How to Address Pregnancy Concerns of Women With IBD

Author:

Nirupama N. Bonthala, MD

Cedars-Sinai Medical Center, Los Angeles 

Citation:

Bonthala NN. How to address pregnancy concerns of women with IBD [published online August 12, 2019]. Gastroenterology Consultant.

More than 800,000 women in the United States have inflammatory bowel disease (IBD),^1,2 which is often diagnosed during their teens, 20s, and 30s—the main childbearing years. IBD during pregnancy can raise many questions and concerns for women. There are 3 key points gastroenterologists should consider when managing a patient with IBD who is pregnant or may become pregnant.

The first key point is that every patient with IBD is high-risk—even if their disease has been in remission since the time they received a diagnosis, which may have been decades ago. In turn, we want to treat them as high-risk patients by making sure we refer them to the proper consultant, which includes a high-risk obstetrician. Sometimes gastroenterologists can get pushback about this from patients because the they may feel fine; however, sometimes the pushback comes from the patient’s obstetrician who says they can manage the pregnancy themselves. Regardless of any pushback, it is important to remember that women are at higher risk for complications in pregnancy even while their IBD is in remission. Because women with IBD are considered high-risk, they should receive additional care and testing, including growth ultrasonography. Gastroenterologists should advocate for their patients to see these different specialists.

The second key point for gastroenterologists to consider is the ideal time for a patient to conceive, which is when her IBD is in endoscopic remission. We want to try our best to help patients achieve endoscopic remission and, once they reach it, give them the green light to go ahead and try to get pregnant. Anything short of endoscopic remission puts a woman at greater risk for complications. We want to do our due diligence by helping them get to that safer point.

Now, what should a gastroenterologist do if a patient does not want to wait until she reaches endoscopic remission to conceive? There are 2 ways providers can approach this. First, discuss it with patients, which I do with all my patients, men and women, in my regular clinic. Let them know that they may feel well, but they may not be completely healed on the inside. A gastroenterologist should let their patients know that allowing a few extra months for their disease to be controlled will be a great benefit to them. It is also worth mentioning to the patient the higher rate of miscarriage in IBD without complete remission; this will often convince patients to wait to conceive.

While it is challenging to talk to patients about waiting to conceive, reframing the conversation may prove helpful. A patient might say that she can handle feeling terrible or that she doesn’t mind going to the bathroom 10 to 15 times per day. A provider can respond to this by saying, “What is best for you is best for the baby. If you are feeling well, great, but let us look inside to make sure. If you are feeling well and you are not quite healed on the inside, let us modify it and get you closer to remission. We really need to be in remission for at least 3 months before you do it.”

The third key point for gastroenterologists to consider is the importance of talking to your patients about the safety of medications. What patients fear most are medications, and they may try to avoid them. Having that conversation with patients—that medications are safe—will be very beneficial in the long term.

Nirupama N. Bonthala, MD, is a member of the Inflammatory Bowel Disease faculty at Cedars-Sinai Medical Center in Los Angeles where her clinical practice focuses exclusively on patients with IBD. Her particular specialty within the field is pregnancy and women’s health.

References:

1.  Shivashankar R, Tremaine WJ, Harmsen WS, Loftus EV Jr. Incidence and prevalence of Crohn's disease and ulcerative colitis in Olmsted County, Minnesota from 1970 through 2010. Clin Gastroenterol Hepatol. 2017;15(6):857-863. doi:10.1016/j.cgh.2016.10.039.

2.  Molodecky NA, Soon IS, Rabi DM, et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology. 2012;142(1):46-54.e42. doi:10.1053/j.gastro.2011.10.001.