Episode Transcript
[00:00:09] Speaker A: Hello everyone. Welcome to the BSG podcast and today the topic is on pregnancy and ibd. My name is Fiona Rees. I'm a consultant pharmacist based down in the University Hospital Sussex on the south coast. And today I'm joined by two lovely colleagues to discuss this very important topic. So I'll hand over to them now to introduce themselves. If I could hand over to Krishna first. Thank you.
[00:00:32] Speaker B: Thanks so much. My name is Krishna Shah. I am a senior gastroenterology registrar and an IBD research fellow currently at the Royal London Hospital.
I'm also the BSG IBD training representative and pregnancy and IBD is my research or academic interest. So I'm really delighted to do this.
[00:00:50] Speaker A: Thank you, Krishna. And over to Mandeep.
[00:00:52] Speaker C: Thank you, Fiona. So, hi everyone, my name is Mandeep Kaylor and I'm an obstetrician and gynaecologist working at the Royal London Hospital in London. So Bart's Health Sister Trust, as a special interest, I have a. I'm a consultant with a background in maternal medicine and I lead on the OBS IBD service at the Royal London. So I have the pleasure of looking after women who have IBD in pregnancy, but also seeing women who require preconception counseling as well.
[00:01:18] Speaker A: That's great. So I'm sure everyone can agree, two excellent colleagues to discuss this topic with. And why I'm involved is I am the pharmacy representative on the BSG IBD committee. And also as part of my role we do clinics where patients are pregnant, come in and discuss medications and also kind of pre pregnancy counselling too.
So we're going to split up this podcast into a few different sections to try and get as much from it as possible. We're going to look at preconception counselling, the impact of IBD on pregnancy, management of flares, drug safety, and then delivery planning and postpartum. So I'll just go on to the first section first of all and maybe direct this to Krishna, if that's okay. So why do you think preconception counselling is so important for women with ibd?
[00:02:05] Speaker B: Thank you. So I think it's a really important topic because firstly, I think it's important to reassure women with IBD that it is possible to have normal pregnancies even with the diagnosis of ibd. And we know that there are lots of misconceptions that leads to anxiety around the topic and this may also then impact the woman's choice to have children. So it's a really good opportunity to talk to women about this. To actually counsel them on what it means to have IBD and how this can impact pregnancy.
And then a really important key is it's an opportunity to really touch base with them, to understand their timeline, so what their wishes are for starting a family and then trying to optimize them as best as possible so that we can get them, make sure that they're healthy throughout their pregnancy and try get the best possible outcome from their pregnancy. And I think it's really important that we use all the opportunities that we have available within the patient's journey through seeing the IBD team to discuss this.
So at the point of transition, it's a really important time to talk about this. And often this may be a time where we don't necessarily speak about this with our younger patients, but we do know that nationally, about 40% of pregnancies are unplanned. And so it's important that we're having these conversations with patients who may not be actively thinking about getting pregnant. And then at the same time as they're transitioning over to adult clinics and then, as you probably are really familiar with doing, Fiona, when we are treating or changing their treatment is a really important time. And another very key time is when they're having a flare, because there are lots of different considerations that we need to think about at that time.
[00:03:47] Speaker A: No, I absolutely agree. And, Mandeep, I know you were talking about earlier, you get quite a lot of referrals from your primary care colleagues, so how can that link really work in with regards to helping our patients with ibd?
[00:03:59] Speaker C: Yeah, so it's really quite tricky because we know, actually our national data tells us that preconception counseling is really key, but it's not done as well as we possibly could do. Like it doesn't reach the people that we need it to do. So at the Royal London, we're quite fortunate that we get a lot of our referrals from our IBD colleagues, but primary care is a key area that we really shouldn't neglect. And women often will have an appointment with their IBD team, but maybe not mention a pregnancy, but they'd be more comfortable speaking to their GP about it. And to be fair to our primary care colleagues, often some of these women have a complex, you know, medical background and they've had lots of different treatments or surgeries and unable to provide that full overview of preconception counseling. So the right thing is that we would get referrals from our primary care colleagues to our maternal medicine service and patients, such as these patients with IBD would get seen in our joint pregnancy IBD clinic where we can go through their pre pregnancy health and plan actually what a pregnancy would look like for them and go through all of the questions that they may have, that they possibly have from kind of medications to, you know, can they get pregnant, for example.
[00:05:10] Speaker A: Yeah, and that's, that's a lot of information for, for patients to be getting. So who do you think is best placed really question to both of you for providing all this information? You've, you've touched on a few pointers there, but is there any one particular team or do you think it's something else?
[00:05:25] Speaker B: So I think it's anyone that is trained and feels comfortable. I think it's, you know, even if you don't necessarily feel comfortable having that conversation, it's asking the question and then directing the patient to the appropr appropriate person. And the patient is seeing IBD nurses, pharmacists, dietitians, infusion nurses. So it may be any one of them that raises the question to the rest of the IBD mdt.
[00:05:49] Speaker C: But also just coming in on that, I actually think it's really key that both the IBT team are involved as well as an obstetrician. So someone is going to manage the pregnancy. So giving that overall kind of, you know, 360 approach to the preconception counting is key. Sometimes it's not possible to achieve that, you know, across, like nationally, across the uk. But ideally any kind of preconception counseling should be achieved by the medical kind of team as well as a specialist who deals with kind of complex medical problems in pregnancy would be the ideal
[00:06:21] Speaker A: thing to do and that would really push that patient centered holistic care when making sure everything's being looked at.
So speaking of that then how important do you think disease control prior to conception is and what are the risks of conceiving with active disease? And I'll pass this to Mandeep first but then obviously Krishna, come in as
[00:06:41] Speaker C: you feel it is really important. So we know that embarking on a pregnancy journey, especially with women who are taking medication, no one wants to take medication or have a medical problem in pregnancy because they feel that it'll be harmful for their child. So actually meeting them in this setting is really important to go through the different risks that could potentially happen in a pregnancy. And often there is a misconception about being on lots of treatments and actually the best thing for the baby would be to stop everything because that's, you know, better for the baby and they can suffer with their IBD symptoms. But actually it's better for the baby not to be on any treatment. So it's really important that we reassure and counsel women that if they're, and often we say this in clinic, that if they are well prior to embarking on a pregnancy, that their baby will also be well and be born, you know, well, and then have a, you know, a normal pregnancy. Normal, same, you know, like any other woman embarking on a pregnancy journey that they should actually have, you know, exactly the same journey. So actually being well beforehand means that they are less likely to have the potential risks of a pregnancy. And the things that we're kind of really talking about are, you know, if a woman has got, you know, active disease or has a flare and does get pregnant, that we worry about this affecting baby's growth. So having smaller babies and also needing to have a preterm birth or going into a preterm labor, that these are things that we really don't want. And these women, you know, if not. Well, yeah, I think they're the main two things that I would say. And I don't know if Krishna wants to come in and add in anything from her point of view.
[00:08:20] Speaker B: Yeah, so exactly like Mandeep says. And, you know, we're quite fortunate that we get to do the pregnancy clinic together, but we often counsel women about the risk of pregnancy loss, as she said, small focusational babies, intrauterine growth restriction, low birth weight. And then I think some other really important risks that may not always be quantified are the risk of psychological distress to a woman who is pregnant and has a flare, the risk of hospitalization and hospital acquired infections. And then a really big one, which I'm sure Mandeep can expand on a little bit more, is the risk of vte. And this has been highlighted as one of the leading causes of maternal mobility and mortality in the uk.
And so these are important risks that we do want to mitigate. And by trying to get women and their disease in control before they get pregnant, we can hopefully reduce the risk of these adverse outcomes.
[00:09:13] Speaker A: And I think as well, because you'll be involving the patient right from the beginning. So right at the start of their journey and, you know, anyone else that wants to be involved, they can be also an advocate for themselves. So obviously we should be checking everything, but then if, you know, they're in clinic and flares are happening and they say, oh, I remember that thing happening, and they can ask the questions or, you know, should I be taking like, VT prophylaxis? That kind of thing, it just spurs on that conversation, doesn't it? So making the patient like an expert patient, I think is really helpful in these situations.
I know on these sort of podcasts, often people are like, I just want to know exactly what I need to ask the patient. So do either of you two have a kind of golden checklist of questions or comments that you go through with the patients in your clinics?
[00:10:01] Speaker B: Yeah, so I think, because there's a lot to go through and it's definitely easy to forget something. So I've got a little checklist that I mostly go through, and I've integrated this into my clinic letters, so just to prompt me in case I forget. But the first key thing is a disease activity assessment. And we really want to make sure that patients are in a clinical and biochemical remission for at least three to six months prior to conception. And if they aren't in this position, then it's an opportunity to get any of the disease investigations that we would want to get to restage their disease.
And then the next is a medication review.
And it's important that we're optimizing any existing medications. So doing drug monitoring for thyroid purines, anti TNFs and dose optimizing that we're making sure that if they are on any teratogenic medications, then we are stopping them appropriately. And I'll let you go into this a little bit more, Fiona, about the different time frames and how long before we should stop. And the other really key thing is that if we are stopping their medication, we need to switch them to something else. So we need to ensure that we're giving enough time to switch them to an alternative medication and that they can, or we can demonstrate that they are in remission on the new medication before we then, per se, give them the green light to get pregnant.
And something Mandeep has taught me that it's really important to offer them contraception during this period because this is a vulnerable period whereby if they do have a disease flare, they then are at risk of having these adverse outcomes. So it's really important that we counsel them not to get pregnant during this point.
The next thing that we do is a nutritional assessment. So things like weight, bmi, correcting any nutritional deficiencies, and then looking at behavioral aspects like smoking, substance use, so making sure that they're stopping smoking. If they're drinking alcohol, they're stopping. If they're taking any recreational drugs, opioids, cannabis, they're stopping that they should start prenatal vitamin supplementation. So 400 micrograms of folic acid or high dose if they're on sulfazalazine, have a history of malabsorption or a family history of neural tube defects and then just making sure that they're up to date on vaccinations, on smears. And this is a really good time for them to check through all of these things and just give them time to sort some of these out if they've not had an opportunity to. But I'll hand back to you, Fiona, just to talk a little bit about the teratogenic medications and at what sort of time frame you usually advise patients to stop.
[00:12:35] Speaker A: Yeah. So I just before I do, just wanted to highlight thanking you for talking about the high dose folic acid because I think that is easy forgotten. And it's not just for sulfazalazine. It's the other two areas that you mentioned as well. And it's really important with regards to teratogenic medications. This is an evolving picture. With the exception of methotrexate, I think methotrexate will always be methotrexate avoid. But at the moment the guidelines say you need a three month washout period of the teratogenic medications before you start looking to conceive. So that's really important because I think as well for some women that seems like a very long time. So we need to be very upfront with them because we want to give them the best chance of making sure they have the safest pregnancy. What I would say with the newer drugs that are coming out, so your JAK inhibitors, the S1Ps is it might be an evolving picture. At the moment it's three month washout period, but I would always go back to the manufacturer's information just to check what the most up to date information is. But I think we're pretty safe on methotrexate. But it's always going to be three months. It's been around a while now. So thank you.
Any extra kind of bits from the checklist there, Mandeep? I mean Krishna's there was very thorough.
[00:13:47] Speaker C: It's quite thorough. And you can see there's a lot to cover because you've got to cover your IBD history and background, but as well as a general pregnancy health because it's quite important to maybe question a little bit about if we're seeing them at this preconception meeting, what are their pregnancy wishes or birth wishes or for example, they might be here a year early. Some people just want that information. So are they planning to try soon. But also, have they had any previous pregnancies? Have they had any previous births? Is always good to check. And also, you know, what are their kind of menstrual periods like? Because often some women may have other issues that they haven't really discussed with us. So generic kind of obstetric and gynecology stuff, as well as IBD stuff. So there is a lot to cover, which is why it's quite nice and important that we have that joint up care from an obstetrician as well as an IBD specialist to lead on these kind of consultations.
[00:14:43] Speaker A: No, absolutely. That joint of care just means that you get the whole picture sorted in one go. Absolutely.
So, thinking about our patients and often they have a troubled journey to pregnancy, when do you think we should start thinking about fertility issues and referring for testing? And maybe if I can direct that to Mandeep, please.
[00:15:02] Speaker C: So it's really difficult, isn't it? And it's really challenging. And I think when you have a chronic medical problem, sometimes some women, I know, we've counseled some women who never thought that they could ever get pregnant because of their condition. So it's been quite heartwarming and nice to actually be able to support women to say, actually you can get pregnant and you can try for a family. So it's important that we get that out there first, that we shouldn't, you know, be ruling out a pregnancy or pregnancy wishes in a patient. But it can be quite difficult. And actually the evidence out there and the data out there tells us that if you're in remission and your IBD is well controlled, then there's no reason why you shouldn't be able to fall pregnant naturally yourself. And so, like the general population, however, you might be one of those women who have difficulty in trying to conceive. And usually what we would say to people is that if you're in remission and there's no other health issues, actually trying for a year is a minimum kind of standard that people would try for a year. And if there was no, you know, positive pregnancy tests or you were, or the woman was unable to conceive, that's when you would refer them onwards. And I'll talk a bit about the referral process in a second. But if you are a little bit older, so let's say you, you're, you know, more than 35 and you've been trying for six months and there's other ongoing health issues, or you've had a complex kind of IBD journey where there's been a lot of surgery involved then actually an early referral for fertility services would be quite appropriate. Now, it's really quite interesting that even being an obstetrician and gynecologist, I can't refer someone for fertility treatment or investigations and it all has to come through primary care. So what we would advise women would be that they would have to go see their gps in the UK and then based on initial investigations, they would then be, if they meet criteria, they would then be referred to fertility centres if treatment was available on the nhs. And actually, it's just something important to note that if you have had a child, you've already got one existing child already, but we're trying to conceive for a second or to expand on your family, you wouldn't be eligible for NHS funding, so you'd have to try and self fund it with private fertility services. So there's different ways to gain that fertility kind of support, but it can be quite a stressful journey already on the background of, you know, having come through maybe some complex treatments with their ibd, but it is important that they seek help from their GPs first if they've never been pregnant before and are finding it difficult to conceive.
[00:17:34] Speaker A: And is there anything that the IBD team can do to help support that referral? Like, is there anything in letters that we need to do or anything like that?
[00:17:44] Speaker C: Absolutely. So there is, as I said, that usually actually women with ibd, if well controlled, then they're. The challenges with fertility are pretty much the same as, you know, someone who's not got ibd. But if there are some women who've had kind of pelvic surgery, deep pelvic surgery or pouch surgery, they might have reduced fertility. So actually having all of that information to the GP to say that we would actually support kind of fertility, you know, fertility referral would be quite helpful. It can be quite a long journey and sometimes the waits are quite long. So it's kind of putting this all into place quite early and therefore getting pregnancy wishes quite early from someone who might be considering a family to know that actually they do want to take that, you know, embark on that journey.
[00:18:31] Speaker A: And again, another reason to be having these discussions at the beginning of their IBD journey, when it's appropriate, so. Absolutely.
[00:18:38] Speaker C: Exactly. Exactly.
[00:18:39] Speaker A: Okay, so we'll move on now to the impact of IBD on pregnancy. We've already talked about some of the risks that can come with pregnancy and IBD and also spoken about how actually pregnancy can be completely normal when you have ibd. But for those that are thinking about the risks, are there any kind of strategies we can do to reduce these risks at all? And I'll put that to both of you, if that's okay.
[00:19:02] Speaker B: So, as we mentioned, getting them into remission before they get pregnant. So data has shown that patients who had active disease in the preconception period had a much higher rate of having active disease during pregnancy.
So continuing their medications that keep them well. And this is really important. So medications that have been deemed to be low risk and are recommended to continue, they should definitely continue those. And then we need to proactively monitor the patients. So the current BSG recommendations, and I know this can be challenging depending on service care models across the nhs, but it's to try and offer a review to patients each trimester and you should be taking some sort of disease assessment. So whether that's non invasive with just a fecal calprotectin or a clinical assessment so that you are able to identify any active disease early on and initiate treatment. So that we can reduce the risk of this having adverse impact on the patients.
[00:20:04] Speaker C: Yeah, and in addition to that. So exactly that, seeing them early because often, yes, we want to get women, you know, in remission before they embark on a journey or get their disease state to be. Be the best that it possibly can be. But if they are not in remission and we want to try to, in a monitor condition, we'd be asking for extra kind of growth scans throughout the pregnancy so we could pick up kind of any concerns with growth early on and manage it appropriately. So it's important that just engaging with, as Krishna said, that we, we're quite fortunate we have this joint up service and we know that not everyone does, but having that really does help help make sure that we're monitoring women appropriately throughout their pregnancy to try to mitigate against any of those potential risks.
[00:20:48] Speaker A: That's great. And I guess even if you don't have a set clinic where it's joint working, it's trying to keep those communication channels open between the IBD team and the OBS team. So really important, if that's okay, we'll move on to management of flares in pregnancy because I think sometimes there's concerns that we might need to do something different, might need to do something extra, etc. So again, I'll go to Chris and then come to Mandy. But how do you think we should be investigating flares during pregnancy and then how are we going to treat them?
[00:21:20] Speaker B: So I think this is a really important question. And so as I mentioned, non invasive markers. So in terms of blood tests, the haemoglobin that can be reduced because of dilutional effects in pregnancy, the CRP can be increased in pregnancy, but the faecal calprotectin is unchanged. So that is a reliable marker of inflammation.
I would investigate a patient as you normally would, but just take a couple of different things into consideration.
So intestinal ultrasound is non invasive and it's growing rapidly in the uk. I appreciate not very many centers may have access to it and we're very fortunate where we work, where we do lots of intestinal ultrasound and this is a really helpful way of monitoring disease activity.
But if you don't have access to that, then MRI scans can be used. But I would avoid gadolinium in the first trimester because that is a teratogen.
So patients, if a patient clinically needs a CT scan and it's going to change their management and there is no alternative form of imaging available, then you should not withhold that CT scan from them.
We know that the dose of radiation from one CT scan is below the threshold to cause any congenital abnormalities, but it's important that you are having an MDT discussion about this if you are considering it and looking at other possible avenues and then with endoscopy. So sigmoidoscopies can be considered low risk, but should only really be done if it's going to change management again and colonoscopies. So we tend to avoid doing them in pregnancy and so they should be a real clear indication if this is something that you are going to pursue and if it is something that you do need to do, then the there should be fetal monitoring throughout the procedure and you should get appropriate obstetric support as well. And then surgery again if it's necessary and required by the patient, then this should be performed at any trimester, but ideally performed at a hospital with the specialist services. And there should be appropriate obstetric monitoring available throughout.
And then when it comes to treating flares.
[00:23:33] Speaker A: So.
[00:23:33] Speaker B: So we have discussed the medications that are currently not used in pregnancy. But as Fiona, you mentioned, this is going to be an evolving picture as we get more data and guidance in the future. But otherwise you would treat the patient as if you were treating a normal IBD flare. So you can use corticosteroids in pregnancy.
There has been data linked to increased risk of adverse outcomes, but again, corticosteroids are used where there is active disease. So it's really difficult to distill whether these adverse outcomes are because of the steroids or because of the active disease.
We know that although thiopurines can be used during pregnancy, they should not be initiated in pregnancy. And this is because of the risk of pancreatitis or other adverse events. And we, we want to reduce that or mitigate that from happening in pregnant women.
And then I think as well, there is evolving data on the use of biologics in pregnancy or the initiation of biologics in pregnancy. But if you are unsure about this, then this is again where you draw in on the expertise of your MDT and also perhaps expertise across the wider maternal networks that might be able to give you support. And Mandy, maybe you can tell us a little bit more about maternal medicine networks, but then there are lots of other obstetric considerations which perhaps you can touch upon now.
[00:24:56] Speaker C: Yeah, no, thank you. So, so exactly all of that that, you know, you said is all really important and actually what we should reassure women is that these investigations that we want to do, like as, as Krishna said, that we wouldn't withhold a CT scan if they really needed it and if it was going to be beneficial to them and change their management. And also, you know, a little bit just going back to about the kind of fetal monitoring, women are obviously nervous having procedures done and if they need an operation or something and they're worried about the baby. But actually, generally speaking, we know that most women tolerate general anesthetic, they tolerate surgery very well. And actually the monitoring that would really be involved, it would just be bought before and after a surgery. And it's, and it's because this is, you know, it's a stressful time. No one wants to be having, you know, an investigation that's a bit more invasive or treatment when they're pregnant. So there's lots of things that we can do to reassure, reassure our women. And as we talked about before, part of the investigations would be their growth scans to make sure that they are, you know, babies growing appropriately.
I know Krishna mentioned, you know, using steroids and things when we, when we manage flares. That's really important in pregnancy because we know that steroids increase the risk of gestational diabetes. So we need to make sure that women are being investigated appropriately and have the appropriate monitoring in place if they are going to be on steroids or long term steroids. So those are some of the key things. But yes, working in a.
And I think maybe this is a time I can talk about maternal medicine networks. But, but maternal medicine networks have been mandated by basically NHSC and So these are networks that run across the UK and in London we have five different networks and we're in East London. And what that kind of means is that in each region there is a, a tertiary center or maternal medicine center that is kind of like the hub of where all the kind of complex women with complex IBD might be seen, or at least seen once to develop a plan. But we work in this model of a hub and spoke model. So being the maternal medicine center, we are like the referral center for all the other kind of hospitals in the region.
And if you've got a straightforward, you know, woman with, with a straightforward pregnancy that has no complications and is on, you know, is, is in remission and there are no concerns, they can stay at their local hospital. But if there's someone with complex, complex active ibd, despite treatments with biologics, those who've had complex surgeries, they might need to be seen in our centre or maternal medicine centre to ensure that an appropriate plan is made. And it might mean that some women need to transfer from their local hospital to a maternal medicine center to give birth, which is something that we do see. And the aim of these networks are that women who need it are seen by the right people at the right time. So, so in that maternal medicine center that, where there is that expertise to deal with those kind of complex possible, you know, possible complications or a complex kind of disease management.
So that's kind of a term of medicine networks and there's a lot out there to read up about. So there's a whole, whole guideline that you can look at. But one thing that we did really want to mention, which I probably should have mentioned a bit earlier, is that women who do have a flare are also at an increased risk of VTE. So DVT and PES. And this is something that is really important in pregnancy. So all women, when they are booked at the beginning of a pregnancy by a midwife, they have a VTE risk assessment. And this risk assessment is there to guide us on. Is this woman at an increased risk of developing a blood clot or not?
But women with a flare, definitely that risk goes up. And we, it's really important that we start or actually counsel women about reducing this risk by giving them prophylactic low molecular weight heparin. And I think, you know, this is important and maybe not done as well as it could be.
And as Krishna mentioned, I think earlier on at the beginning there's national kind of data from our national maternal mortality rates from Embrace UK and Embrace UK is basically just a national maternity audit tool that looks like at maternal deaths during pregnancy and up to six weeks later. And VTE is the biggest cause of maternal death in the uk and therefore it's really important that we are trying to reduce the risk of our women who are having a flare, especially to developing a VT el. So this is something that we need to be more proactive about and ensure that women are aware of the signs and symptoms of a VT el, but also that we treat them with prophylactic low molecular weight heparin.
[00:29:36] Speaker A: Great. And what about. Because I know I get a lot of questions from pregnant women and they get preeclampsia and then they're told to go on aspirin and they instantly say, I can't go on aspirin. I know that's an NSAID because it will flare up my ibd.
So we always say, please, that's fine, you need to look after your preeclampsia. But from your point of view, is there anything different that you would say?
[00:29:58] Speaker C: I mean, no, not at all. So I think that aspirin is an incredible drug in obstetric and it is an important drug to reduce the risk of maternal preeclampsia. So high blood pressure in pregnancy with other kind of multi organ involvement, but also it reduces the risk of small babies. So it's something that we use a lot in pregnancy and there is data out there, or that data that's coming through that women with IBD are at an increased risk now of developing preeclampsia. So should we be offering aspirin to all of our women with ibd? And I don't think that's in our national guidelines yet, but it's something to put out there. Aspirin is very safe and actually it is an NSAID and women do get anxious about it, but it is very low dose and so women tolerate it very well. So it's not like having a high, the normal dose of something like ibuprofen or diclofenac. So it's something that we would be quite happy to give to our women with iud. And it's just having that conversation with them to reassure them that most women tolerate it very well and it is a very low dose and therefore we don't worry about it as like unlike
[00:31:02] Speaker A: other enzymes sense that's it, the, the benefits for it far outweigh any possible cons to them causing a flare with their ibd. Absolutely agree. Lovely.
So we kind of started talking about medication. So we'll Just continue. We've been doing it, I think, throughout the whole podcast because I think medications is probably the one thing that patients really worry about, or at least that's, I mean, I'm very biased. I'm a pharmacist. They come to my pharmacy clinics to talk about medication. So I know I'm skewed, but I think it would be useful just to mention that. So I know we can't ever call medication safe within pregnancy, but we categorize them against risk and we look at huge data sets to see the outcomes of pregnant women that are taking certain medications versus pregnant women that aren't taking medications and look at the risk category. And I think we're very fortunate within ibd if you, if you yourselves agree that we do have now a lot of data on medications that do show this low risk profile in pregnancy and so we can with confidence say to patients, the best thing for you to do is take your medications, take them throughout pregnancy. So you're making sure that you're in remission throughout pregnancy, but also that you continue that remission postpartum, which is obviously that high flare risk stay.
So I just wanted to check first of all that you both agree with that because I think that's a really important message. And then we can just kind of briefly touch on what we've currently got guidance wise on which ones are the low risks and which ones to avoid. So, Mandeep, did you agree?
[00:32:35] Speaker C: Yes. No, absolutely. I think that we see a lot of women as we talked about who do not want to be on any medication in pregnancy.
And that's from simple things like even taking paracetamol. So to be on know significant medication for their ibd, it can be quite anxious for them. So it's reassuring women that we have a lot of data now of women who have been pregnant with IBD who have now given birth. And actually that data showed us that actually the medication is low risk and actually babies are being born fine. Mums have been absolutely fine throughout the pregnancy. So it is just having that conversation with them and reassuring them about the safety data that we do have. So that's really important. I'm not sure if, Christian, you want to add anything to that part.
[00:33:24] Speaker B: Absolutely agree with both of you. And like everything we do in medicine, we always talk about risk versus benefit. And we know from studies that women who stopped their biologics in pregnancy, especially those who had, based on previous guidance, stopped their biologics in the third trimester, they had an increased risk of flare. So we also have that data to explain to patients that this is the risk of stopping your treatment. And so hopefully that reassures them further that it is the right thing to do to continue taking them.
[00:33:55] Speaker A: Yeah, and it's that message, isn't it? We need to look after mum to make sure baby's going to be fine, but also mum's going to be well enough to look after the baby once they're born, so. Absolutely. And I think it's worth mentioning that the current BSG guidelines have a really good table of summaries of the drugs that currently are low risk, medium risk and to avoid. So the common ones everyone will know at the moment low risk are things like thiopurines, anti TNFs. There's more data emerging for the IL23s, the anti integrins, and as more and more drugs come through, we'll get more and more information. But as it stands, the ones to avoid are methyl, the TREX8, your Jacci's and your S1. P.S. but I would just keep looking at the current guidance because I do think that is going to be a really evolving picture and really useful as well.
I think we've probably covered a lot about the medication and during pregnancy, but what about now, the actual delivery itself and postpartum.
So, Mandeep, as our resident obstetrician, would you mind talking about how the birth should be planned in women with ibd?
[00:35:00] Speaker C: No, no, absolutely. And so, and actually, believe it or not, birth planning, we should talk about what you know at the beginning of the pregnancy rather than towards the end, because you will often find that women have a lot of questions about, or don't really think about birth. And there's a lot of choices. And it is all about birth choice, putting the patient at the center of all of this and going through what their concerns are and what kind of birth they would like. So there's a lot of variability. Some women want to have. Have a planned cesarean section, where some women want to have a, you know, a vaginal birth. So there's a lot of, lot of variation with it. And so it's having those discussions quite early on so that you can provide the information and let women and their partners go away and read up about all options and then come back a bit later on when we make a final birth plan. Now, in general, we have these discussions early, but we make a final birth plan at around 36 months, weeks, unless there's a reason for an earlier birth. But generally between kind of 32 and 36 weeks, we should kind of have a birth plan in place for women.
And, and this may be, as I said, a planned cesarean section or a vaginal birth. And it really is a choice. There is no real reason why we need to offer women one over the other, except a few exceptions. And so for most women, we would say there is a choice for every, you know, all types of birth. However, there are a group of women where we would actually recommend a cessation caesarean section or planned cesarean section. And those would be women from an obstetric point of view if you've had more than kind of two cesarean sections. So this is nothing to do with the ibd. This is to do with their, you know, just pregnancy background. And so we would advocate that they should have a third one because a vaginal birth would be, would be high risk and we would need to counsel these women. But if women have got perianal disease as well, it's really important to actually review this throughout their visits with either if we're in a joint service or with a IBD doctor is to review the perineum, review the perianal regions if they do suffer from perianal disease. Because we know that if you were to embark on a vaginal birth, there might be several vaginal tears that could impact perineal healing and that could have long term implications for the mother.
And so that's important to kind of discuss, discuss. And we would also kind of offer and, and kind of recommend a cesarean section for women who've had kind of pouch surgery because again, having perineal tears would mean that wound healing or to long term problems that, you know, we wouldn't potentially be able to sort out for them that they could have like long lasting effects on in the future after baby's born. So these are some of the reasons why we might kind of recommend a cesarean. Kristen, you're going to come in.
[00:37:42] Speaker B: Yeah, I was just going to say. And then there's also the group of women with rective vaginal fistulas that we would recommend the C section to.
So yeah, it was just active perianal disease. Rector vaginal fistulas and those with a pouch.
[00:37:55] Speaker C: Yes, exactly. So and it's important to bring that up early on because when you put this information on someone in the third trimester, they really sometimes find this quite of a surprise and they haven't really thought about it in detail.
And so it's quite important to get these discussions either in the preconception counselling that you've already had, or if they haven't, then quite early on when they see you in the antenatal clinics.
[00:38:18] Speaker A: And I guess as well, it's important for women that have already had children because they might have an expectation it will be the same as last time, but there might be differences because of surgery or fistula or things like that. So it's important to make sure that they're aware that things might need to change. So no on to postpartum management. So one of the main questions we're often asked is, can I breastfeed my child while I'm on these medications? Do I need to do extra pumping, that kind of thing.
And I think this is again, very well laid out in the BSG guidelines. So it's quite easy to say. But the general rule, if it's been low risk in pregnancy, it's low risk in breastfeeding. And again, that table's there, that's available.
So the ones I mentioned earlier, mesalazines, thiopurines, anti TNFs, and there's more and more data coming out about the other ones. So I think it's just good that there's that reassurance for our patients that, you know, they can continue to have that breastfeeding if they want to, and they need to continue taking the medications to make sure that they stay in remission for their ibd. Again, anything to add to that from both of you?
[00:39:24] Speaker B: I was just going to add that if for any reason the woman has had to start or the patient has had to start a JAK inhibitor or an S1P postpartum to control their disease, then the current guidance is that they should not breastfeed.
[00:39:40] Speaker A: Yeah, no, absolutely.
[00:39:41] Speaker B: Yeah.
[00:39:41] Speaker A: I assumed the same medication you were at throughout, but you're right, if there's any changes in medication, almost the whole conversation has to restart with regards to is this safe and low risk in breastfeeding.
[00:39:52] Speaker C: Great. And then not, not just, you know, it's looking at all the other medications as well. So some of these women, for example, if we have started them on prophylactic low molecular weight heparin, you know, because they've had a flare or they've needed it for some reason in pregnancy, we would continue this postnatally because that is quite a key window where a very high risk window for developing a VT El. So we want them to continue that for at least six weeks. And that is also completely safe for breastfeeding. So even though they have to continue this injection, it is very safe and they can breastfeed on it.
[00:40:22] Speaker A: No, really important point. Thank you, Mandeep.
The next thing we thought would be useful to discuss is the current hot potato topic of vaccines post birth. And really that we were highlighting that there's quite a few differing practices across the country and between different specialties. So I was wondering, Mandeep, if you wanted to kind of expand on that with your experience in the networks that you have.
[00:40:46] Speaker C: I mean, it's really challenging, isn't it? So I think that we unfortunately have lots of different national guidelines that we follow for different kind of disease specialties. And. And there is a bit of variability with the fact that we would advise women that when their babies are born that they should not have a live vaccine for 12 months, and that is your BCG and rotavirus. But there is variability across other guidelines which state that actually it is safe to have the road or the baby to have, safe for the bab to have rotavirus. And I think really these guidelines do make it difficult for us, but also make it difficult for our women as well. And I just generally hope that in time that we can all align and come up with one generic kind of consensus.
And I'm not sure if there are plans to do that. And maybe, I don't know, Krishna, you have more information about that or what your thoughts are on this, but it is quite difficult when you work across different specialties as well in.
Especially from my point of view in maternal medicine.
[00:41:47] Speaker B: So I completely agree with you. There is. So we know that there is the global consensus guidelines that were written from the US and Europe and they have at present, or they are recommending that patients on biologics get the rotavirus vaccine.
And so what I'm kind of, instead of my practice is to highlight to patients that there is a change in guidance. And so things may change, change. But at the moment we're sort of going by our local guidance. And this is also just to reassure them if they get different advice from a different center, that they might be booked or a different team, they're seeing they still are able to retain trust within the team and they don't feel as though they're getting a mixed message. So I think just explaining that to patients and that it's evolving is quite probably quite helpful for them.
[00:42:35] Speaker A: Yeah, absolutely. And that there is that absolute want to align practices. I think that's also really important, isn't it? So. And if patients know that and know that we're all talking to each other, that really helps with that trust that you mentioned onto the next thing with regards to postpartum, we know that unfortunately there is that increased risk of flare Krishna within your practice. How would you manage that?
[00:42:58] Speaker B: So as you mentioned, it's a really busy time for the new mum and often they may forget about their own needs during this time. So it's really important to remind them to continue taking their medication in the postpartum period and just highlighting to them that there is a risk of flare and then making sure that they are signposted so they know who to contact and if this is the IBD advice line to get through to any member of the IBD team so that we can identify these early and treat these early. So I think that's the key point and through that as well, just making sure that we're signposting them about psychology, psychological support and also other risk factors. As Mandeep mentioned, the risks in bte. So they know what kind of things to look out for and they know how to raise the alarm early.
[00:43:44] Speaker A: And thinking about those risks, Mandeep, what about contraception planning in this particularly tricky time?
[00:43:51] Speaker C: Absolutely. And it's like a, you know, the kind of pregnancy journey is like a cycle because once this baby's born we then start thinking about preconception again. But, but actually this is where contraception is so important. So someone who, you know, a pregnant woman who's had a baby with a, with a chronic medical problem like IBD really kind of, as we said, they kind of put themselves second when the baby's born and we do see unplanned pregnancies and really we want them to be a long term contraception so that actually when they're ready to embark on a maybe, possibly if they want to, a future pregnancy, that their idea, IBD is well controlled before they take on that journey. So we actually discuss contraception quite like in, at the Royal London in BART south, we discuss contraception and I'm sure other kind of units across the UK do this quite early on in the pregnancy and gauge what kind of contraception someone might want to choose. And we're quite fortunate that before women go home we offer immediate contraception before they even go home. So it used to be a practice that when a pregnant woman has given birth they will have a six week check with their GP and then they talk about contraception. But actually now those discussions are happening in the pregnancy, but then on the postnatal ward and we offer non estrogen based contraceptions such as the subdermal implant or the hormonal or non hormonal intrauterine device. And if people need, if women need more time to think of, you know, we can also offer the mini pill as well. But ideally we want them to be on something long term so they don't have to worry about, you know, an unplanned pregnancy, which is important in women with a chronic medical condition like ibd.
[00:45:36] Speaker A: Yeah, and probably not top of their list, but absolutely we know it can happen. So yeah. So I think we've gone through the main sections of pregnancy and IBD that we've wanted to discuss. So I just wanted to put cook back to yourselves if you have any kind of take home messages or key guidelines that you'd like to let the audience know about just as we start to close. So Krishna, over to you.
[00:45:58] Speaker B: So I think my key take home messages are the importance of pre conception counselling and making sure that we are getting patients into remission before pregnancy. And then another key take home mention is the proactive monitoring of patients in pregnancy so that we're detecting any flares early and, and treating them early to reduce the risk of adverse outcomes.
[00:46:20] Speaker A: And Mandy?
[00:46:21] Speaker C: Yeah, I completely agree. So I'm going to say exactly the same thing because if we get it right with preconception counseling, we really can change a pregnancy journey for a woman because they will be embarking on a pregnancy at the best possible place, therefore making outcomes for themselves and baby the best possible that it can be. So for me it is that preconception count counseling and not finding it difficult to actually talk about contraception and offering contraception because I also think that lots of people find that quite difficult and challenging. So those are kind of two things, like be open about talking about contraception as well.
[00:46:57] Speaker B: And what about you, Fiona?
[00:46:59] Speaker A: I think ditto to everything you two have said, but I'm absolutely going to go and look up the maternal medicine networks and try and plug in to make sure we have that direct line for any of our complicated patients.
I think really about empowering the patient, whether that be themselves or their partners or their family, to make sure that they feel as educated and as supported as possible through pregnancy. So no question is too small. And finally, just to obviously big up the MDT and involve everyone as much as possible because I think that does provide the best kind of care package we can for these patients.
Thank you both. I think that's the end of this podcast. I found it really useful and enjoyable. I hope everyone else does too.
And we'll close now and look forward
[00:47:44] Speaker B: to the next one.
[00:47:44] Speaker A: Thanks, Krishna. Thanks Mandeep.
