In pregnancy, how should biologic therapy be approached for a patient with IBD?

• A. All biologics should be stopped at conception.
• B. Most biologics are relatively safe in pregnancy; maintain disease control; coordinate with obstetric provider; avoid methotrexate; monitor for neonatal immunosuppression.
• C. Biologics are contraindicated in pregnancy.
• D. Methotrexate is safe during pregnancy.

Answer: (B)

The main idea here is that maintaining control of inflammatory bowel disease during pregnancy using biologic therapy is typically appropriate and beneficial. For many patients, continuing biologic treatment, especially anti-TNF agents, during pregnancy is considered safe based on pregnancy data and registries. Stopping therapy at conception or during pregnancy often leads to a flare, and active IBD poses greater risks to both mom and baby than the drugs themselves. Therefore the best approach is to keep disease activity under control in close coordination with the obstetric team.

An important part of the plan is to avoid methotrexate in pregnancy because it is teratogenic and must be stopped prior to conception. There is also a need to watch for neonatal immunosuppression in infants exposed to biologics, particularly if exposure occurs later in pregnancy, so planning includes informing the pediatric team and monitoring the newborn as needed. In short, continue biologic therapy to maintain remission, involve obstetrics in the plan, avoid teratogenic medications like methotrexate, and be mindful of potential effects on the newborn.