How is a flare treated if it occurs during pregnancy?
Dr. Dubinsky: A flare during pregnancy is treated the same as a flare outside of pregnancy. We want to use noninvasive ways to confirm it, but I think we don’t need to overly investigate in most of our women. If they’re already on a biologic, you may consider changing.
Some women may need corticosteroids. It’s not our favorite move, but there is an urgency to getting a flare under control during pregnancy because of possible complications.
Dr. Mahadevan: Some of this is contingent on when during pregnancy the flare occurs. A patient who has a flare at 38 weeks’ gestation will likely proceed with delivery and the flare will be dealt with separately. Someone at 8 weeks’ gestation is at high risk for pregnancy loss, so treatment should be quick and effective.
As does Dr. Dubinsky, I do try to avoid steroids if possible. For example, I would rather start an effective biologic right away than drag out steroids to see if they will respond.
Dr. Kane: I would add that, if a mother is losing weight, she might need to be hospitalized for additional nutritional support. If surgery is necessary, we usually try to time it for the second or third trimester.
What needs to be taken into consideration regarding mode of delivery? Also, if a woman has undergone prior surgeries, do they increase the risk of delivery complications?
Dr. Sunanda V. Kane
For ulcerative colitis, mode of delivery is based on obstetric, not gastrointestinal, variables. For Crohn’s disease, if there is evidence of perianal disease, then a cesarean is appropriate.
If there is no history of perianal disease, then delivery is based on obstetric variables.
For a woman who has a J pouch, if possible, the surgeon who created it should be contacted to ask about the technical aspects of the pouch and how it lies in the pelvis.
What’s the risk of a postpartum flare if a woman’s IBD remains in clinical remission during pregnancy?
Dr. Mahadevan: There is no increased risk of postpartum flare if a woman continues her IBD medications after delivery. Many of the reports of flare are from stopping medications (mistakenly often) to breastfeed.
Dr. Kane: As Dr. Mahadevan said, the risk of a flare is usually because a woman stops taking her medications because she thinks that medication will be passed to the infant through breastfeeding, which in most cases is not true.
Otherwise, there is not an increased risk of a flare in a 12-month period. However, it is important to monitor for symptoms after delivery; the risk of a flare is not zero.
What symptoms should women watch out for after delivery that may indicate an uptick in disease activity?
Dr. Kane: The same symptoms as before they were pregnant. Diarrhea, abdominal pain, and rectal bleeding are not normal after delivery and should be considered signs of returning disease.
