Breaking Down the AGA’s IBD in Pregnancy Clinical Care Pathway

A report from the American Gastroenterological Association (AGA) IBD Parenthood Project Working Group advises on key considerations for the management of inflammatory bowel disease (IBD) and pregnancy, making it easier for clinicians to approach multidisciplinary management of these patients, said Sunanda Kane, MD, a gastroenterologist from the Mayo Clinic, Rochester, MN, and coauthor of the report.¹

“This was a multidisciplinary working group of gastroenterologists, maternal fetal medicine specialists, teratologists, lactation specialists, and patient stakeholders who all sat at a table and [tackled] some of these issues,” she said during her presentation. “It really does take a village to take care of a pregnant patient or a woman who is interested in potentially getting pregnant.”

Dr Kane highlighted key points of the report, called the IBD in Pregnancy Clinical Care Pathway,² that included how to approach IBD management during family planning and preconception, which medications are safe for use during pregnancy, post-delivery treatment considerations, and more.

According to Dr Kane, for contraception, non-estrogen containing medications are preferred because the estrogen component is pro-thrombotic. “It is important to remember that for oral contraceptives, their efficacy is based on absorption,” she said. “And in your patient with Crohn’s [disease (CD)] who has active small bowel disease, who has had a lot of resections, or rapid small bowel transit, oral contraceptives may not be as effective.”

Dr Kane said the risk of genetically transmitting CD is higher (risk ratio, 6.3%) than it is for UC (3.7%). However, the absolute risk for both illnesses is relatively small (under 3% and under 2% for CD and UC, respectively). Dr Kane added that the risk does increase, however, to more than 30% when both biological parents have IBD.

For patients with IBD in remission or who have not undergone surgery, fertility rates are equal to the background population. It is active disease that has been associated with decreased fertility, which is also true for men, Dr Kane said. She explained that voluntary childlessness is still “predominant” in this patient population—it is estimated to be 17%, vs 6% for the general population. “Hopefully we will be able to move that needle in a few years,” she said.

Health care maintenance and disease management are important to think about in this patient population, Dr Kane said. Stability on a drug regimen should be about 3 months before a patient should think about actively trying to get pregnant. If a patient is on steroids, then they should not try to conceive.

Depending on the therapy, it may be necessary to obtain a baseline drug level. “The injectable adalimumab levels during pregnancy do not change, but this is something you may want to consider if [the patient] is on infliximab. We don’t know yet about levels during pregnancy for vedolizumab,” Dr Kane said.

She said tofacitinib should be a wash-out of 1 week before conception based on the half-life—it is not recommended a patient be on tofacitinib at the time of preconception and should not be on it if they are pregnant because of concerns with the health of the placenta.

Biologic monotherapy should continue throughout pregnancy without interruption. The use of calprotectin is acceptable during pregnancy—data has shown that disease corelates with levels during pregnancy, so pregnancy does not change the science of the molecule, Dr Kane said.

It is important to monitor gestational weight gain in patients with IBD, as it can be low and is a risk factor for poorer outcomes. Prenatal vitamins can help with making sure the patient is gaining weight. “I recommend to all my patients to start on a prenatal vitamin right away—there is no reason not to,” she said. “You want to make sure you are doing aggressive maternal and fetal monitoring if there is active disease involved.”

A cesarean delivery is recommended if there is any evidence for rectal fistula or active perianal disease. “It might seem like a no-brainer, but again I think it is important that we say that this is now consensus,” Dr Kane said. Vaginal delivery does not affect subsequent risk for IBD development in the child, Dr Kane said. If cesarean delivery is needed, then anticoagulation prophylaxis should be performed. If a patient has a pouch, delivery is decided on a case-by-case basis and should be a discussion with the obstetrician-gynecologist and the surgeon who performed the actual pouch procedure in the patient.

In post-delivery care, medications should be dosed based on pre-pregnancy weight.

For lactation, a patient cannot nurse if they are on tofacitinib or methotrexate. For other medications, pumping and dumping breast milk for fear of medication in the milk is no longer recommended, Dr Kane noted. “We used to talk about pump-and-dump if you were on thiopurines and biologics; it is now discouraged because the amounts of any of our therapies that end up in milk is so minute that it is not worth the inconvenience and the hassle of pumping and dumping,” she said.

Vaccinations should be administered to the infant as scheduled, with the exception of live virus vaccinations in infants who experienced in utero exposure to biologics. The measles, mumps, and rubella (MMR) vaccine and varicella vaccinations are live but are administered at 1 year, so those are appropriate to give on schedule.

“Everything I’ve spoken about are things we have talked about in the past, but now we have a really nice consensus from multidisciplinary groups, so all of our talking and teaching points are on the same platform,” Dr Kane said.

—Melinda Stevens

References:

1. Kane S. Update: parenthood project consensus statement. Presented at: 2019 AIBD Meeting; December 12-14, 2019; Orlando, FL.
2. Mahadevan U, Robinson C, Bernasko N, et al. Inflammatory bowel disease in pregnancy clinical care pathway: a report from the American Gastroenterological Association IBD parenthood project working group. Gastroenterology. 2019;156(5):1508-1524. doi:10.1053/j.gastro.2018.12.022.