The management of inflammatory bowel disease (IBD) during pregnancy presents unique challenges, requiring a balance between maternal health, disease control, and fetal well-being. A global consensus conference, led by a multidisciplinary team of gastroenterologists, content specialists, and patient advocates was held in May 2024 to standardize care across countries with evidence-based recommendations. In this article, key guidance is provided on preconception counseling, maintaining disease remission, and safe medication use throughout pregnancy and lactation. We also address fertility preservation, risk mitigation during delivery, and neonatal outcomes. Collaboration between gastroenterologists, obstetricians and colorectal surgeons (if needed) is essential to optimize outcomes. This article also provides recommendations for a foundation of consistent care and highlights areas for future research, particularly regarding novel therapies and long-term neonatal health.

Introduction

The management of inflammatory bowel disease (IBD) during pregnancy is a complex intersection of maternal health, fetal development, and disease management. This article synthesizes global consensus derived from the recent international meeting of leading gastroenterologists, maternal-fetal medicine experts, and patient advocates.¹ The guidelines aim to standardize IBD care during pregnancy, emphasizing evidence-based practices while considering regional variations in resources. This summary highlights the key findings and actionable recommendations for gastroenterologists.

Methodology

The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system provided a robust framework to assess the quality of evidence and the strength of recommendations. For questions that had inadequate data for GRADE, the RAND appropriateness method was used to vote on consensus recommendations. 

Preconception Counseling and Optimization

Pregnancy represents a period of intense metabolic, hormonal, microbiome and immunological changes. The interaction between pregnancy and IBD is bi-directional, and it may increase the risk of maternal, fetal and obstetric complications.^2,3 Proactive management before conception is critical to minimize risks for both mother and child.

Women with IBD are advised to achieve stable disease remission and optimize their nutritional status before conception to improve pregnancy outcomes. Preconception counseling is also recommended to enhance medication adherence, reduce the risk of disease flares during pregnancy, and minimize the likelihood of delivering low birth weight infants.

Fertility

Women with IBD may have reduced fertility compared to women without IBD due to reduced ovarian reserve.⁴ While there is a lack of data, based on the experience of the expert group, they may undergo oocyte retrieval without increased risk of flare. Additionally, women with IBD are suggested to have a higher risk of infertility when their disease is active compared to when it is in remission. In women with ulcerative colitis (UC), undergoing an ileal pouch anal anastomosis (IPAA) is associated with reduced fertility in comparison to UC patients who have not had this surgical procedure. However, women with IBD may have similar success rates with assisted reproductive technology (ART), including live birth outcomes, as women without IBD. Similarly, those who have undergone pelvic surgery for IBD show comparable effectiveness of in vitro fertilization (IVF) in terms of live birth rates to their non-IBD counterparts.

Table 1.
Optimal Timing for IBD Therapy Discontinuation Prior to Conception

Maternal Factors Impacting Pregnancy 

The risk of developing UC and Crohn’s Disease (CD) among offspring of patients with IBD is 2-13 times higher than the risk in the general population.⁵ Furthermore, children born to a parent with CD may have higher risk of developing IBD than children born to a parent with UC.⁵ IBD disease activity is also positively associated with adverse pregnancy outcomes such as pre-term birth, low birth weight and small for gestation age.^6,7 The placenta is an embryonic/fetal organ that expresses an equal complement of maternal and paternal genes without eliciting a maternal immune response and rejection of this organ. The placenta is a highly immunologic organ and may have a role in adverse outcomes among women with immune dysfunction.⁸ Additionally, maternal and fetal microbiome may be altered through prenatal antibiotic use and maternal diet, possibly leading to an increased risk of IBD in offspring.^9,10

Disease Activity Management During Pregnancy

Maintaining disease remission throughout pregnancy is essential, as active disease correlates with adverse maternal and fetal outcomes. Pregnancy is marked by significant immunological changes, which may require medication adjustment and disease monitoring, with noninvasive tools, preferentially.

We recommend that IBD surgery during pregnancy be performed when it is required, without basing the decision solely on the trimester. Endoscopy should be considered only when it is likely to influence treatment decisions. In cases where cross-sectional imaging is needed during pregnancy, the use of intestinal ultrasound or MRI without gadolinium is preferred over a CT scan. Additionally, fecal calprotectin is suggested as a useful tool for monitoring disease activity throughout pregnancy.

Management of Pregnancy and Delivery

Pregnancies for women with IBD should be considered high risk. Aside from maintaining IBD remission, successful pregnancy and delivery in women with IBD require careful consideration of several nuanced factors. Women with IBD should be assessed early in pregnancy or preconception for nutritional status, weight gain and micronutrient deficiency. Pregnant women with IBD are also at an elevated risk for developing preeclampsia.¹¹ The presence of an IPAA or perianal disease plays a critical role in determining the most appropriate mode of delivery. Disease activity monitoring and continuation/resumption of maintenance therapy in the postpartum period are vital. 

We recommend that pregnant women with IBD begin taking low-dose aspirin with food between 12 and 16 weeks of gestation to reduce the risk of developing preterm preeclampsia, noting that there is no evidence of an increased risk of IBD flare with this practice^12,13 and that stopping aspirin at week 36 may help reduce the risk of bleeding. Additionally, for those with Crohn’s disease and active perianal disease, we recommend opting for a cesarean section to prevent the worsening of perianal symptoms. Furthermore, we suggest that pregnant women with IBD who have previously undergone an IPAA consider cesarean section, as this may help reduce the risk of a decline in pouch function that can be associated with a complicated vaginal delivery.

Medication Use During Pregnancy and Conception

IBD medications can generally be continued on schedule throughout pregnancy and lactation. This includes all biologics and biosimilars, mesalamine and thiopurines. The exceptions are methotrexate (teratogen – absolute contraindication) and janus kinase (JAK) inhibitors and sphingosine-1-phosphate (S1P) receptor modulators – which should be avoided unless essential for maternal health (Table 1). Disease activity at conception and during pregnancy, and de-escalation of biologics during pregnancy or after delivery are associated with postpartum disease activity and increased complications of labor and delivery in women with IBD. Continuing effective medication can mitigate this risk.¹⁴

Corticosteroid therapy may be used when clinically necessary with appropriate monitoring, as data do not demonstrate an increased risk of congenital malformation. However, the drug and/or underlying disease activity may lead to increased complications for infant and mother.

Table 2.
Medical Therapy Recommendations During Pregnancy and Conception

In women with IBD who continue thiopurines during pregnancy, precaution should be taken for intrahepatic cholestasis by measurement of liver enzymes, metabolite levels and consideration of split dosing.¹⁵ Women with IBD who are pregnant and have infections, fistula or pouchitis that require antibiotics may take an appropriate course of a low-risk antibiotic. Women with IBD may initiate or continue calcineurin inhibitors (cyclosporine and tacrolimus) during pregnancy with careful monitoring if there are no viable alternative treatment options available. Table 2 summarizes the medication management recommendations. 

Table 3.
Medical Therapy Recommendations During Breastfeeding

Lactation

Breastfeeding is strongly encouraged as it offers numerous benefits for the infant and does not exacerbate maternal IBD. For most drugs, a weight adjusted percentage of the maternal dosage (relative infant dose) of ≤ 10% is considered relatively safe.^16,17 In infants exposed in utero to infliximab, adalimumab, vedolizumab or ustekinumab, maternal breastfeeding did not affect neonatal clearance of the drug.^18,19,20  Due to limited human safety data including unknown effects on the immune system of the infant, breastfeeding should be avoided in case of treatment with JAK-inhibitor.²¹ Table 3 summarizes the medication management recommendations. 

Maternal and Fetal Outcomes

The interaction between IBD and pregnancy outcomes is bidirectional, with active disease increasing the risk of complications. Controlling disease activity during pregnancy among women with IBD is critical to reduce maternal and fetal adverse outcomes. 

We suggest that women with IBD face an increased risk of adverse pregnancy outcomes, including low birth weight and preterm delivery, compared to women without IBD. Moreover, those with moderate to severe disease activity are at a higher risk of spontaneous abortion than both women without IBD and those with milder forms of the disease. In addition, pregnant women with IBD are more likely to experience venous thromboembolism (VTE) during pregnancy and in the postpartum period compared to their counterparts without IBD and should be considered for prophylaxis, particularly after cesarean section. 

Short and Long-term Neonatal Outcomes

Emerging evidence supports the safety of in utero exposure to most IBD medications.

We suggest that children born to women with IBD experience higher rates of neonatal ICU admissions and hospitalizations during their first year of life compared to those born to women without IBD. Additionally, children born to women with active IBD are more likely to be small for gestational age and have a low birth weight compared to those born to women with inactive IBD. We further suggest that treatment with biologics during pregnancy does not increase the risk of early childhood malignancy or developmental delays, and similarly, thiopurine therapy during pregnancy does not appear to elevate the risk of early childhood developmental delays.

Vaccinations

Inactive vaccines should be given on schedule to infants of women with IBD regardless of in utero IBD medication exposure. Children exposed to thiopurine monotherapy, JAK inhibitors or S1P receptor modulators in utero may receive appropriate live vaccines after 1 month of age and live vaccines can be given to infants of mothers breastfeeding while on biologics. Previously, guidelines recommended avoiding live vaccines for 6 months after in utero biologic exposure, however, evidence suggests that the rotavirus vaccine when administered to infants exposed to biologics in utero did not result in any serious adverse events.^22,23 Bacillus Calmette-Guérin (BCG) vaccine, however, is greater risk. Infants exposed to in utero biologics should not receive BCG vaccine until after 6 months of age or until the time when infant serum concentrations of drug are undetectable. 

Conclusion

The global consensus on IBD management in pregnancy provides a robust framework that underlines key strategies in the management of this vulnerable population, ensuring that gastroenterologists are well-equipped to facilitate effective decision-making and specialist collaboration. The pregnant patient with IBD requires multidisciplinary care from gastroenterologists, obstetricians and maternal-fetal medicine specialists as well as surgeons and nutritionists as appropriate. Key takeaways include prioritizing preconception counseling and ensuring that patients with IBD are in remission before conception to optimize both maternal and fetal outcomes. Educating patients about the safety of continuing most IBD therapies—including monoclonal antibodies—throughout pregnancy and lactation empowers them to make informed decisions. All IBD patients may be at risk for pre-term preeclampsia and should initiate low-dose aspirin between 12 to 16 weeks of gestation to mitigate this risk. Infants should receive all inactive vaccines on schedule regardless of in utero drug exposure. The live vaccine, rotavirus, can also be given on schedule, but BCG should only be given after 6 months if biologic exposure in utero. 

Future research should aim to fill current knowledge gaps, particularly regarding newer oral therapies and long-term neonatal outcomes. By integrating these practices and focusing on maternal health, healthcare providers can play a pivotal role in safeguarding the well-being of both mother and child. 

References

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