Management of Patients With IBD During Pregnancy

In this podcast, Sunanda Kane, MD, speaks about her bonus session at the American College of Gastroenterology 2022 Annual Meeting titled “Management of the Pregnant IBD Patient,” including the outcomes of women with inflammatory bowel disease (IBD) who undergo assisted reproductive technology, pregnancy-related epidemiology, post-delivery care in women with IBD, daycare infection rates in children born to mothers with IBD, and the management of patients with heartburn during pregnancy. 

Sunanda Kane, MD, is a professor of medicine in the division of gastroenterology and hepatology at the Mayo Clinic (Rochester, Minnesota).

TRANSCRIPTION

Jessica Bard: Hello everyone, and welcome to the Obstetrics and Gynecology Learning Network. I'm your moderator, Jessica Bard, joined by Dr Sunanda Kane, professor of medicine in the division of gastroenterology and hepatology at the Mayo Clinic in Rochester, Minnesota. Dr Kane is here to speak with us today about her bonus session at ACG 2022 titled, "Management of the Pregnant IBD Patient." Thank you for joining us today, Dr. Kane. Can you please provide us with an overview of your session?

Dr Sunanda Kane: Sure. This is a bonus session that will be available to anyone who is registered for the meeting, and it's recorded presentations. During my presentation on pregnancy in IBD, I focused on 4 different topics. The first was on fertility and assisted reproduction, and I was sharing that there is a very nice meta-analysis just published a year ago looking at the outcomes of women with IBD who undergo assisted reproductive technology. It turns out that pregnancy rates overall are the same, and that the safety of the technology and medications is the same. What seems to drive decreased outcomes is surgery, whether that is for an ulcerative colitis patient or a Crohn's patient.

In males, it's interesting that there is a nice study that shows that infertility in men is linked to active disease, not to medications or to smoking. There are some data from 2018 published that looked at ectopic pregnancy rates in Denmark prior to the biologic era, and that there was an increased risk in Crohn's disease. I bring up the older data because, at this year's meeting, we are actually presenting Mayo data to show that ectopic pregnancy rates look to be perhaps lower than anticipated, and that is updated data looking from 2015 through 2021, and that we think that the use of biologics may decrease the risk of ectopic pregnancy.

The second topic that I was covering was just pregnancy related epidemiology, and I'm presenting a paper that looked at pregnancy onset IBD in the Boston area. It was interesting that patients were more likely to be diagnosed with ulcerative colitis compared with controls, and that they were spread out over the continuum of pregnancy through each trimester, and then actually in the postpartum year, which suggests that women who had symptoms were not getting appropriate workups until they had had actually chronic symptoms, and that if they were diagnosed during pregnancy, they had a fourfold risk of being hospitalized for that disease than those who were diagnosed not during pregnancy. It's important to know that it is safe to do endoscopy during pregnancy if it changes your management, i.e., makes a diagnosis.

I'm also presenting, just reminding everybody about fecal calprotectin can be used during pregnancy to help assess for disease activity. There was a study initially from 2018, but then a follow up from 2020 that shows that you can actually use calprotectin to predict a disease flare. That monitoring during pregnancy actually may be very helpful, and a noninvasive way to follow your pregnant patients. A newer study, which was interesting, looked at calprotectin during pregnancy and showed that just overall it was higher than in the normal population. Interestingly, in the children as well, fecal calprotectin was found to be higher, but then over time drops to basically the normal rates. Again, that pregnancy does not contraindicate endoscopy if it's going to change your management.

Then, there was a very nice meta-analysis that was just published this year looking at the biologics and the safety during pregnancy. I think that this is just a really nice culmination of everything that we know, including all of the anti-TNF agents, the alpha-integrins, and the anti-interleukins, and basically showed that the pregnancy outcomes were equivalent to the general population with exposure to any of those biologics. Very nice in one slide can put people at reassuring women that they should be continuing their therapy.

In terms of newer data for Vedolizumab and Ustekinumab, that they were comparable between groups so that there did not appear to be any kind of safety signals that you should be choosing Vedo over Ustekinumab if you were going to start a biologic. Vedolizumab clearance is rapid. There are new pharmacokinetic data to show that specifically Vedolizumab is cleared quite quickly in the neonate compared to an anti-TNF that can last for months there. But, there is very intriguing data from the translational science world that Vedolizumab does interact with the placenta, because placental MAdCAM expression is important, and when you inhibit that, that potentially you are causing issues with placental health, which may lead to spontaneous abortions or early delivery because of placental mouth dysfunction. That's something that we need to watch in the future.

That again, looking at fathers and paternal exposure, that we showed the fertility is not related to fertility rates. This is looking at paternal exposure to thiopurines and also some of the older biologics. There was no association between paternal medication exposure and risk of preterm birth or low birth weight or congenital malformation. It's safe for mom and dad to be on therapy.

Lastly, just some post-delivery care that, right now, we do not recommend that if a woman is on a small molecule that she breastfeed, that she needs to avoid that. That, nowadays, pumping and dumping is discouraged for any therapy that a woman is on postpartum. It's important to remember that the risk of relapse does not go away just because a woman has delivered, and it's actually higher, and that you cannot stop therapy once a patient has delivered. If she wants to nurse, then discussion with a lactation consultant to make sure that they understand that you can breastfeed, that that becomes very important. Then lastly, that daycare infection rates are no higher in infants born to mothers with IBD, even if there is exposure to biologics, and so the children in real world are not sacrificing their health if there is onboard biologics when they go to daycare. That, in a nutshell, is basically the contents of what I'm going to update people on at this year's ACG.

Jessica Bard: Thank you for that synopsis, Dr Kane. One last question. We know heartburn can be common in pregnancy. Can you speak to any updates in the management of a patient with heartburn during pregnancy?

Dr Sunanda Kane: Heartburn is common in everybody, and it's not more common in patients with IBD. But, heartburn is a very common symptom to pregnancy in general, and that we recommend first line interventions, which means not eating late, sitting up when eating, and avoiding certain foods that will precipitate heartburn. Then first line therapy are antacids that contain calcium. If those do not work, then over the counter antacids, so the antihistamines first and then the proton pump inhibitors would be the third line, but are found to be relatively low risk for the folks that need them. That heartburn that results in difficulty swallowing, or if heartburn is such that you are actually spitting up or vomiting blood, that is a big deal and requires endoscopy at that point. But, most heartburn is related to the size of the uterus, and so happens as you get more pregnant, and the management is not really any different than what we tell a heartburn patient who isn't pregnant.

Jessica Bard: Well, Dr Kane, thank you again for joining us on the podcast today.

Dr Sunanda Kane: Absolutely.

Jessica Bard: For more ACG 2022 annual meeting coverage, visit the OBGYN Learning Network on HMPgloballearningnetwork.com.