Case 5: Discussion
Cindy Law, MD, a gastroenterologist at Massachusetts General Hospital, discusses the case:
Editor’s note: The following is an automatically generated transcript of the above video.
“In summary, this case emphasizes several important points. Achieving sustained remission before conception is crucial in IBD. Persistent inflammation can affect every stage of the pregnancy and is associated with decreased fertility, higher rates of miscarriage, low birth weight, and preterm birth. Ideally, patients should be in clinical and endoscopic remission for three to six months before becoming pregnant.
Other things to consider when seeing patients in the preconception period are whether the patient's vaccines, PAP tests, and surveillance colonoscopies are up to date. Also, medications should be carefully reviewed to ensure that they are safe in pregnancy. In some but not all cases, it may be prudent to refer to MFM and colorectal surgery at this stage in planning. During pregnancy, fecal calprotectin is a valuable marker as serologic markers of inflammation such as CRP can be naturally elevated in pregnancy as demonstrated in this case. Intestinal ultrasound can be safely used to assess disease activity during pregnancy. If there is a strong indication, lower GI endoscopy can be safely performed.
With regards to delivery, coordination with OB is key. Patients with active perianal disease should deliver by C-section. A C-section may also be considered in patients with a history of complex fistulizing disease or j-pouch. In the postpartum period, live vaccines should be avoided for the first six months in infants exposed to biologics in utero. IBD medications should generally be continued to prevent postpartum flares. Most IBD medications are safe to continue while breastfeeding, with the exception of methotrexate into small molecules. Thank you for joining this presentation. I hope you found this information valuable.”