New Guidelines Introduced for Inflammatory Bowel Disease in Pregnancy

TUESDAY, Jan. 29, 2019 (HealthDay News) — The American Gastroenterological Association (AGA) report, Inflammatory Bowel Disease (IBD) in Pregnancy Clinical Care Pathway, was published online Jan. 15 in Gastroenterology.

Uma Mahadevan, M.D., from the University of California in San Francisco, and colleagues created these evidence-based materials to empower patients and facilitate conversations with health care providers. The AGA developed the pathway in a multidisciplinary fashion in partnership with the Crohn’s & Colitis Foundation, the Society for Maternal-Fetal Medicine, and the patient support network Girls With Guts.

The authors recommend pregnant women with IBD coordinate their care with a maternal-fetal medicine (MFM) subspecialist to determine the type of monitoring needed and the necessary frequency of prenatal visits with an obstetric provider, while also being followed by a gastroenterologist with expertise in IBD. For patients without access to IBD experts and MFM subspecialists, any gastroenterologist, obstetrician/gynecologist, or specialized physician assistant, nurse practitioner, or midwife can follow the care pathway to optimize outcomes. Preconception planning should be a component of gastroenterologist visits, and an IBD diagnosis should be shared during an initial visit with an obstetric provider. The pathway also addresses fertility, genetics, treatment, delivery options, and overall postpartum care.

“With proper planning and care, women with inflammatory bowel disease can have healthy pregnancies and healthy babies; however, misperceptions and fears have driven many women with inflammatory bowel disease to delay pregnancy or be voluntarily childless,” Mahadevan said in a statement.

Among the resource’s many detailed recommendations are the following:

Fertility Concerns. Women in remission from IBD and UC who have never had surgery should be reassured that fertility rates are equal to those in the general population. Those, however, who have had ileal pouch-anal anastomosis, proctectomy, and permanent ostomy have reduced fertility. IBD medical therapies, including all biologics, steroids, thiopurines, methotrexate, and 5-aminosalicylic acid, do not decrease fertility.

Genetic risk. Patients should be reassured that the risk of having an IBD-affected child is often overestimated. The absolute risk of a child’s developing Crohn’s disease (CD) in the setting of maternal CD is 2.7%; the risk of ulcerative colitis (UC) in the setting of maternal UC is 1.6%.

Preconception counseling. This should include a recommendation for a remission of 3 to 6 months before conception to reduce the risk of flaring along the spectrum from conception to gestation and postpartum; preconception care should optimize nutritional status, maintain iron and folic acid supplementation, and the achievement, if possible, of an ideal weight.

Multidisciplinary care. The pregnant IBD patient should ideally be monitored by a gastroenterologist and a specialist in maternal-fetal medicine and may need consultation with a nutritionist.

Disease management. Care providers must check laboratory values and correct any abnormalities as well as supplement with folic acid; corticosteroids may increase the risk of gestational diabetes and adverse pregnancy outcomes, and are not recommended as maintenance therapy.

Medications. Methotrexate must be stopped at least 3 months before conception owing to its teratogenicity; thiopurines and biologics are considered low-risk during pregnancy and breastfeeding; serum drug levels of biologics should be measured and escalated or de-escalated as necessary, before conception.

Delivery. Vaginal delivery is safe in most cases, unless active perineal disease is present around the time of delivery; cesarean section is recommended for women with previous rectovaginal fistulas since avoiding perineal trauma may prevent recurrent damage or incontinence.

Postpartum care. Biologics may be resumed 24 hours after vaginal delivery and 48 hours after cesarean delivery; methotrexate again excepted, other IBD medications should be continued in the postpartum period.

Ostomy management. In patients with ostomy, stomal problems such as displacement, enlargement, retraction, stenosis, and prolapse may occur because of the stretching of the abdominal wall. Patients should work with a nutritionist if needed to avoid excessive weight gain.

Breastfeeding. Most IBD medications are either undetectable in breast milk or present in concentrations too low to the infant. The Pregnancy in Inflammatory Bowel Disease and Neonatal Outcomes registry found that infants exposed to immunomodulators, biologics, or combination therapy had similar milestone achievement and were no more susceptible to infections in the first 12 months of life than unexposed infants. No IBD treatments are known to suppress lactation. The galactagogue fenugreek is not recommended as it may cause diarrhea and bleeding.

Developmental milestones. No evidence suggests that babies born to mothers with IBD, regardless of medication exposure, have any developmental delays. Pro-inflammatory mediators, however, have been shown to negatively influence brain development, further underscoring the need for good inflammatory control during pregnancy.

Several authors disclosed financial ties to the pharmaceutical industry.

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