Chapters Transcript Video Update in Management of Pregnancy in IBD Angelina Collins discusses preconception for men and women with IBD. very happy to introduce Angelina Collins who is a nurse practitioner um in the inflammatory bowel disease center at the University of California san Diego. And she is going to be speaking to us about management and updates and pregnancy in IBD. Thank you so much melissa, I really appreciate it. So I hope everybody is still awake this afternoon. You saw my disclosures. So I tried to really pare this down in the interest of time. There's a lot that we can talk about. I have some great resources at the end, so I will just end up kind of showing you those. But here's what we'd like to do is talk about preconception for men and for women, there was some really great new data, I think that includes men who are often the forgotten ones. Um so it'll be nice to actually be able to show you that talk about pregnancy postpartum, some lactation and then you know beyond basically. So jumping in. I really loved a number of years ago I saw someone do the key points and they did the summary slide like first and I thought that's brilliant, this is the best way to do it because everyone's still sort of awake at the beginning of talks and then at the end they sort of get a little more tired. So I wanted to tell you the key points up front. So maybe you don't have to listen to anything else after this and you didn't see that. Listen to this one slide. Um but I think these are the really important kind of key concepts because you don't want to get bogged down with a lot of data maybe, and you just want to be able to say like what do I need to know to to take care of my patients and do a good job taking care of my patients. So I think the mantra, healthy mom healthy baby is a really simple one. Um, if we've learned nothing else from all of our conversations with our patients and with our colleagues and that if we just keep a simple message, it really is much better understood. So healthy mom, healthy baby, that means take care of mommy, because if you take care of the mommy, then you're going to naturally be able to take care of the baby, so that I think is really important. The other big piece of the puzzle is discussing pregnancy um, prior to conception because once they're pregnant sort of like too late, right? Like they've already gotten pregnant, But there's things that you really want to be able to talk about before they get pregnant, like number one conceding during remission. This is a key key key takeaway. And if you're wondering how to keep the baby healthier, how to make sure you have it. You know, mom could have a healthy baby, you have the woman conceived during remission. This is a major point. Um, and I think this is a really important one, and then you also want to make sure and you want to tell your patients upfront why to do this, make sure they're continuing on their therapy. A lot of women may mistakenly, you know, pregnant women probably get the most unwanted and unsolicited advice just in general, right? Like I was pregnant twice. I would. I mean, not even I remember being in the check out the checkout line at a grocery store in a perfect stranger asked me as I was getting much bigger, she was like, are you going to breastfeed? And I was like, what? What do you mean? Am I gonna breastfeed? This has nothing to do with you. This is not a conversation, but it's just a point that a lot of pregnant women get unsolicited advice or questions. They're hearing a lot of advice from their mother in law, et cetera. You know, their pediatricians, dogs, son's mother's father, you know, it just goes on and on what they hear about. So you want to tell them to make sure that they stay on their medication. If it's one that seemed to be safe during pregnancy, that is going to lead to point number one healthy mom, healthy baby. The other point is to make sure that you have a game plan if a flare is going to happen because they do happen and you want to know how can you manage it safely. So we'll talk through that as well. And then really when you think about how is this woman going to deliver the only contra indication for a vaginal delivery is active parry international disease. There's actually a 10 fold increased risk for fourth degree laceration for our patients that have active periodontal disease. And this is devastating because if they have 1/4 degree laceration they will most likely are going to be set up for incontinence later on in life. Which is a devastating consequence of periodontal disease. Rectal surgeries and things like that. And we see that sometimes and it's really there's this is probably one of the most complicated things but it's also something that really needs to very poor quality of life and outcomes. So I think that's a really important piece. And then I also would say caution with anyone with a j pouch and vaginal delivery. Make us again for that risk for incontinence because if they do have incontinence that's going to be trouble later on as well. So something just to think about here and then most importantly to and I'm gonna show you some data about this. Um or I'm going to talk about the safety of medications but babies exposed to biologics in utero should not receive any live vaccine. But if you're following the standard vaccine guidelines in the U. S. The only the only vaccine this would affect is rotavirus. Okay so what does preconception um you know counseling discuss or what should we be thinking about. So remember that 50% of pregnancies are unplanned. So that really means that we need to talk about this really essentially with all of our patients. Um and if we think about this is important because there are some types of contraception that are probably contra indicated, we need to think about the use of oral contraceptions in women who may be actively flaring their increase of risk of blood clots, right. Um that's one of the other reasons why thinking about, you know, what are we going to do for patients and how if they want to prevent pregnancy, how do they go about doing it? Um But also the other piece of the puzzle is there's actually a higher voluntary childlessness rate in women who have IBD compared to the general population and that is probably for a bunch of different reasons, but part of it probably has to do with some misconceptions. So women thinking that the chances of, you know, passing the genes on to the baby that are going to make the baby more susceptible to inflammatory bowel disease or having crimes are all sort of colitis as they grow up is higher than it probably realistically is. Um they may be concerned about the medications that they're on. Um all of those things. Maybe a piece of the puzzle into this voluntary childlessness. The other thing to keep in mind too is that fertility rates and actually in fertility rates are really very similar in women who have IBD that is well controlled. It's comparable to women who do not have IBD. So that means that their likelihood of getting pregnant is about the same if there are diabetes well controlled. Of course, we know that if their IBD is not well controlled, unfortunately, there's a higher rate of miscarriage. Now there's decrease, there's decreased fertility with advanced age and that's probably something that was still consider as well. So for young women who have disease, not well under control that are saying I'm going to wait a little while, we have to watch that time clock and see, you know, when is waiting too long. That's something that I probably leave to my uh colleagues in maternal fetal medicine and G. Y. N. To discuss. Um But active disease already mentioned and all sort of class patients undergoing pelvic surgery. Um That would be one concern as well. Um The other thing to think about is really talking about in the preconception mode is conceiving during remission. And what this actually means is conceiving during a three month steroid free remission. That's really important. So we would like our patients to be off steroids in, you know, known remission for about three months before they decide that it's time to start trying to get pregnant. It's also important to think about what their medications currently on and are there are other medications safe to continue throughout their pregnancy. The biggest one here, there's two that I would really think about offhand and that would be um Tofu Sydney which we know is not recommended. It's not recommended to get pregnant on Tokyo Sydney or to continue in the first trimester specifically. So that would need to be addressed and before pregnancy. And then also Metro night is all if you have a patient who has has a need for an antibiotic, that's probably not the best antibiotic for the patient to be on before getting pregnant. And even for breastfeeding, that's not the ideal medication. Um We do want our patients to continue medication throughout pregnancy and we'll talk about this in a bit. And then again the mantra, healthy mom, healthy baby in case you didn't get it the first time I mentioned it. Yeah. Okay. So what else should we think about? Well medication management. This is a big piece of the puzzle. So we can provide some reassurance to our patients by saying and letting them know especially when it comes to biologics. So placental transfer of biologics does not occur during the first trimester. So most of it's actually happening in the third trimester. Um So in the 1st 10 weeks when organogenesis is occurring, the biologics aren't transferring. So they're actually not getting to the baby during that time period. That's most important for all the organs to develop and that I think is really a critical piece. And then there's been some really nice updated work with the piano registry which now has comprised over 1400 mom and babies. And what's great about this now is we have data over I believe it's 13 years. And this is really giving us really nice information that mom's um more or babies who are exposed to fire periods or biologics um in utero did not have increased rates of congenital malformations, spontaneous abortions, preterm birth, low birth weight or increased infections in the first year of life. This is an update to what we've kind of been seeing already. And this was really I think fantastic because now we're saying this is like this is a large number of mom and babies. And this is really helpful to see if we can tell our patients this up front. Which is why then when we say I want you to continue your biologic medication and or your fire period. You know, you can feel confident that there's data behind it. And not only that your patient can as well. And so if you tell mom that upfront or mom to be up front, I think they're going to feel much more confident that in your recommendations and actually plan to continue throughout the pregnancy. The other nice piece of the puzzle is that exposure of the medications um was not exposed to differences in developmental milestones for the baby during that first year or two that they were followed. So that's also really good to hear. Um And again, I think it's reassuring. So I said we talk about the boys. This is a nice little study that came out of the team um dr Singh and joe deserve at UCSD. And so what was really great to see is that um paternal exposure to immuno suppressive biologic therapies around contraception also was shown to not increase risk of adverse neonatal outcomes. It's actually looked at quite a large number of patients. They were going through a lot of doing some analysis of these. They actually were able to kind of see and you see on the left hand side, I like this visual descriptor because it really kind of shows you really nicely how many patients were really were looked at or how many dads were looked at and what they saw was there were no major congenital malformations, low birth weight or preterm birth, there was no increased risk. So I think that's really helpful to see this was looking at over almost 7500 babies. So that's really kind of um I think that's really cool and really great to see because we didn't previously have much data on dad's and there was some mixed data as well as to what to do or whether or not you have to tell the dad to hold the methotrexate or not. Um And so I think here's some information about what it actually looks like in in this larger group and that's updated information. So that's great to see. So now you've got someone sitting in front of you mom's pregnant and you're having this conversation about what to do. Well again still important to remember to tell your mom in front of you to continue biologic therapy throughout the third trimester. There has been there or there had been debate in the past as to when to say when should you last dose the biologic do you does it when? So there's been some discussion about should you dose it so that the mom basically so that the drug would be at trough at the time of the delivery. Well that's a really tricky thing to say because here you have a brand new mom and I will tell you I've tried to get their dose of the biologic in house say it's inflicts a mob for example And you try to get that dose you know in there 1-2 days that they're staying overnight in the hospital. It's really tricky to get that as an impatient for the mom or then you're telling the mom that she has to come back to the infusion center when babies just a couple of days old and get her infusion. And that's a really tricky time as well. Um if you've ever had a newborn in your house. So it may be better to say you know to does it at an appropriate time to have them stick with schedule. I've had to have some moms actually does it so that they've got a couple of weeks time and that felt better for them. But I think the most important message to mom is to let mom know to continue it right through the third trimester. What they actually found was is that if you stopped it prior 24 weeks gestation, you ended up having increased maternal disease. So mom was more likely to flare by 10-25%. But you weren't reduced any of these, any of the of the potential, like you weren't getting any benefit out of it. So all that was happening was potentially increased risk with no real benefit. So it's not stopping early. It's better to dose kind of straight through and when you go straight straight through, you're going to reduce flares during pregnancy and also postpartum and there's a lower incidence of adverse pregnancy outcomes. So I think that's really important to kind of think about and if also you have a weight based dozing, then use the pre pregnancy weight for a moment. Now, what about during pregnancy? What else do we need to think about and do? So it is important at least to have mom have one visit with maternal fetal medicine during their pregnancy or high risk obese sometimes the other name that they follow under. And that's probably a really important thing to do so that their followed and managed a little bit more closely. Um I mentioned already about delivery um when you know could be vaginal delivery, when to consider doing a C. Section. So the periodontal disease patients, I think that's actually really important piece. Um And then again with j pouches as well, something to really kind of consider and have um mom, you know, kind of think through if the sir and some of them still have really nice connections with their surgeons and so they feel really comfortable talking with their surgeon about this as well. Now, what do you do if your mom flares during pregnancy? It's unfortunately it may well happen. Um You know, 30 to 35% of pregnancies will result in, there will be a flare during the time in their pregnancy. Um And I think probably one of the most important things to consider is, you know, why did the mom flair? And one big piece of the puzzle to ask his mom still taking her medication because sometimes this occurs because mom stop the medication. Um And that's something that you really want to figure out early on. I think that's important. Um So the risk of flare increases if conception occurred when the disease was active versus when the disease was in remission. Um So it's much more likely that you're going to see active disease throughout the pregnancy if the mom conceived when there was active disease versus if the moms in remission, there's basically an 80% chance he's going to stay in remission throughout the pregnancy. The rate of um flare increases the risk of spontaneous abortion, preterm birth is like a two fold increased risks. That's significant loan between and then if the mom is flaring, then they have low weight gain that's going to make small for gestational age babies. So that's something to really think about. Um And then it also increases the infants infection, especially if they're being born early. So all these things happen from mom flaring. Unfortunately, what's really critical is managing these flares really promptly. It's not a great idea to say, oh yeah, this person can come in in four weeks and see me in four weeks or something like that. They really need to get in pretty quickly. Um You do want to obviously check labs and stool studies, but remember there's a few things that happened just in the rate of a normal pregnancy. So hemoglobin, hematocrit are reduced during pregnancy, abdomens, also reduced during pregnancy. Crp and said rates can be increased during pregnancies. Um fecal cal protecting maybe reliable, but it's better probably have a comparator or and if you were on earlier in the morning, we had really nice conversation with dr july and dr sanborn about the role of fecal cow protection. How this is one that's really nice to be measured over time. So it be better to have something to compare to than just to do one, you know, a one and done sort of thing. And then can you scope your patient who is pregnant? And the answer is yes. Um Un sedated on prep flex. Sig if you think it's going to change management. If you don't think it's going to change management, then it's sort of like ordering a test. Then you don't know what you're going to do with the result. Well, don't bother ordering the test. If you don't know what you're gonna do with it or how it would change. It's just not worth it for you. Or you know the stress that you're probably gonna put your pregnant mom under. Yeah. And then what else to do? Well, it goes back to what I had said just a few moments ago, which is you know, no question number one is mom taking her medication. I think that's important. Um You can use pregnancy predniSONE to treat flares. But of course remember pregnant zone has its own set of risks. Um It's not meant for long term management. And then also so consider risk for increasing gestational diabetes, preterm birth, low birth weight. So um as we know anyway and the rest of IBD. It is not a perfect medication and it's not also within managing flares and pregnancy either. Um But you can use it if you need it. Um I did make this kind of crazy, probably super busy slide. But I he was trying to think about this. And it actually kind of even helped me to think about, well what can we do and what can be used. Um This will be in the slide deck that's going to be available, it sounds like it'll be about a month away when you'll have access to this. So you'll kind of see the main considerations here about what to do here and there. The only thing I draw your attention to is at the end um where I've listed out like used to kenya map and vandalism, can you continue those during pregnancy? I think the general consensus is yes. Um with just the consideration that there's limited pregnancy data, but there's more in growing. Um, so, and there's more published data on this too. So I think, you know, most people feel pretty comfortable continuing this, you know, throughout pregnancy. Um would you have a new start? You know, I think that's another kind of conversation that I'd have belief, you know, for you and um, you know, the team of providers that are probably taking care of mom also. Um but again, it's important to keep the, it's important really to manage the flares and get the disease under control so that you can have a healthy baby. So I think that's really kind of critical as well. And then what about postpartum? Well, there's a number of factors that can affect flaring during postpartum. So active disease at conception. I mentioned this already, it worsens outcomes during, during pregnancy and then even afterwards active disease during pregnancy is going to increase it um, you know, for the postpartum period and then if you discontinue the biologic during the third trimester and don't treat through that also is another risk factor as well. So basically have your mom continue on, you know, conceive that remission have the mom continued throughout the whole pregnancy and there are the things to know about lactation. So encourage continuation of medications. I mentioned this kind of upfront. Metronet is all should not be used for breastfeeding moms, methotrexate. There's very limited data. So most people do not consider this to be a great idea and then to have a signature should not be continued. You don't need to pump and dump for other medications. However, so it's probably just important to tell your mom to take the medication and breastfeed the baby. Those are really helpful things if you want to reduce the risk of um IBD in the baby's, it does look like breastfeeding is a it would be an important factor. Um And so and also I think this happens, this has happened so much and I'm sure there's probably lots of people, hopefully there's people in the audience that are shaking their head now that they've been in a situation where either the pediatrician or the Obi Joanne has voiced concerns about the mom taking certain medications and yet you never heard about it. So you're managing her IBD. But you never heard that there was a concern and mom stopped medication because of some concern that was brought up, Just have mom talked to you about it. So if anything pops up, have her send a note to you have to give you a call something or better yet have a visit every single trimester with mom. So that then you can talk through all of these things are inevitably going to come up because they do. So here's the end of it. Again, just some key points if they didn't quite catch it and healthy mom, healthy baby, discuss pregnancy prior to conception. Um, and throughout the whole time, um, probably one of the key points should have been to have a visit. If you can with the mom to be in each of the trimesters, then you can kind of talk through all of this. Hammer home some of the points and not just dump information straight out as um, as can be done as I'm doing to you guys right now And then you can actually kind of think through it at each of the different visits, continue the biologic or combination therapy throughout pregnancy and breastfeeding have game plans and babies can get all of their usually scheduled vaccines except for rotavirus and then last but not least this is the last one. I promise. Um, these are really fantastic and valuable resources. The IBD parenthood project. If you have not seen this. I think it's like phenomenal because it's almost like I, if it was, if it was IBD and pregnancy for dummies like this is it, it's really easy to follow. It has really nice plan. Um It's just a fantastic resource. Um and so it's, I think very, very simple and it's like really useful information. And then the LaCma database is also fantastic because this will tell you about, you know, what's safe to use during breastfeeding and what's not um if you need some additional information about medications. So those are great resources. I actually use these all the time. Um and I hope youll find them useful too, if you're not already using them. So thank you so much for listening. Published Created by Related Presenters Angelina Collins, NP University of California, San Diego Angelina Collins is a Nurse Practitioner at the Inflammatory Bowel Disease Center at the University of California, San Diego. View full profile
