The Management of IBD With Biologics in the Third Trimester of Pregnancy

Abstract

Introduction: The management of inflammatory bowel disease (IBD) during pregnancy can provoke a great deal of anxiety in patients and physicians alike. Fortunately, biologics - the most effective therapeutic option, have proven relatively safe during pregnancy. Many IBD gastroenterologists consider terminating biologics in the second trimester so as to minimize placental transfer in the third. An important issue that has not been addressed adequately is how to manage the recurrence of IBD activity in the third trimester. We present such a scenario. Case Report: A 33-year-old woman with a history of ulcerative colitis (UC) was admitted to our hospital 30 weeks into her second pregnancy, passing 10-15 bloody bowel movements per day with crampy, LLQ abdominal pain, and tenesmus. She was diagnosed 3 years prior with mild left-sided UC that responded well to mesalamine enemas. An exacerbation during her first pregnancy also responded to topical therapy. She was otherwise healthy, without any other significant past medical or family history, and stopped smoking over a decade ago. Her disease was in clinical remission until 6 weeks prior to presentation. She was initially treated with oral mesalamine and steroids without response, so she was admitted to a hospital and given IV and PR steroids. But she continued to pass bloody stools, required 4 units of pRBCs, and was transferred to our hospital. Her examination was significant for a gravid abdomen with LLQ tenderness. The hemoglobin was 10.2, CRP was elevated at 4.6, and work-ups for C. difficile and latent infections were negative. A flexible sigmoidoscopy demonstrated severely friable, ulcerated mucosa from rectum to hepatic flexure. Infliximab was then initiated at 5mg/kg, leading to an improvement in her symptoms the very next day. After 5 days of observation, she was discharged passing semi-formed stool without any gross blood. Eight weeks later, she delivered a healthy 7-lb 13-oz (3.54 kg) baby girl via Csection at full term without any complications. The infant did not receive any live vaccines for the first 6 months, and did not develop any infections. The mother’s UC continues to be in remission on infliximab every 8 weeks. Discussion: Biologics have proven to be relatively safe in the treatment of IBD during pregnancy. In patients whose disease is in remission, the timing of the last dose of a biologic should be determined after weighing the proven risks of disease activity against the theoretical risks of the drug on the newborn. Conversely, uncontrolled disease during the third trimester is clearly an imminent threat to the mother and fetus. Our experience favors continuing or even initiating biologics in the third trimester when clinically warranted.