Women with inflammatory bowel disease who are either contemplating pregnancy or already have become pregnant face many uncertainties, as well as known risks. If their inflammation is uncontrolled, they are at increased risk of flares during pregnancy, which can lead to newborns who are small for gestational age, intrauterine growth restriction, preterm birth, and miscarriage.
And, although many medications that are used to treat IBD are safe, providers and patients are often reluctant to continue with them during the pregnancy for fear of harming the fetus.
With that in mind, the UCLA Center for Inflammatory Bowel Diseases, in partnership with UCLA’s Department of Obstetrics and Gynecology, has established a multidisciplinary Preconception, Pregnancy, and Postpartum + IBD clinic, among the first of its kind.
The clinic, which is co-led by an IBD physician who specializes in women’s health and an OBGYN who specializes in maternal-fetal medicine and high-risk pregnancies, collaborates with patients and their health care providers through preconception planning, pregnancy, and the postpartum period to address fears, dispel misconceptions, and maximize outcomes.
“This is a coordinated effort to make sure mom and baby do as well as they possibly can,” says the clinic’s co-director, Nirupama Bonthala, MD, associate clinical professor of medicine at the David Geffen School of Medicine at UCLA and director of women’s health in inflammatory bowel disease for the UCLA Vatche and Tamar Manoukian Division of Digestive Diseases.
Dr. Bonthala explains that patients typically visit the clinic for one of two reasons: They are interested in becoming pregnant and have questions about how their disease might impact the pregnancy as well as how they can set themselves up for the best outcome; or they are in the early stages of preconception planning, their provider wants to ensure their IBD is under control, and they have questions about the safety of certain medications.
“In addition to working closely with our patients, we are committed to educating their referring GI and OB providers so that everyone is on the same page,” Dr. Bonthala says. “This is add-on care — extra eyes that can monitor and advise patients in addition to the excellent care they’re already receiving.”
At the clinic, women receive personalized guidance to ensure their IBD is well controlled prior to and during pregnancy, along with high-quality obstetrics care that includes close maternal-fetal medicine monitoring.
Before becoming pregnant, patients make an initial visit to discuss preconception concerns.
“Keeping their IBD well controlled gives patients the best chance for a successful pregnancy,” says Ilina Pluym, MD, assistant clinical professor of OBGYN at the David Geffen School of Medicine at UCLA and the high-risk obstetrician who codirects the clinic.
During the pregnancy, patients are monitored for any indications of preterm labor, preeclampsia, or other complications, as well as for signs of IBD-related flares. Patients visit the multidisciplinary expert team at least once each trimester during the pregnancy, as well as returning for a postpartum visit. The clinic brings in other experts as well, including colorectal surgeons for any structural concerns; family planning physicians for issues related to complex contraception; and allied health professionals to offer patients personalized dietary guidance, mental health care, and lactation support as needed.
The clinic is also conducting research in an effort to learn from its experience in ways that will improve patient outcomes.
When women with IBD are considering becoming pregnant, inevitably they want to know whether their IBD medications will be safe through the pregnancy and during breastfeeding.
“It’s natural to have some doubt about whether staying on a medication is keeping the baby safe, and in some cases a well-intentioned health care provider who doesn’t have experience in this area might recommend not taking it, just because of that doubt,” Dr. Bonthala says. “As a result, I have had patients who are flaring terribly by the time they come to see me.”
Adds Dr. Pluym: “Everyone wants to err on the side of caution, thinking that’s the safest approach, but not taking the medication and flaring as a result is actually the greatest risk for the baby.”
Many women with IBD also assume they will need to deliver by C-section when that is generally not the case, Dr. Pluym notes. Some patients worry that their IBD will impact their ability to become pregnant. As part of their preconception counseling, patients are advised that if they have been trying unsuccessfully to become pregnant for six months, they should see an infertility specialist.
In some cases, part of the clinic’s education involves explaining to patients that unless they keep their IBD fully under control, they are a high-risk patient.
“Women with IBD who are in their reproductive years tend to be otherwise healthy, without some of the comorbid conditions that we see more often in our older patients, so some will assume there is nothing to worry about,” Dr. Bonthala says. “It’s important that we make sure these patients are having conversations with their providers about the potential risks associated with not keeping their disease under control.”
Dr. Bonthala points out that assuming they are closely monitored and address any flares quickly, the vast majority of IBD patients will have healthy pregnancy outcomes.
“IBD is actually one of the more common conditions a maternal-fetal medicine specialist sees,” adds Dr. Pluym. “As long as there is good planning and counseling, they are likely to do well.”
