and soon after delivery.

Based on new and emerging data, there's no increased risk of peripartum infection with biologic therapy, which is very reassuring. Few patients will require hospitalization in the postpartum period for a flare. In our study, we learned that about 30% of our patients will flare in the postpartum period. This is supported by some of the other studies I talked about. Very reassuringly, again, these tend to be mild and managed in the outpatient setting.

My take on this, and this is what I do for all of my patients, is that it's really important to educate your patients on this risk and to help them mitigate the possibility of flare by iterating the importance of continuing medicines.

I also discussed not to ignore any symptoms that may occur in the postpartum period so that we can treat things early before they might go into a full-blown and severe flare as some new moms may forget their health is as important as their newborn’s.

An attempt at self-care is important, so I talk about trying to get some semblance of sleep, managing stress, and mental health, and asking for help as much as possible. My job is to take care of them in this period so they can take care of their new baby.

Thanks so much.