The Fundamentals of Inflammatory Bowel Disease Management in Pregnancy: A Practical Review for the Gastroenterologist

Abstract

This narrative review explores the management of Inflammatory Bowel Disease (IBD) during pregnancy, emphasizing its unique challenges to maternal and fetal health, particularly within the Canadian Gastroenterology setting. Seven key principles are highlighted: 1) Preconception counselling, aiming for steroid-free remission confirmed by objective markers, should be routine for female IBD patients. 2) Medication safety, with an eye to future pregnancies, should be addressed upon initiation. Methotrexate and small molecules are contraindicated during pregnancy, while most 5-ASA therapies, biologics, and thiopurines can be continued throughout pregnancy and breastfeeding. Steroids, though not without risks, can be utilized if necessary. 3) Routine monitoring during remission should include serum biomarkers and fecal calprotectin each trimester. 4) Routine endoscopy and imaging are not required, but if indicated, lower GI endoscopy, ultrasound, and unenhanced MRI can be used. Computed tomography and gadolinium enhanced MRI should be avoided. 5) Caesarean section is advised for patients with previous ileal pouch surgeries or active perianal disease, but other patients should follow obstetric indications for delivery. 6) Postpartum period may see more active disease, requiring continued monitoring. Breastfeeding is encouraged, and routine childhood vaccinations are advised, but live vaccinations in the first 6 months warrant detailed review. 7) Complex IBD patients may benefit from a multidisciplinary approach with robust communication between gastroenterologists and obstetricians.

Keywords: Crohn's disease; Inflammatory Bowel Disease; Ulcerative colitis; pregnancy.

Figure 1.

Approach to clinically active IBD in pregnancy. In those with active disease, investigations should include an assessment of inflammatory features and infectious workup at the outset. If there are signs of active inflammation on non-invasive investigations, medication optimization or induction therapy can be considered without endoscopic assessment. Induction therapy can include a tapering prednisone course; budesonide course; re-induction of biologics; or 5-ASA induction. Rectal 5-ASA or rectal steroids should be used for isolated distal disease. Changes in therapy should only be considered with endoscopic or imaging confirmation.