Clear advice on how best to manage pregnancy and Crohn’s disease or ulcerative colitis aims to clear up confusion on which meds are safe for expectant moms.
For women with inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis (UC), confusion over potential pregnancy complications is common, says Sherry Ross, M.D., a women’s health expert and OB/GYN at Providence Saint John’s Health Center in Santa Monica, CA.
“There has been quite a bit of misinformation and fear around this topic, with some women becoming anxious that they’ll flare during pregnancy or that taking certain medications might be dangerous,” she says. “It’s crucial to understand that women with IBD can have healthy, safe pregnancies with regular monitoring and support from a care team.”
Now, expectant IBD moms and their health providers have better guidance than ever. That’s because this past summer an international consortium of Crohn’s and UC specialists, as well as patient advocates, issued 34 recommendations and 35 consensus statements for IBD specialists to follow to help resolve inconsistencies in previous pregnancy guidance—all as part of the first unified global guidelines for managing pregnancy in women with IBD.
Addressing Complications in IBD Pregnancies
Pregnant women with IBD face many challenges, says Kecia Gaither, M.D., an OB/GYN and director of perinatal services and maternal fetal medicine at NYC Health + Hospitals/Lincoln in New York City. Risks include pre-term delivery and low birth weight, she notes, since the chances of such outcomes occurring are higher for those with active disease and symptoms.
That’s not all, though. Research published in the International Journal of Colorectal Diseases looked at the outcomes of pregnancies among women with IBD and found higher incidence of gestational diabetes, postpartum hemorrhage, and hypertensive complications, along with pre-term delivery and low birth weight babies, compared to pregnancies in women without IBD. The studied cohort also tended to have longer hospital stays after delivery. Additional research in Frontline Gastroenterology emphasized that while roughly 80% of pregnancies in expectant mothers with IBD were uncomplicated, it was important for both physicians and pregnant patients to be aware of potential health complications, says Dr. Gaither.
“Disease remission prior to conception and continued effective disease management during pregnancy are crucial to minimizing risks to both mother and fetus,” she explains. “Collaboration among gastroenterologists, maternal fetal medicine specialists, obstetricians and other specialists is advised for optimal care.” Although Dr. Gaither wasn’t involved in the development of the recent guidelines, she believes they’re an important step forward.
Putting Guidelines in Real-World Context
The new guidance is designed to replace the kind of conflicting advice that has long led to uncertainty among both IBD specialists and their pregnant patients, Dr. Gaither notes. Key pieces of advice in the guidelines for physicians include recommendations to:
Putting Guidelines in Real-World Context
The new guidance is designed to replace the kind of conflicting advice that has long led to uncertainty among both IBD specialists and their pregnant patients, Dr. Gaither notes. Key pieces of advice in the guidelines for physicians include recommendations to:
Assess Nutritional Status for Deficiencies
Women with IBD are already at risk of developing malnutrition and micronutrient shortfalls due to factors like restrictive diets, frequent diarrhea, and malabsorption of vitamins and minerals, the guideline authors note. “Pregnancy may further worsen these deficits because of increased micronutrient, protein, and energy requirements essential for normal fetal development,” they write. Because of that, it’s essential for providers to evaluate and identify any nutritional challenges and treat them with supplements if needed.
Avoid Small-Molecule Drugs During Pregnancy and Lactation
These are medications that can enter cells easily (unlike large-molecule drugs such as biologics). Examples include ibuprofen, acetaminophen, statins, and some antihistamines. For IBD specifically, small-molecule drugs include JAK inhibitors such as Rinvoq (upadacitinib) and Xeljanz (tofacitinib) and S1P receptor modulators such as Zeposia (ozanimod). According to the Journal of Controlled Release, small-molecule drugs can cross the placenta, which raises risk to a fetus’ development.
Continue With Biologics and Thiopurines
The use of biologics throughout pregnancy and lactation has been one of the biggest sources of confusion and anxiety for those who are pregnant and have IBD, leading some to believe that use of any medication for IBD will harm a fetus, says Dr. Ross. Having this clear guidance should provide some assurance for expectant IBD mothers who might be concerned that they have to change their treatment plan due to pregnancy, she adds. In the consensus statement, the experts write that “medication cessation leads to an increase in disease activity, which then is associated with an increase in maternal and fetal adverse outcomes.”
Reduce Preterm Preeclampsia Risk With Low-Dose Aspirin
Due to systemic inflammation and the immune system dysregulation that can cause, pregnant women with IBD are more likely to develop preeclampsia. That happens because immune dysfunction can affect the placenta, a key factor in preeclampsia. Low-dose aspirin can lower inflammation and improve blood flow to the placenta.
That’s why recommending low-dose aspirin has been a longstanding practice for those with higher preeclampsia risk, according to Dr. Ross, but it’s helpful to have it clarified in the guidelines. Technically, aspirin is a small-molecule drug, but it is safer when given in low doses, the guidelines suggest. Also, the guideline authors add that women with IBD may be at higher risk of developing preterm preeclampsia.
With IBD, All Pregnancies Are High-Risk
The new global guidelines propose that even those in remission who are likely to have uncomplicated pregnancies should be considered high-risk. Viewing them as such will lead to more frequent monitoring, suggests Dr. Gaither.
That’s important, conclude the 39 physicians and seven patient advocates who worked on these guidelines, because women with IBD often don’t receive appropriate counseling and education surrounding pregnancy-related concerns. The hope is that these guidelines will help to change that situation.
“The guidelines are quite comprehensive,” Dr. Gaither points out. “They give cogent advice as to necessary care that needs to be rendered to the pregnant patient with IBD.”
