Chapters Transcript Video IBD Breakout: Evidence Based Updates in Pregnancy and IBD IBD Breakout Session: Evidence Based Updates in Pregnancy and IBD *Not Eligible for CME Credit Hi, everyone. Good. Uh Thank you for joining us. Uh Pleasure to be here and talk about some evidence updates in pregnancy and I V D. I'm Sherzad from the last session. Um I'm the director of Pete's Gastrology and Chair department of pediatrics here at Cedars and I'm joined by the expert Dr Bana. Thank you. Thank you, Shervin. So I'm so happy to be here today and update everybody on just some uh uh pregnancy updates. Those are disclosures really our objectives today are gonna be two fold. I am on the adult side of things and I run the I V D pregnancy clinic here. So I will be talking about mom in this case and then a little bit later on, we will kick it over to our pediatrician, Doctor Rob Aza to talk about the baby. So just to keep it simple, mom and baby. So first I always like to start with saying, well, why does this topic matter? It seems a bit esoteric um compared to all the other wonderful talks that we saw today. But I really want to remind you that I B D affects a lot of people in the United States now, anywhere from, you know, 2 to 3 million and at least half are women. So it's a lot of people here that this I I B D affects and when you really look at women, um, I mean, it affects a lot of women during their childbearing years. So at this point in life, when people are getting initially diagnosed with Chromos and ulcer titi, maybe in their late teens, early twenties, you know, one of the things that they're also going to think about is, well, am I gonna be able to start a family? Well, how does this affect my years to come? Especially during my so-called childbearing years. And if you look at the graph here, you'll see that pregnancy in the United States really closely mirrors and follows um on average just after the age of diagnosis. So this is a topic even if they don't say this to you, it will be on a lot of women's minds when they see you for their IP D care. So let's just start with the case. This is Amy. She's 22. She's had a year a year history of pain, weight loss, loose bowel movements, her belly is tender and when you do a work up, you do see some elevated inflammatory markers in the blood in the stool. You do a colonoscopy shows about 10 centimeters of moderate ileal inflammation. You diagnose her with Crohn's. She gets started on a stereo taper given that she does have pretty significant symptoms. And uh after, you know, discussion with, you decided to start her on Adalimumab. So you'll notice I have a pictogram down below of all the different stages that a woman goes through in her life. And at this point, you're gonna be picking up Amy as she's sort of transitioning from being a young adult to then thinking about a few years down the line. When you've seen her, she's done really well on Adalimumab. She has had an I U D in place, which is our preferred method of long term reversible contraception in women. She has her career under way and she says, you know, I think I'm ready to have kids. So she wants to talk to you to say, well, now that I have a history of Crohn's, am I gonna have some issues conceiving? What do I do with my medication? And then the questions, you will certainly answer those for her, but you should also have some for her to say we need to make sure you're in continued remission. And are we up to date with everything that we need before we kind of lose you to pregnancy for a couple of years? And our, our modalities are a little bit more limited. So let's start with sort of saying that we're gonna take Amy through and get her through pregnancy. So let's start with answering some of these questions. So the first one what is fertility look like in those who have no surgeries? All right. So in women in general with Crohn's disease, technically speaking, if you look at the studies, there seems to be a reduction in fertility. But when you really, really compare this, you know, and, and kind of dive into the data of why this is the case for patients who haven't had surgery. It's really, or that it's just linked to what we call voluntary childlessness. They feel like because they have this condition that's quite, you know, severe and chronic and that they're on these medications that perhaps they shouldn't have kids. And we now know that honestly, that's not necessarily the case as long as they're with a good gastroenterologist and have a good team in place, we can really counsel them very specifically. Now, this is in the non surgically treated I B D population. Now, what happens if they had surgery? And more specifically, the one I want to talk about today is the J patch or the IP A. Now, this one, why do I single this one out? The other surgeries that patients typically have may be an ileocolic reception or a segmental resection, either the small bowel or um colon. They don't have as much data showing that they've had any decreases in um fertility. But the J pouch does. And why is that the case? And I want to go over briefly the three stages of AJ pouch because this matters if you are considering this for a woman. So, in the first stage, um you will see that what they will do is take out the majority of the colon. They will leave a bit of the stump in place and then there will be what we call an end ileostomy. All right. Second stage is when the actual pouch is created, where they will take down the small intestine, pull it down into the rectal area and either remove all of the residual rectal stump and go directly to the anus or perhaps leave a little bit of a cuff down there. They will still have a temporary what we call it diverting loot box because this needs to heal. And then the third stage is just sort of reversing that ostomy. Now, when you see that they pull this down and they remove the rest of the rectal sump area, there is a decrease in fertility with those who have undergone all three stages of the IP A up to about three fold. And the reason for that is that when you take a look at this diagram that also now superimposes the other things that we have, which is the uterus here and the fallopian tubes and the ovaries, you can see that this is very close to the rectal area where the surgery occurs. And these fallopian tubes are quite honestly flimsy and they get damaged very easily with adhesions. So a lot of our patients who have IP A s do have decreased fertility in what we call tubal factor in fertility. And that the egg once it gets released from the ovaries really is having a hard time making it through the tubes. Now, the good news is, is that, you know, uh if patients do have it, they do have the options of I V F. Bad news is it's quite expensive but, you know, you do want to counsel patients for it. So I have had some patients where they want to have Children. We sometimes leave them actually at the after the first stage they undergo and have their Children. And then later on down the line, we think we go ahead and do the completion of the surgeries. Now, what about medications? This is the biggest thing people will ask you about. Now in the past, they used to have FDA approved our FDA categories for risk, but this was done away several years ago. So they really say you have to individualize the risk to your patients. Ok. So I want to kind of also bring this up. A lot of times people have this, you know, misconception that all medications are harmful. And as long as they can put up with the symptoms, they, they, they want to do so to keep their baby safe. But what I want you to really push back on is to say, well, you know, what are the risks for uncontrolled disease. What happens if you go off of your medications or you flare? What are the risks for that? And honestly, there's serious consequences to uncontrolled disease. So, multiple studies have shown that if you conceive when you are not in remission and you are a higher risk for flare and that flare will lead to a higher risk for preterm birth, low birth weight and a higher risk for miscarriage. Now, one of the things I also want to stress is that even if you're well well controlled, you still, your patient is still at a higher risk for preterm birth and low birth weight just by having this disease. So all of our patients, whether or not they are 20 or 40 and trying to get pregnant, they were all considered high risk. So they really should be, um, seen in conjunction with a high risk O B as well. So, one of the things that I, you know, do want to emphasize though is that almost all the I B D medications can be continued because almost all of them are really quite safe. So let's actually first start with the ones that you don't want to use during pregnancy. So first methotrexate, which I think is a very obvious one. It is actually used to um end pregnancies. So we don't want to use that one in any woman of childbearing age and thalidomide. Now, even our center has very, very few thalidomide patients So I don't think this is gonna be pretty common, but how about the rest of them? Almost everything else can be used. And with a couple of exceptions that are on the newer, which I'll talk about now, where do we have this data um come from? So that in the next few sides, I'll, I'll talk about some of the recommendations. A lot part of this comes from the wonderful studies that our um guest speaker earlier this morning, Dr Mahadevan has really pioneered and, and, and done so with in conjunction with the Ronit Foundation, she has started a prospective registry of pregnant I I B D patients and has followed them throughout pregnancy and follows the child at least the first year of life. But as a son is really in its 14th year, we have data, long term data on some of these Children too and she's had over 1600 women that are enrolled. So let's go over some of the findings from that study and then also our general recommendations. So first amino solicits they're safe. So these are the mesalamines, the sulfaSALAzine, the balsalazide, they're low risk. There used to be an older formulation called AOL H D. That one did have a coating that was pro potentially tara. But honestly, in the US, we don't really have that anymore. So I I don't think it's much to consider or worry about, but you can continue a prepregnancy dose for all the other meal and you can, you know, safely breastfeed as well for this by appearance. Actually, they are also safe. They are lower risk and monotherapy. Is there some potentially slightly higher risk for infant infection and combination therapy with anti potentially? So this is where you know, even prior to pregnancy, individualize that therapy and see can you repeat come off of the opine or can we check levels and see if we can get them to the lowest level possible. Now, these are also safe for breast milk in the breast milk um and compatible with breastfeeding. The old adage of pump and dump for the opines is no longer holds true. How about anti T N F biologics? So there's several on the market these days and in general, they are quite safe. So the anti T N F biologics, they cross over to the placenta, this predominantly in the third trimester at the highest where the placenta expresses this one F C receptor. Um but you know, in general, they are quite safe and you want to try to aim for the last dose to be somewhere around, you know, where the patient will deliver trough. So if they're on Infliximab and they're on every eight weeks, you wanna try them to try the last dose somewhere around 32 weeks. Um assuming they have a normal 40 week pregnancy due date. Ok. Now, one exception is SZA we don't need to make any adjustments for these because it doesn't cross the placenta. It doesn't have actually the um you know, the F C portion of, of the, the molecule. So it doesn't actually cross over it. You don't have to worry about it. Now, how about non anti T N F biologics? So, the data that we do have for the natalizumab or the I L 12 23 Lustica and, or the anti integra metal Liza does show that they are safe for pregnancy and for breastfeeding, I'll talk a little bit about the newer I L 23 specific Riza in a second. How about steroids? Now, steroids, you know, if you need to use them to control a flare to prevent as much as you can a preterm birth um due to the flare or a risk of miscarriage fla, they then use them, just use them in conjunction with the O B G Y N so that they will know uh uh you know, really to monitor them from a blood pressure side and glucose side on their side. Now, how about the newer medications? So right now are, you know, we don't have enough data to just say, go ahead and use them. But I will say have I've had patients who are on these medications I have, but it's through extensive counseling. So right now, the newer I L 12 23 antagonist, the risen Kim, um it has insufficient data now, likely I do think this will probably be fine later on down the line. But just to, you know, mechanistically, I I don't see why it would be any different. But until there is more data, see if there are other alternatives. Uh prior to starting somebody on this, how about the jack inhibitors? They're convenient, they're oral, they're usually highly effective for a lot of patients. Right now. There is insufficient data to recommend using it in pregnancy. Again, we have used them at the lowest dose possible. But this is after very, very extensive counseling on our part and also on the part of the uh high risk O B G Y N s. And then how about the um ozat mod? This one really does not have enough data and um you know, there usually are other options for treatment. Uh So this one I would caution against for now. Now how is Amy doing? She's pregnant? She's doing well and then she asks, well, should I have a vaginal delivery? Is there some reason I can't, can I breastfeed? And the questions you have to monitor her during pregnancy is, well, what's your calprotectin? And you also wanna, you know, think about uh post pregnancy about corresponding with her pediatrician. So let's kind of take her through this entire area. So one monitor during pregnancy now, well, you may or may not know this but the C R P and C rate that we use during our, you know, routine um blood work for I B D, it is naturally elevated in all pregnant patients, whether they have I B D or not. So the said rate can go as high as 70 before you give birth. So these are a little bit um harder to interpret in pregnancy, but I would say the fecal cal protect. And there's been multiple studies that the show that one is not, not as um uh affected by pregnancy. So I typically do get a calprotectin every trimester um in my patients. Now, MRI S C T scans again, you know, uh very limited use in pregnancy. MRI S could potentially be used if needed, but there is some risk with gadolinium. So you again, you want to see if you are needing to use the MRI uh use it. So in conjunction with the high risk of V G I M, now, I mostly leave this up here so that you can reference back to this um in the future. Should your patient have a flare? But if they do, this is really a quite nice algorithm that helps you go through what what trimester it is, whether they have Crohn's or Oitis if they're biologic naive or not. And if they've had response to steroids or not, but this is the top all in and of itself. So I'm going to go ahead and just leave that here for you and I'm happy to answer any questions if that comes up later. Now, how about endoscopy. So flexible sigmoidoscopy is the preferred method for uh evaluating disease activity in pregnancy if it is strongly indicated. So this is if somebody comes in and you suspect they may have ulcer oitis, but you're not sure. And this is an initial presentation that is a good indication or if you're really concerned that something is going on and you need to escalate their therapy. That is when you will want to do it performing in the hospital setting with the M F MS. And this is a um procedure. You should try to do yourself non fellow involved and try to get in and out as quickly as possible, but it is safe. And doctor Maja actually did show recently flexible sigmoidoscopy uh in I B D was quite safe and 70% of people that they did this on changed management. So I'm going to start taking, going over to Doctor Raza for this. But from our standpoint, from uh when you know, our patients ask, well, you know, can I have ac, do I have to have ac section? Because I have I B D, the, the vast majority of uh of our patients can actually deliver vaginally. You know, even those with ostomies, the ones you wanna think about C section are, if anybody has any active per disease, I've had lots of patients who we get their disease under control except for that per se will never come out, you know, so those are patients that will continue with uh ac section or if they've had any really significant history of rectovaginal fistula, you really don't want them to have a higher, um what we call higher order uh laceration which involves the anal area. Everybody else, you know, uh really can't have a vaginal and with pouches, you know, I think you have to individualize it. Patients who have had great pouches who really haven't had many issues with the pouch. The baby is not too big, the baby is not breach. Um Then that is a consideration for vaginal too and then went to resume. So let's say that with uh our patient, Amy assuming that she's done well, she has a vaginal delivery, truly can resume her um aluminum injections within a day or so after vaginal delivery or 48 hours after ac section. Um The one other thing I caution to the O B G Y N is that, you know, a lot of the O B G Y N s do use nsa's postpartum as their predominant um method for pain control. So you just want to limit that because that can lead to postpartum flares. Um And Fenu Greek, which is common in lactation supplements. A lot of our patients actually also flare with that. So I do try to ask them to if they're gonna use lactation supplements, use a A Fenu Greek free one. Now, so now she's uh Amy has done postpartum she's doing well. I'm gonna bounce this over to Doctor Rabaa. So to talk about a little bit about lactation and then talk about what should we look out for in her kid? Great. Thanks so much, Nero. So the questions that are gonna come out at this point is that should she breastfeed? Uh, and what's the risk towards her child overall? And with Nero just mentioned before going over those medications right there, we of course, on the pediatric side, really want to encourage breastfeeding overall. And even on these medications, the women uh for the child can breastfeed without any sort of modified patients. Overall, there may be some drug obtained through the breast milk overall. But that it's been shown that it has no ill effects on the child short of this one caveat, which is this idea of live vaccines, just like we discourage live vaccines for biologic receiving patients. We also discourage live vaccines for the babies born to mothers on biologics for that first six months of life. Uh And the only real live vaccine during that time period is the roto virus vaccine. So that's the one that can be avoided during that time. The exception is there are those patients on Certa Liza since that doesn't cross the placenta. Uh and those patients can receive the rotavirus vaccine. And it's really important uh to send that note to the pediatrician. So they're aware and they understand why the perspective of that overall, in terms of hereditary aspects of the disease, um there is an increased chance for the Children to have inflammatory bowel disease when their parent does have it, but it is non Mendelian pattern of inheritance and there's some genetic anticipation as well. And so if one parent has it, the risks are somewhere between three to percent, 3 to 7% chance of the inflammatory bola and offspring. And if both parents have it, that increases to 10 to 20%. So a slightly increased risk that we do counsel the families about. What about symptoms in terms of presentation? Really? No difference when you look at the symptomology of these patients and how they present overall, it's the same as you would expect any other patient presenting. So these Children will present in the same way. The exceptions are the younger patients, the younger they are the very small subset of the very early onset of inflammatory bowel disease patients and less than six year olds will talk about in a second, are usually more colitis in presentation, bloody stools and diarrhea, whether they're Crohn's or U C. Uh that's how they present overall, but there are some protective um sort of risks and non risks in terms of developing IVD in these patients, vaginal delivery. Again, is protective. Breastfeeding is actually protective, limiting antibiotic exposure is in that first year of life is protective and obviously not having a family history, which in this case is not, is not relevant but protective against developing it overall. So things that we can encourage and counsel for the family overall. The other symptom that we always bring up in pediatrics is growth without any other gi symptoms, growth can be the only presenting issue in Pubertal Crohn's disease patients can be seen in up to three quarters of those patients overall. And the growth pattern that you see typically is a decrease in height velocity and a decrease in weight, but a decrease in body mass index uh that is substantial as well. So that really differentiates it from other things like constitutional growth delay or endocrine when they are body mass index is well below what is expected as well with a decrease in their height velocity and not growing to the extent that we would predict them to be. So just really briefly, very early onset I B D is one of those unique subgroups of less than six years of age on presentation. As I said, they mainly present with colitis type symptoms. Uh There are some exceptions there as well. Um But that doesn't necessarily mean that they're all sort of colitis patients. They may turn out to be Crohn's patients overall. But this group, we want to make sure that we rule out other common conditions lead to bloody diarrhea, like allergic colitis, infectious colitis and immune deficiencies. And this group also has a strong genetic component, strong monogenic disorder component. And that's why we do genomic analysis in all these patients overall. Lots to talk about in terms of therapies and treatments and those to discussions, which is a whole talk in it by itself overall. But as I said, the monogenic component is about 20% of these patients overall. And that's why we do want to do a genetic panel on these patients and it can make a difference. The big case study was the one you see to the top right there, which was a group of patients with endo contain fistula recurrent folliculitis, impaired wound healing. On presentation. They had an I 10 R defect and were treated with stem cell therapy that was curative for them. Overall, there is no suspected increased risk of very early onset I B D just because mom has inflammatory bowel disease at pregnancy overall. But more and more these patients in general are increasing in numbers. So we see more and more of them overall, irrespective of mom's uh status. So just to excuse me, close off the talk, if you only take away one message from this talk, try to get your best to get your patient and endoscopic remission a conception because that leads to better outcomes and it takes a village. So please have the patient, you know, not just see just their O B but to have a whole team in place. And we're gonna leave a little bit of some preconception checklist, a pregnancy checklist and then also a website that is incredibly helpful called I B D Parenthood project dot org, where they really will be able to kind of go through and guide you as well as the patient on how best to move forward with family planning and postpartum. Created by
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