How to manage small bowel Crohn's disease in a pregnant woman during the second trimester?

Management of Small Bowel Crohn's Disease During Second Trimester of Pregnancy

For pregnant women with small bowel Crohn's disease in the second trimester, the decision to continue or discontinue anti-TNF therapy should be based on disease activity, with continuation recommended for those with active disease or high risk of flare to optimize maternal and fetal outcomes.

Assessment of Disease Activity

• Disease activity should be objectively evaluated during pregnancy as active IBD is associated with poor pregnancy outcomes including premature delivery, low birth weight, and higher spontaneous abortion rates 1
• Pregnant women with IBD should be managed by a gastroenterologist throughout pregnancy 1
• For women requiring hospitalization due to disease flare, transfer to a tertiary center with access to both gastroenterology and high-risk obstetrics is recommended 1

Medication Management During Second Trimester

Anti-TNF Therapy

• For women with active disease or high risk of flare:

  • Continue anti-TNF therapy throughout pregnancy to maintain remission 1
  • Disease activity during pregnancy is associated with low birth weight (OR 2.05) and preterm birth (OR 2.64, increasing to OR 3.6 in moderate to severe disease) 1
  • Meta-analyses confirm no increased risk of adverse pregnancy outcomes, congenital abnormalities, preterm birth, or low birth weight with continued anti-TNF therapy 1

• For women with quiescent disease:

  • Anti-TNF medications may be safely discontinued at week 22-24 of gestation (second trimester) if there is low risk of disease flare 1
  • Case-control and cohort studies show no increased risk of flare if anti-TNF therapy is stopped at week 25-30 in women with quiescent disease 1

Thiopurines (Azathioprine/6-Mercaptopurine)

• Continue thiopurine maintenance therapy throughout pregnancy if already established 1
• For women on combination therapy (anti-TNF plus thiopurine), the decision to switch to monotherapy should be individualized based on disease severity and prior response 1

5-ASA Medications

• Continue 5-ASA maintenance therapy throughout pregnancy if already established 1
• For mild to moderate disease flares while on 5-ASA maintenance therapy, optimize dosing to induce remission 1

Management of Disease Flares During Second Trimester

• For disease flares on optimal 5-ASA or thiopurine maintenance therapy:

  • Systemic corticosteroids or anti-TNF therapy are recommended to induce symptomatic remission 1
  • For corticosteroid-resistant flares, starting anti-TNF therapy is recommended 1

• For patients who are thiopurine-naïve and starting anti-TNF therapy:

  • Anti-TNF monotherapy is preferred over combination therapy with thiopurines 1

Imaging and Endoscopy During Pregnancy

• Limit radiologic investigations to ultrasound and MRI when possible 1
• Flexible sigmoidoscopy or colonoscopy can be performed if results will affect antenatal management of IBD 1

Thromboprophylaxis

• Anticoagulant thromboprophylaxis is recommended during hospitalization for IBD flares 1

Special Considerations

• Urgent surgery to manage complications of IBD should not be delayed solely due to pregnancy 1
• The decision regarding cesarean delivery should be based on obstetric considerations and not IBD diagnosis alone 1
• Therapeutic drug monitoring may be beneficial when using infliximab during pregnancy due to greater variability in drug levels compared to adalimumab 1

Common Pitfalls to Avoid

• Discontinuing effective IBD medications during pregnancy often leads to disease flares, which pose greater risks to pregnancy outcomes than the medications themselves 1
• Methotrexate is absolutely contraindicated during pregnancy due to teratogenicity 2
• Delaying necessary treatment due to pregnancy concerns can lead to worsening disease activity and poorer maternal and fetal outcomes 1

By following these guidelines, the management of small bowel Crohn's disease during the second trimester of pregnancy can be optimized to maintain maternal health while ensuring the best possible outcomes for both mother and baby.