Management of Inflammatory Bowel Disease in Pregnancy: A Practical Approach to New Guidelines

Table 1

Summary of consensus recommendations for the management of IBD in pregnancy.

Impact of IBD during pregnancy: role of disease management
Statement #1: We recommend that women with IBD of reproductive age receive preconception counseling to improve pregnancy outcomes. GRADE: Strong recommendation, very low-quality evidence.
Statement #2: In women with IBD who are contemplating pregnancy, we recommend objective disease evaluation prior to conception in order to optimize disease management. GRADE: Strong recommendation, very low-quality evidence.
Statement #3: In women with ulcerative colitis who are contemplating pregnancy and taking a 5-ASA formulation containing di-butyl phthalate (DBP), we suggest switching to a 5-ASA drug without DBP. GRADE: Conditional recommendation, very low-quality evidence.
Statement #4A: In women with IBD who are taking methotrexate and contemplating pregnancy, we recommend stopping methotrexate at least 3 months prior to attempting to conceive to minimize the risk of teratogenicity. GRADE: Strong recommendation, very low-quality evidence.
Statement #4B: If a woman becomes pregnant while taking methotrexate, we recommend immediate discontinuation of methotrexate and referral for obstetric counseling. GRADE: Strong recommendation, very low-quality evidence.
Statement #5: In pregnant women with active or complicated IBD, we recommend consultation with an obstetrician, preferably one affiliated with a high-risk obstetrics program. GRADE: Strong recommendation, very low-quality evidence.
Statement #6: In pregnant women with IBD, we recommend their IBD be managed by a gastroenterologist throughout pregnancy. GRADE: Strong recommendation, very low-quality evidence.
Statement #7: In pregnant women who require hospitalization for their IBD, we recommend transfer to a tertiary center with access to a gastroenterologist and an obstetrician, preferably one affiliated with a high-risk obstetrics program. GRADE: Strong recommendation, very low-quality evidence.
Medical management of IBD during pregnancy
Statement #8: In pregnant women with IBD on oral and/or rectal 5-ASA maintenance therapy, we recommend continuation of 5-ASA therapy throughout pregnancy. GRADE: Strong recommendation, very low-quality evidence.
Statement #9: In pregnant women with IBD on thiopurine maintenance therapy, we recommend continuation of thiopurine therapy throughout pregnancy. GRADE: Strong recommendation, very low-quality evidence.
Statement #10A: In pregnant women with IBD on anti-tumour necrosis factor (anti-TNF) maintenance therapy, WE RECOMMEND CONTINUATION of anti-TNF therapy. GRADE: Strong recommendation, very low-quality evidence.
Statement #10B: In select pregnant women at low-risk for an IBD relapse who have a compelling reason to discontinue anti-TNF therapy TO MINIMIZE FETAL EXPOSURE, we suggest administering the last dose at 22–24 weeks gestation. GRADE: Conditional recommendation, very low-quality evidence.
Statement #11: In pregnant women with IBD on combination anti-TNF and thiopurine therapy, we suggest that the decision to switch to monotherapy should be individualized. GRADE: Conditional recommendation, very low-quality evidence.
Statement #12: In pregnant women with ulcerative colitis who have a mild-to-moderate disease flare while on 5-ASA maintenance therapy, we recommend combination 5-ASA oral and rectal therapy be optimized to induce symptomatic remission. GRADE: Strong recommendation, very low-quality evidence.
Statement #13: In pregnant women with Crohn’s disease with perianal sepsis requiring antibiotic therapy, we suggest metronidazole and/or ciprofloxacin. GRADE: Conditional recommendation, very low-quality evidence.
Statement #14: In pregnant women with IBD who have a disease flare on optimal 5-ASA or thiopurine maintenance therapy, we recommend treatment with systemic corticosteroids or anti-TNF therapy to induce symptomatic remission. GRADE: Strong recommendation, very low-quality evidence.
Statement #15: In pregnant women with IBD who have a corticosteroid-resistant flare, we recommend starting anti-TNF therapy to induce symptomatic remission. GRADE: Strong recommendation, very low-quality evidence.
Statement #16: In pregnant women with IBD who are thiopurine naïve and starting anti-TNF therapy, we suggest anti-TNF monotherapy over combination therapy with anti-TNF and thiopurine therapy. GRADE: Conditional recommendation, very low-quality evidence.
Statement #17: In pregnant women hospitalized for IBD, we recommend anticoagulant thromboprophylaxis during hospitalization over no prophylaxis. GRADE: Strong recommendation, very low-quality evidence.
Imaging, endoscopy and surgery for IBD during pregnancy
Statement #18: In pregnant women with suspected IBD or IBD flare, we recommend use of flexible sigmoidoscopy or colonoscopy if the results will impact the antenatal management of the IBD. GRADE: Strong recommendation, very low-quality evidence.
Statement #19: In pregnant women with suspected IBD or IBD flare, we recommend limiting radiologic investigations to the use of sonography and magnetic resonance imaging where possible. GRADE: Strong recommendation, very low-quality evidence.
Statement #20: In pregnant women with IBD, we recommend that urgent surgery to manage IBD complications not be delayed solely due to pregnancy. GRADE: Strong recommendation, very low-quality evidence.
Issues around delivery for pregnant women with IBD
Statement #21: For pregnant women with IBD, we recommend basing the decision for cesarean delivery on obstetrical considerations and not IBD diagnosis alone. GRADE: Strong recommendation, very low-quality evidence.
Statement #22: For pregnant women with IBD who have undergone an ileal pouch anal anastomosis (IPAA) procedure, we suggest consideration of cesarean delivery to reduce the risk of anal sphincter injury, in consultation with an obstetrician and surgeon. GRADE: Conditional recommendation, very low-quality evidence.
Statement #23: For pregnant women with Crohn’s disease who have active perianal disease, we recommend cesarean delivery over vaginal delivery to reduce the risk of perianal injury. GRADE: Strong recommendation, very low-quality evidence.
Statement #24: For pregnant women with IBD who have undergone cesarean delivery, we recommend anticoagulant thromboprophylaxis during hospitalization over no prophylaxis. GRADE: Strong recommendation, very low-quality evidence.
Breastfeeding and vaccination of newborns of women with IBD
Statement #25: In women with IBD, we suggest that use of 5-ASA, systemic corticosteroids, thiopurines, or anti-TNF therapy should not influence the decision to breastfeed, and breastfeeding should not influence the decision to use these medications. GRADE: Conditional recommendation, very low-quality evidence.
Statement #26: In women with IBD who are breastfeeding, we suggest avoiding methotrexate therapy. GRADE: Conditional recommendation, very low-quality evidence.
Statement #27: For newborns of women who were on anti-TNF therapy during pregnancy, we recommend against administration of live vaccinations within the first 6 months of life. GRADE: Strong recommendation, very low-quality evidence.