The Pregnant IBD Patient.

Why does that one word bring fear, uncertainty and insecurity into my mind.

No one wants to manage the pregnant woman with inflammatory bowel disease (IBD). And why would they? Why volunteer to add complexity to an already complex disease by now having to take into consideration an unborn child?

IBD affects both males and females during their peak reproductive years, with approximately one quarter of patients having their first child after diagnosis¹. This raises important questions and concerns by patients and their partners regarding conception/fertility, pregnancy and breastfeeding.

“Can I take this medication if I want to try for a family?”

“Can I breastfeed whilst on immunosuppression?”

“What are the risks of infertility?”

“Should I delay my IBD treatment until after I have children?”

It is completely natural for patients to have these thoughts, as pregnant women are no longer thinking about themselves but their unborn child and is driven by the need to want to protect them from any harm. I write this as a clinician whilst on my maternity leave, fully aware of the medical treatments licensed for pregnant and breastfeeding women, yet still too scared to take any medication other than paracetamol.

Thus, it is not surprising why our IBD patients would opt to stop or refuse to start treatment if they have plans for conceiving in the near future. In fact, voluntary childlessness has been reported in 17% of women with IBD compared with 6% in the general population^2,3. A survey further reported that 50% of women with IBD were concerned about risk of infertility, 25% would rather tolerate symptoms than expose foetus to medication, 33% thought that any medication taken for IBD would be dangerous for their child and 75% were worried about disease transmission risk to their offspring⁴.

The benefits of continuing medical therapy in IBD pre-, during and post pregnancy has been well established. Refusing treatment despite having active symptoms is not a decision that is made lightly. Patients are relying on our expertise and knowledge to help them make informed decisions, not just about their disease but about their future. And that is a big burden to shoulder.  It is, therefore crucial that we, as their healthcare professionals and advocates, need to be fully aware and armed with the correct information to impart onto our patients. Unfortunately, the lack of clinical trial data and objective evidence for pregnant and breastfeeding women can lead to lack of information, or even misinformation among healthcare providers. To avoid contradictory or ambiguous information, communication must be shared amongst all of the patients’ healthcare providers, including the gastroenterologist, IBD nurse, obstetrician, general practitioner, paediatrician and surgeon. Indeed, preconception counselling has persistently shown to promote healthier behaviours and improve pregnancy outcomes⁵.

Therefore, I highly recommend all healthcare professionals to read the following papers written by Selinger et al who have provided detailed guidance in managing pregnant women with IBD:

Selinger CP, Nelson-Piercy C, Fraser A, et al. IBD in pregnancy: recent advances, practical management. Frontline Gastroenterology. 2020

Wolloff S, Moore E, Glanville T et al. Provision of care for pregnant women with IBD in the UK: the current landscape. Frontline Gastroenterology. 2020.

Selinger C, Carey N, Cassere S et al. Standards for the provision of antenatal care for patients with inflammatory bowel disease: guidance endorsed by the British Society of Gastroenterology and the British Maternal and Fetal Medicine Society. Frontline Gastroenterology. 2020.

Knowledge is the antidote to fear.

But knowledge without practice is useless.

And practice without knowledge is dangerous.

Arm yourself with the knowledge. Read the papers Understand the guidance. Now put it to practice. And eliminate the fear.

 

References:

1. Ng SC, Shi HY, Hamidi N et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies. Lancet. 2018;390 (10114): 2769–78
2. Selinger CP, Ghorayeb J, Madill A. What factors might drive voluntary childlessness (vc) in women with IBD? does IBD-specific pregnancy-related knowledge matter? J Crohns Colitis. 2016; 10: 1151–8.
3. Livingston G, Cohn D. Childlessness up among all women; down among women with advanced degrees. Washington (DC): Pew Research Center; 2010.
4. Selinger CP, Eaden J, Selby W et al. Inflammatory bowel disease and pregnancy: lack of knowledge is associated with negative views. J Crohn’s Colitis. 2013 Jul;7(6): e206–13.
5. Selinger CP, Nelson-Piercy C, Fraser A, et al. IBD in pregnancy: recent advances, practical management Frontline Gastroenterology Published Online First: 19 May 2020.