Caring for the Pregnant Patient With IBD

Dr Uma Mahadevan discusses the key factors to consider when caring for patients with inflammatory bowel disease who are or who want to become pregnant.

Uma Mahadevan, MD, is a professor of medicine and director of the Center for Colitis and Crohn’s Disease at the University of California San Francisco. 

Hello. I am Dr. Uma Mahadevan, professor of medicine from the University of California San Francisco. And today I am going to be talking about pregnancy in patients with inflammatory bowel disease. The most important thing to remember is that the health of the mother determines the outcome of the pregnancy and the adverse events of the baby. So women with inflammatory bowel disease have higher rates of miscarriage, preterm birth, complications of labor and delivery like preeclampsia, as well as low birth weight infants. They do not have an increased risk of birth defects. These adverse events are increased further if the mother has active disease.

So one of the most important things you want to do is preconception counseling, where you confirm that the mother is in remission, you optimize her medications and stop medicines that can cause birth defects or pregnancy loss such as methotrexate. And you reassure the mother that the safe medications she's on can be continued during pregnancy and breastfeeding.

We also recommend that all pregnant women with inflammatory bowel disease are followed as high-risk pregnancies because of these increased complications, even if their disease is in remission, even if they're young and healthy. We also recommend that all women with inflammatory bowel disease start baby aspirin 81 to 162 milligrams a day, beginning at week 12 gestation. This has been shown to reduce the risk of preeclampsia, which is increased in women with IBD once they're pregnant. It's important to continue to follow the patient throughout pregnancy and make sure that her disease continues to be under good control.

Medications that can be continued at low risk include 5-ASAs, thiopurines, and all the monoclonal antibodies. Because monoclonal antibodies or biologics are actively transferred across the placenta by the FCRN receptor, which starts around week 14, there's little to no exposure during the key period when the baby's organs are forming in the first trimester.

Therefore, even if a biologic is new, most providers will continue it throughout pregnancy. We do know biologics cross the placenta and can be present in the infant for the first several months of life. Because of that, we recommend no live vaccines in the first 6 months of life. In the United States, that is just rotavirus. And if the baby is at high risk for rotavirus based on socioeconomic status, HIV, et cetera, it's actually okay to give the rotavirus given data suggesting low harm. But most infants won't need that one. All other vaccines can and should be given on schedule. And at 6 months, any other live vaccines the infant may need can be given, such as an early MMR. Women on biologics, 5-ASAs or thiopurines can also breastfeed without evidence of any harm to the infant.

Now the newer small molecules, the S1Ps like ozanimod, etrasimod, and the JAK inhibitors, upadacitinib and tofacitinib, have very limited pregnancy data. And we do know that they will cross the placenta in the first trimester because they are small molecules, not biologics. And because of that, and an animal study suggesting harm, we do try to avoid these medications in pregnancy and in breastfeeding if we can.

Much of the information we have to share with pregnant women and their providers comes from the PIANO registry—Pregnancy, Inflammatory bowel disease And Neonatal Outcomes. This ongoing prospective registry across the United States has been providing data since 2007 and it's where we get a lot of our safety data. If you have a patient with inflammatory bowel disease who's pregnant, particularly if they're on newer biologics and small molecules, you can enroll them remotely wherever you are in the United States. You can look at our website, piano study.org and the patient or you can directly contact us to enroll and be part of this study helping women with IBD.

With that, I will close by saying that taking care of the pregnant patient with inflammatory bowel disease requires a multidisciplinary team of the GI provider, a high-risk OB, often a regular OB who will be the one to deliver the child. In a patient who has surgical complications or prior history of surgery, your colorectal surgeon may be involved. You may need a nutritionist, you may need a psychotherapist. All of these people are important in the care of the pregnant woman with inflammatory bowel disease. Thank you.