IBD should be controlled before pregnancy

OB/GYN News, Feb 15, 2003 by Bruce Jancin

SEATTLE -- A The most important advice regarding pregnancy for women with inflammatory bowel disease is to attempt conception only while in clinical remission, Dr. Daniel H. Present said at the annual meeting of the American College of Gastroenterology.

Large studies indicate that when women become pregnant while their ulcerative colitis or Crohn's disease is in remission, their relapse rate during the next 9 months is the same as in nonpregnant patients--25%-30%.

If they get pregnant while their inflammatory bowel disease (IBD) is active, however, their IBD will worsen in 45% of cases and continue to be active throughout pregnancy in another 25%, posing increased risk to both mother and fetus. If the patient's IBD becomes fulminant, fetal mortality approaches 50%, he said.

"You want to bring their disease under control before pregnancy--it increases their chances of a normal baby," emphasized Dr. Present of Mount Sinai School of Medicine, New York.

Indications for bowel surgery are the same as in nonpregnant IBD patients. But ileal pouch anal anastomosis, a procedure that's increasingly popular with IBD patients, is best delayed until patients are done having children. It's recently become apparent that this procedure, which entails extensive work in the pelvic cavity, reduces fertility by roughly 20-fold.

"If your patient wants to have children and is active with colitis, what we're recommending is a subtotal colectomy with the standard temporary ileostomy. Then after she has her children, she can have the ileal-anal anastomosis," Dr. Present said.

Relatively few medications used in the management of IBD are known to be teratogenic, and those that are increase the risk of congenital malformations only by about twofold.

Limited information is available regarding the safety of various IBD drugs in pregnancy. What's known comes from extrapolation from the experience with the same drugs in patients with other diseases and from postmarketing patient series.

In one such series, Dr. Present retrospectively examined the use of 6-mer-captopurine (6-MP) in 155 IBD patients with 325 pregnancies and 233 live births. Many physicians advise discontinuing 6-MP prior to conception, but Dr. Present found that use of the drug before or at conception or throughout pregnancy wasn't associated with increased prematurity, spontaneous abortions, congenital anomalies, early childhood infections, or neoplasia (Gastroenterology 124[1]:9-17, 2003).

He then gave his opinion on the safety of other IBD drugs in pregnancy:

* Safe drugs: Mesalamine, sulfasalazine, topical 5-ASA, systemic corticosteroids, cephalosporins, ampicillin, and erythromycin.

* Probably safe drugs: 6-MP, azathioprine, ciprofloxacin, metronidazole, and cyclosporine. He noted that cydosporine is reserved for patients who have active IBD and hence shouldn't become pregnant.

For now, infliximab also belongs in the "probably safe" category A soon-to-be-published series of 147 pregnancies in IBD patients on infliximab shows rates of live births and miscarriages reassuringly similar to those in the general population. "So far, there's no bad news, but I think we need to have a lot more data," the gastroenterologist observed.

* Unsafe drugs: Methotrexate and tetracycline.

Safety data for IBD medications during breast-feeding are nearly nonexistent. Mesalamine, sulfasalazine, and topical 5-ASA are clearly safe during breast-feeding, Dr. Present said.