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The American Gastroenterological Association’s new guidance on pregnancy-related gastrointestinal and liver diseases offers peer-reviewed expert advice on the clinical management of pregnant patients and emphasizes the need for multidisciplinary care of this complex patient population.
Citing increased pregnancy-related morbidity and mortality in the United States, particularly for high-risk pregnancies, the practice update panel wrote that “recognizing a worsening disease course, triaging the level of maternal health, and prescribing appropriate medication and interventions are essential.”
Lead author Shivangi T. Kothari, MD, a gastroenterologist at the University of Rochester Medical Center, in New York, told Gastroenterology & Endoscopy News that evaluation and treatment of GI conditions in pregnant patients can be challenging and requires a multidisciplinary approach. Managing the “range of physiological changes that can impact the GI tract and liver function” from pre-existing conditions and conditions that are related to pregnancy itself “often requires expertise from various specialties for optimal patient and fetal outcomes,” Dr. Kohari said.
“Women with chronic illness are high-risk for pregnancy complications,” added Uma Mahadevan, MD, the director of the Colitis and Crohn’s Disease Center at the University of California, San Francisco, who was not involved in the practice update. “Approaching them in silos and focusing on only one aspect of their health leads to confusion, stress and, sometimes, incorrect management. The obstetrician and gastroenterologist need to be on the same page with respect to what medications can be continued, mode of delivery, monitoring needed, et cetera.”
Best Practice Recommendations
Although not a systematic review, the practice update offers 13 Best Practice Advice statements based on the published literature and expert advice (Gastroenterology 2024;167:1033-1045). The statements provide practical advice for the management of pregnant patients, referencing recommendations from the American College of Obstetricians and Gynecologists.
Among the Best Practices listed is a recommendation of early treatment of nausea and vomiting with vitamin B6, doxylamine, hydration, adequate nutrition, ondansetron, metoclopramide, promethazine and glucocorticoids to reduce the incidence of hyperemesis gravidarum (HG). “Methylprednisolone can be given as a last resort to patients with severe HG,” the panel noted.
“While ondansetron and methylprednisolone can be effective—especially in cases where dehydration, malnutrition or significant weight loss become dangerous for the patient and fetus—the decision to use them involves a careful risk–benefit analysis and discussion of side effects. For patients with severe symptoms and risk of serious complications, the benefits may outweigh the risks of these medications,” Dr. Kothari said.
Dr. Mahadevan agreed. “In general, pregnant women should not be denied medical therapies that are needed and shown to be low risk. HG can be a serious condition. If patients cannot be treated with conservative measures, then ondansetron and methylprednisolone have a role and should be given based on severity.”
For patients with inflammatory bowel disease, appropriate treatments can be used throughout pregnancy and postpartum, the panel stated. Biologic agents can be continued to maintain remission, but other treatments, such as methotrexate, thalidomide and small molecule drugs, should be stopped before pregnancy. (See our story on PIANO Conference guidance on IBD in pregnancy in our October issue.)
“The main goal with IBD is to maintain disease remission for optimal patient and fetal outcomes. Biologic agents, such as anti-TNF agents, can be continued since the aim is to prevent disease flares, which can be detrimental for patient and fetus,” Dr. Kothari said.
According to Dr. Mahadevan, biologics are “well studied,” and monoclonal antibodies don’t cross the placenta in the first trimester, when key parts of organogenesis occur. “Lack of early exposure likely contributes to the lack of birth defects seen. The late transfer results in infants born with detectable levels of drugs. However, this has not been associated with adverse events for the newborn,” she said.
Collaborative Team Approach
The panelists encouraged practicing physicians to adopt a collaborative strategy for common and unique GI conditions during pregnancy, emphasizing that the “paramount goal is to keep both the patient and fetus safe.”
“Managing the pregnant patient with chronic GI disease takes a team. Gastroenterologist, obstetrician, surgeon, nutritionist, et cetera should be involved from preconception counseling,” Dr. Mahadevan said. “They should agree on a treatment plan throughout pregnancy and lactation so patients receive a consistent message they can be confident in.”
“Evaluation and treatment of various GI disorders requires a multidisciplinary team to manage patients during pregnancy and the postpartum period,” Dr. Kothari said. “Procedures, medications and other interventions to optimize maternal health should not be withheld because a patient is pregnant. Rather, they should be individualized after an assessment of the risks and benefits.”
This article is from the December 2024 print issue.