Gillian Watermeyer, MD, on Management of Pregnancy Among Patients With IBD

Dr Watermeyer reviews the consensus of her panel on management of pregnancy among patients with inflammatory bowel disease.

Gillian Watermeyer, MD, is senior consultant and head of the IBD Clinic at the University of Cape Town in Cape Town, South Africa.

TRANSCRIPT:

Good afternoon, good evening, wherever you may be in the world today. My name is Gill Watermeyer. I'm a consultant physician and gastroenterologist. I practice in the division of Gastroenterology of Groote Schuur Hospital, the University of Cape Town in Cape Town, South Africa. And it has been my great privilege to head up the working group addressing the management of pregnancy course in women with IBD. We came up with 3 formal recommendations for which there was sufficient evidence to use GRADE methodology. In addition, there are 3 consensus statements for which evidence is limited, and here a modified Delphi RAND process was followed based largely on expert opinion. And details of these processes are presented in a separate video.

So our first GRADE statement suggests that pregnant women with IBD take low-dose aspirin by 12 to 16 weeks of gestation to prevent preterm preeclampsia. The level of evidence was considered low and the recommendation conditional. Preeclampsia is one of the leading causes of maternal and perinatal mortality and morbidity, and it is defined as the development of hypertension after 20 weeks of gestation with associated proteinuria or other end organ dysfunction. Women with IBD may have an increased risk of preterm preeclampsia. And it's been shown that low-dose aspirin may prevent preeclampsia in high-risk patients. And the best evidence to support the role of low-dose aspirin comes from the ASPRE study, which was published in NJM in 2017. This was a very large randomized placebo controlled trial, including over 1700 patients who were randomized to receive aspirin at a dose of 150 milligrams per day from 11 to 14 weeks of gestation up to 36 weeks. These patients were all considered to be high risk for preterm preeclampsia, and the results showed a significant reduction in the risks of preeclampsia in patients taking lo- dose aspirin.

Unfortunately, IBD patients were not formally assessed in this study. The conclusion was that women at high risk of preeclampsia without IBD benefit from low-dose aspirin. There is no evidence to date of an increased risk of IBD flares in women taking low-dose aspirin, although data really only comes from retrospective cohort studies. Just to reiterate, it must be started before 16 weeks of gestation. A recent meta-analysis showed that there really is no benefit to starting low-dose aspirin at a longer point in the pregnancy, and one should probably consider stopping it at week 36 to reduce the risk of bleeding.

Woman with IBD may have an increased risk of preterm preeclampsia. A large Danish national birth cohort of more than 85,000 women, including 278 with Crohn's, 388 with UC, showed that there was no increase in the risk of preeclampsia overall, but severe preeclampsia was elevated in women with IBD 2-fold. In another large national inpatient survey of more than 8 million pregnancies, including about 8000 women with Crohn's and 5000 women with UC the risk of preeclampsia and eclampsia in Crohn's disease was increased, but the same was not shown in ulcerative colitis.

The second GRADE statement that was formulated was a suggestion that pregnant women with Crohn's disease and active perianal disease undergo cesarean section. And there are several studies which show worsening of active perianal disease in patients who have a normal vaginal delivery.

The final GRADE statement suggests that pregnant woman with IBD and a prior ileal pouch anal anastomosis should consider cesarean section. There are conflicting data on the impact of vaginal delivery in women with ileal pouch anal anastomosis. One systematic review of 8 studies with 358 patients showed no difference in pouch function except in those patients who had complicated vaginal deliveries. These studies were pretty low quality and the only one that actually used anal manometry did show a reduced squeeze pressure, more sphincter defects and worse quality of life in woman having a vaginal delivery compared to cesarean section.

I'll then move on to the 3 consensus statements. The first is that women current or past history of recto-vaginal fistulae should undergo using a cesarean section. Now there's very limited date on the risk of recto-vaginal fistulae, recurrence, or worsening of symptoms following vaginal delivery in women with IBD, so this recommendation is largely based on expert consensus.

The second consensus statement is that women with IBD should be assessed early in pregnancy or preconception for nutritional status, weight gain, and micronutrient deficiency. We know that women with IBD are at risk of malnutrition and micronutrient deficiencies. This is multifactorial due to reduced intake, diarrhea, malabsorption, and uncontrolled disease activity. Pregnancy may further worsen these deficits because of increased requirements, which are essential for normal fetal development. The most common deficiencies are iron, vitamin B12, vitamin D, and folic acid. Of course, all women who are pregnant as well as preconception are recommended to take folic acid supplementation. So it's really only the other deficiencies which need to be actively looked for and treated if necessary. The most important of these is iron deficiency, which we know is extremely common in IBD and has multiple deleterious effects on the mother and on the fetus. It is very important, if possible, to have the iron restore repeat before conception because intravenous iron is contraindicated in the third trimester.

The final consensus statement is that pregnancies for women with IBD should probably be considered as high risk for complications. We know that pregnant women with IBD are more likely to have pregnancy-related complications, particularly venous thromboembolic disease, gestational diabetes, I've mentioned eclampsia and preterm delivery, and this suggests that pregnancy in the setting of IBD should possibly be considered as high risk, prompting more intense monitoring of the mother and the fetus. Of course, how this is managed will depend very much on what the resources are that are available if possible, which would be in a first-world country. Patients should be managed in a specialist IBD clinic and have input from a maternal fetal medicine expert. Of course, in most countries across the globe, obstetric care is usually due to the midwives and obviously they will require education about the risks that I have just mentioned. So with that, I thank you for your attention and I hope this pregnancy consensus proves useful in your daily clinical practice in managing pregnant women with IBD. Thank you.