IBD in pregnancy: recent advances, practical management

Abstract

Inflammatory bowel disease (IBD) poses complex issues in pregnancy, but with high-quality care excellent pregnancy outcomes are achievable. In this article, we review the current evidence and recommendations for pregnant women with IBD and aim to provide guidance for clinicians involved in their care. Many women with IBD have poor knowledge about pregnancy-related issues and a substantial minority remains voluntarily childless. Active IBD is associated with an increased risk of preterm birth, low for gestation weight and fetal loss. With the exception of methotrexate and tofacitinib the risk of a flare outweighs the risk of IBD medication and maintenance of remission from IBD should be the main of care. Most women with IBD will experience a normal pregnancy and can have a vaginal delivery. Active perianal Crohn’s disease is an absolute and ileal pouch surgery a relative indication for a caesarean section. Breast feeding is beneficial to the infant and the risk from most IBD medications is negligible.

Fetal exposure to tofacitinib during the first trimester: A healthy newborn case report

“…Table 1 shows separately the outcomes of pregnancies from clinical trials and postmarketing studies reported in other publications until February, 2020 (Clowse et al, 2016;Mahadevan et al, 2018;Mahadevan et al, 2020). A fact of considerable importance about these results is that a group of 13 patients in rheumatoid arthritis clinical trials received concomitant treatment with methotrexate, a known teratogenic drug (Selinger et al, 2020;Verberne, de Haan, van Tintelen, Lindhout, & van Haelst, 2019). This could have influenced the outcomes as a confounding factor, although its impact was not assessed (Clowse et al, 2016).…”

“…According to expert opinion and the European League Against Rheumatism (EULAR) guidelines, therapy with tofacitinib should be discontinued between 4 and 8 weeks before conception when possible (Förger & Villiger, 2016;Giles et al, 2019;Gisbert & Chaparro, 2020;Götestam Skorpen et al, 2016;Puchner et al, 2019;Richez et al, 2019;Selinger et al, 2020). Although tofacitinib has a half-life of approximately 3 hr in plasma (Dowty et al, 2014;Pfizer Inc, 2019;Richez et al, 2019), this longer window is needed due to the persistence of its pharmacodynamic effects.…”

“…Nevertheless, the clinical significance of this effect is currently unknown (Pfizer Inc, 2019). Tofacitinib's small molecular size suggests that it is very likely to be able of crossing the human placenta, although evidence does not exist to confirm this (Balbi et al, 2019;Gisbert & Chaparro, 2020;Puchner et al, 2019;Selinger et al, 2020).…”

Lower gastrointestinal bleeding in pregnancy: Differential diagnosis, assessment and management

“…It can also be used as a marker of disease activity in established IBD. However, studies assessing the value of calprotectin during pregnancy are conflicting [5][6][7] and results therefore need to be interpreted only with correlation within the clinical context. Faecal immunochemical testing (FIT), which detects minute amounts of blood in the stool, is increasingly being used in primary care to screen for bowel cancer.…”

Editorial: the risk of chronic diseases and congenital malformations during childhood and adolescence after inutero drug exposure to thiopurines

“…The management of inflammatory bowel disease (IBD) in pregnancy involves a delicate balance between maintaining optimal maternal health while avoiding harm to the foetus 1,2 . Poor disease control is associated with negative outcomes including small for gestational age and low birth weight (LBW).…”