1. August 2019 Interactive Case: Uncomplicated Pregnancy
Author:
Elena fisher, FNP-BC, MS, RN
Gastroenterology Nurse Practitioner
Department of Veterans Affairs
New Mexico VA Healthcare System
reviewed by the Crohn’s & Colitis Foundation’s Nurse & Advanced Practice Committee

2. Instructions
To begin, please enter into “Presentation mode” to enable full interactivity of case and questions. (Click “slide show” tab) When you see words or phrases that are underlined click on the underlined word and this will take you to the next screen. To continue the presentation make sure you click back in the bottom left corner.

3. Objectives
1.The reader will be able to discuss preconception planning with an IBD patient 2. The reader will be able to feel confident on providing safety information to the pregnant patient regarding IBD treatments 3. The reader feel more confident in helping manage and IBD patient with a normal pregnancy

4. Introduction/Background
Sarah 23 y/o woman
Diagnosed left sided ulcerative colitis 4 years ago
Initial presentation moderate to severe
Required 2 courses of steroids
3 years ago started on infliximab 5mg/kg every 8 weeks
Last colonoscopy 1 yr. ago revealed mild inflammation in the rectum otherwise normal

5. Initial Visit “Feels well”
Reports 2-3 soft stools a day, no pain or blood for a year
Weight is stable BMI 20
Labs – mild anemia Hgb 11, MCV 75
Works fulltime as a teacher, getting married in 6 months
Medications - infliximab 5mg/kg q 8 weeks, azathioprine 50 mg q day
MVI she takes occasionally

6. Initial Visit Continued
PE – no concerns
Labs – repeat CBC, iron panel, CMP, ESR, Hepatitis panel, TB quant
Imaging - DEXA if not done previously
Colonoscopy – mild changes in rectum a year ago, repeat?
Vaccinations - no records reports history of flu vaccination yearly
Psychosocial issues – Depression scale?

7. Preconception Planning
Goal optimization of IBD health and treatment during preconception and pregnancy to produce the best pregnancy outcomes
Up to 50% of patients have poor knowledge of IBD and IBD related treatments during pregnancy. This often leads to non-adherence in therapy.
Wierstra, K., Sutton, R., Bal, J., Ismond, K., Dieleman, L., Halloran, B., ... & Huang, V. (2018). Innovative Online Educational Portal Improves Disease-Specific Reproductive Knowledge Among Patients With Inflammatory Bowel Disease. Inflammatory bowel diseases.

8. Preconception Planning Continued
Multidisciplinary team including: primary care provider, gastroenterologist, obstetrician, and maternal-fetal medicine specialist
Patient should be up-to-date on her healthcare maintenance, vaccinations, and surveillance colonoscopy
Disease activity should be assessed either by endoscopy, fecal calprotectin, or imaging as appropriate
Disease control should be optimized and medications adjusted to achieve a steroid free remission
Teratogenic medications should be discontinued

9. Sarah Pregnancy Case Discussion
Initiate discussion – wedding in 6 months
Birth control method?
Family planning discussed with fiancé?
Medications – risks versus benefits of infliximab and azathioprine during pregnancy and breastfeeding

10. Sarah’s Concerns Not planning on pregnancy for at least 2 years
Was hoping to stop all medications prior to conception-Concerns?
Wants to breastfeed-Which medications are safe for breastfeeding?

11. 4 Month Follow-Up
Sarah reports she continues to do well but has some looser stools and cramping 1-2 weeks prior to infusions.
Labs Hgb 9, MCV 76, Calprotectin 560 (baseline when well <100)
Weight stable
Next steps:
Check Infliximab level at trough
Colonoscopy?

12. Follow-Up after labs reviewed
Infliximab level was 2, no Antibodies
You decide to increase to 10mg/kg every 8 weeks, continue azathioprine 50mg q day and monitor
Patient was started on iron 325mg po daily with Vitamin C 500mg a day and recommend daily chewable MVI

13. Sarah Returns 4 month later
Recently married, feels well. No further cramps or loose stools
Afraid she might be pregnant
Stopped azathioprine herself 2 weeks ago
Last Infliximab was 1 month ago 10mg/kg
Colonoscopy was not completed as previously recommended

14. What Do You Want To Do Now?
Colonoscopy ?
Imaging ?
Labs ?
Referrals?

15. Follow-Up Sarah returns is doing well, no complaints
Found to be 14 week pregnant EDD
Labs Hgb 11, MCV 80, Calprotectin 200
Remains on Infliximab 10mg/kg q 8 weeks – levels rechecked IFX 8, No antibodies

16. Monitoring Sarah is seen every 2-3 months until delivery
Weight and labs are stable
Infliximab is scheduled through week 32 and 2 days after delivery
Patient is provided information regarding vaccinations for newborn
Patient will be scheduled for colonoscopy in the future either after breastfeeding or if any symptoms
Discussion regarding adding back azathioprine can wait until after colonoscopy

17. Normal pregnancy Sarah is seen for infusion 2 days after delivery
Reports normal vaginal delivery, no complications
Infant and mother are doing well, breastfeeding is going well
No bowel changes at this time
Weight and labs are stable

18. Crohn’s & Colitis Foundation Resources
Patients
Fact sheets: (
Pregnancy
Women and IBD
Support groups:
Online:
In-person: Locate at
IBD Help Center: available by phone ( ), or online chat
Providers
Inflammatory Bowel Disease in Pregnancy Clinical Care Pathway: A Report From the American Gastroenterological Association IBD Parenthood Project Working Group (
Other educational videos on pregnancy: (

19. End of Presentation

20. Stopping Medications Back
Woman who has active disease at the time of conception is more likely to have active disease throughout pregnancy than a woman in remission at conception RECOMMEDATION: Women to be in remission at the time of conception
Back

21. IBD Medications During Pregnancy and Breastfeeding
Most experts consider use during breast feeding to be acceptable. Women studied show low or unmeasurable amounts in breastmilk.
Infliximab is usually not detectable in breastmilk, probably destroyed in infants GI tract.
References
Mothertobaby.org Azathioprine has not been proven to cause birth defects. The majority of pregnancies (1300) studies had no birth defects. Birth defects were similar to mothers with similar health conditions.
Mothertobaby.org 2017 Multiple small studies have not shown an increased risk in birth defects with Infliximab.
LactMed App- search all medications and risks for lactation
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22. Medication Use During Lactation
Drug
Breastfeeding Recommendations
Mesalamine/sulfasalazine
Compatible
Corticosteroids
Compatible, Dose >20mg (Delay feeding 3-4 hr. after dose)
Thiopurines
Compatible (Delay feeding 4 hr. if possible)
Anti-TNF
Methotrexate/thalidomide
Contraindicated
Metronidazole
Ciprofloxacin
Compatible (Delay feeding 3-4 hr. after dose)
Mahadevan, U., McConnell, R. A., & Chambers, C. D. (2017). Drug safety and risk of adverse outcomes for pregnant patients with inflammatory bowel disease. Gastroenterology, 152(2),
Back

23. Infliximab Levels
Infliximab levels between 3-7 ug/ml in patients with CD was consistent with more patients in remission, lower CRP.
Gastrojournal.org Niels Vande Casteel et al published online Feb
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24. Colonoscopy During Pregnancy
Colonoscopy/sigmoidoscopy low risk for baby and mother
If possible should be avoided until 2nd trimester
NCBI.NIM.NIH.GOV
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25. Imaging During Pregnancy
American college of Obstetricians –Ultrasound/MRI no associated risks but should only completed when deemed necessary for treatment
Gadolinium should not be used in pregnancy
If CT deemed necessary should be low dose radiation
ACOG.org
Back

26. Monitoring Disease Activity in Pregnancy
Hemoglobin - altered by pregnancy as well as disease Albumin – altered by pregnancy as well as disease ESR - not accurate in pregnancy CRP – not affected by pregnancy Fecal Calprotectin – not enough data to suggest if useful in pregnancy
Winter, R., Nørgård, B. M., & Friedman, S. (2015). Treatment of the pregnant patient with inflammatory bowel disease. Inflammatory bowel diseases, 22(3),
Back

27. Referral to High Risk Maternal Fetal OB
Maternal-fetal medicine plays a critical role in genetic counseling, stratifying risks and supporting the baby and patient while continuing on medical management for treatment of IBD.
Frequent office visits between specialties and fluid communication keeps the IBD patient confident in her care plan and providers.
Back
Mahadevan, U. Matro, R. (2015). Care of the Pregnant Patient with Inflammatory Bowel Disease. Obstetrics and Gynecology, (2):

28. Vaccinations
Biologic therapy-medication level may be present in infants over 9 months after birth
Infant should receive all non-live vaccines on time
Live vaccines including rotavirus & oral polio should be held until 9 months of age
Back
Beaulieu, D. B., Ananthakrishnan, A. N., Martin, C., Cohen, R. D., Kane, S. V., & Mahadevan, U. (2018). Use of biologic therapy by pregnant women with inflammatory bowel disease does not affect infant response to vaccines. Clinical Gastroenterology and Hepatology, 16(1),

29. Thiopurines (Azathioprine/6MP)
Thiopurines – low risk in monotherapy
Delayed infant infections with combination therapy
Back
Mahadevan, U., McConnell, R. A., & Chambers, C. D. (2017). Drug safety and risk of adverse outcomes for pregnant patients with inflammatory bowel disease. Gastroenterology, 152(2),

30. Biologics
A systematic review including > 1500 pregnancies exposed to anti-TNF revealed no evidence of increased rate of adverse pregnancy outcomes or congenital anomalies1
Infliximab is considered low risk in monotherapy2
Timing of the medication during the third trimester should be adjusted if possible, to a dose at the end of second trimester/beginning of third trimester to limit placenta transfer of the medication to the baby 3
Back
1 Nielsen OH, Loftus EV Jr, Jess T. Safety of TNF-alpha inhibitors during IBD pregnancy: a systematic review. BMC Med 2013;11:174.
2 Mahadevan, U., McConnell, R. A., & Chambers, C. D. (2017). Drug safety and risk of adverse outcomes for pregnant patients with inflammatory bowel disease. Gastroenterology, 152(2),
3 Mahadevan, U., Wolf, D. C., Dubinsky, M., Cortot, A., Lee, S. D., Siegel, C. A., ... & Miller, J. (2013). Placental transfer of anti–tumor necrosis factor agents in pregnant patients with inflammatory bowel disease. Clinical Gastroenterology and Hepatology, 11(3),