25 March 2019

Better pregnancy outcomes for IBD patients

Clinical Gastro O&G Women

Women with inflammatory bowel disease (IBD) can safely conceive and have healthy children with a bit of planning, authors of a recent review say.

These women’s best chance for a healthy pregnancy was to be in remission before trying to conceive, said the researchers following their analysis of expert recommendations on the issue published in the MJA.

“Disease activity before conception and during pregnancy is the main driver of adverse pregnancy outcomes in patients with IBD,” they wrote.

The topic should be raised with these patients as to whether they want to have children, and if they do, clinicians need to be suggesting pre-conception counselling preferably even before they start trying to conceive.

“GPs play a really important role  because they will often be seeing these patients as the first point of call if they become pregnant, or want to get pregnant,” said Dr Emma Flanagan, co-author of the review and gastroenterologist at St Vincent’s Hospital, Melbourne.

A pre-conception consult for IBD patients should include a consultation with the patient’s gastroenterologist to cover disease management before and during pregnancy, as well as a medication management plan.

Disease control is important pre-pregnancy as women whose IBD which is quiescent will generally have normal fertility, the review authors said.

During pregnancy, the aim is to avoid IBD flares which have been shown to be associated with spontaneous abortion, pre-term birth and a low birthweight.

Women should be generally advised to continue taking their medications as normal, the MJA review stated.

Non-compliance with IBD maintenance during pregnancy occurs frequently, chiefly due to the fear of adverse effects of the medication on the developing fetus.

“Patients have a lot of anxiety about the medication,” Dr Flanagan said. But patients needed to be reassured that their baby was more at risk from IBD flares than from their maintenance therapy, including monoclonal antibodies.

The best chance of a healthy baby is by keeping the IBD in remission, she said.

Most women who are taking maintenance therapy when they fall pregnant will require medication throughout the pregnancy to prevent disease relapse.

Methotrexate, however is the exception to this. Methotrexate is teratogenic and ideally should be stopped six months prior to conception and should not be used while pregnant or while breastfeeding.

If an IBD patient presents with an unplanned pregnancy, they need to be advised to stop their methotrexate immediately, and while other medications should be continued it is recommended they be reviewed by their gastroenterologist.

Another point worth noting with regard medications, is that while anti-tumour necrosis factor- therapies have been shown to be safe in pregnancy in terms of fetal outcomes they are transferred across the placenta. Therefore infants exposed to these agents in utero should not be given live vaccinations, including rotavirus until 12 months of age.

MJA 2019, 25 March