Pregnancy presents additional challenges in IBD
ORLANDO — Pregnancy has the potential to present some difficult medical scenarios for women with inflammatory bowel disease. Sunanda V. Kane, MD, MSPH, FACG, of the Mayo Clinic in Rochester, Minnesota, told Healio Gastroenterology and Liver Disease that to manage these patients, there needs to be an emphasis on collaboration, the disease needs to be controlled beforehand if possible and physicians need to talk to the mother to find out her preferences at the beginning of the process. Finally, they need to know when to be aggressive to get the disease under control.
Kane participated in a discussion panel at Advances in IBD that presented several difficult cases involving pregnant women with IBD to help physicians manage some of the important scenarios that could come around during pregnancy.
When is the right time for operation?
The panel presented a case involving a woman who developed a small bowel stricture in the middle of her pregnancy. Kane said she had done well on thiopurine monotherapy but was admitted to the hospital where imagining revealed the obstruction.
“She was started on steroids. but she didn’t get better,” Kane said. “After 2 days we said, ‘Let’s talk to the surgeon.’ We don’t really want to operate. What can you do? Her nutritional status is so key right now.”
The patient started receiving total parenteral nutrition (TPN) and was able to tolerate some fluids. Doctors made the decision that continuing TPN was safer than surgery, Kane said.
“Once she delivered, that’s when she went to surgery to get this stricture fixed,” she said. “TPN is safer than surgery in that scenario.”
Some patients do not receive an IBD diagnosis until after they conceive. Kane said this appears to be different phenotype of disease that can be more aggressive.
“Whether that’s because there might be a delay in diagnosis because of the pregnancy, vs. just your normal milieu,” she said. “The other thought is if you were a smoker and you stopped because you were contemplating pregnancy, that can make you flare or develop the disease. You aren’t going to tell a pregnant woman to smoke, but all different factors are playing a role there.”
The panel discussed a case where a woman was repeatedly admitted during her pregnancy and was allowed to go home without having her disease under control.
“You can’t let a woman who is sick be inflamed for 4 weeks while she’s pregnant,” Kane said. “She’s at high risk for losing the pregnancy or having a compromised baby.”
Although there are concerns, Kane said it is okay to start a biologic during the pregnancy if it is going to help the disease.
“You need to treat that patient as if she’s not pregnant and do what the guidelines say,” Kane said. “She went into labor early, and that didn’t surprise anyone. Fortunately, the baby was okay, but you couldn’t guarantee that.”
The panel also described a case involving a patient with a pouch. Throughout her pregnancy, doctors treated her with antibiotics and steroids, and it was finally time to deliver the baby.
Kane said a few more issues can arise during that part of the process, particularly among patients with a pouch. Having a high-risk obstetrician on hand is critical, and so is having contact with another important person.
“If you can, you want to talk to the original surgeon who built that pouch,” Kane said. “The original surgeon is going to understand the technical parts of that pouch being built and what are the risks of it either failing or something bad happening to it.”
Be ready to adapt
The final case involved a woman who received approval from her doctors to have a vaginal delivery. However, several complications during the birth resulted in tearing. Eventually, the patient had to undergo colectomy, Kane said.
“Just because they say you can have a vaginal delivery doesn’t mean there can’t be complications,” she said. “If there’s trouble you need to convert to a c-section to avoid tearing.”
If there is active rectal disease at the time of delivery, Kane said the patient can be more prone to non-healing tears. In cases like this where the mother has to move on to colectomy, Kane said there can be an extra step to give the mother more time to recover.
“It’s okay to do a diversion ileostomy until you figure everything out, until you get the patient’s head in the right place,” she said. – by Alex Young
Kane S, et al. Pregnancy in IBD. Presented at: Advances in Inflammatory Bowel Disease; Dec. 12-14, 2019; Orlando.
Disclosure: Kane reports no relevant financial disclosures.