The American College of Gastroenterology (ACG) recently released a consensus statement regarding the management of pregnancy along an inflammatory bowel disease (IBD) diagnosis. The Global Consensus Statement on the Management of Pregnancy in Inflammatory Bowel Disease arises from the Global Consensus Consortium, a group of 39 IBD and content experts along with seven patient advocates from six continents. The consortium convened to assess the latest data and reach a consensus on best practices based on the observed research. 

The resulting 34 recommendations, listed below, fall within the ten categories set by the consortium, along with 35 additional consensus statements. 

The recommendations all have Low or Very Low levels of evidence supporting them, and eight of the 34 recommendations feature Strong recommendation levels, with the rest being labeled as Conditional.   

Recommendations from the 2025 Consensus Statement on the Management of Pregnancy in IBD:

The following 34 recommendations are divided into ten unique categories. Each recommendation is accompanied by a recommendation level and a level of evidence rating. Associated consensus statements are listed following the recommendations in each category.

Maternal Factors Impacting Pregnancy to Be Addressed In Counseling:

  • We suggest counseling that children with first-degree relatives with IBD, as compared with those without, have an increased risk of development of IBD. (Conditional, Low)
  • Consensus Statement: Children born to a parent with Crohn's disease may have a higher risk of developing IBD than children born to a parent with ulcerative colitis.

Fertility

  • We suggest counseling that women with IBD may have decreased fertility compared with women without IBD. (Conditional, Very Low)
  • In women with ulcerative colitis, we suggest counseling that prior ileal pouch anal anastomosis is associated with decreased fertility when compared with women with ulcerative colitis who have not had ileal pouch anal anastomosis. (Conditional, Very Low)
  • In women with IBD, we recommend counseling that active disease increases the risk of infertility as compared with inactive disease. (Strong, Very Low)
  • We suggest counseling that women with IBD may have comparable effectiveness of assisted reproductive technology when compared with women without IBD as measured by live birth. (Conditional, Very Low)
  • We suggest counseling that women with IBD who have undergone pelvic surgery with IBD have similar effectiveness of in vitro fertilization when compared with women without IBD, as measured by live birth. (Conditional, Very Low)
  • Consensus Statements: Women with IBD may have reduced fertility compared with women without IBD due to reduced ovarian reserve. Women with IBD may undergo oocyte retrieval without increased risk of flare.

Preconceptional Counseling and Optimization

  • We recommend that women with IBD undergo preconceptional counseling. (Strong, Low)
  • Consensus Statements: Women with IBD desiring contraception should use long-acting reversible contraception over estrogen-containing contraceptives. Women with IBD should be in documented remission and medically optimized prior to elective conception.

Management of Disease Activity During Pregnancy

  • We suggest that urgent and emergent IBD surgery during pregnancy be completed when required, and not based on trimester. (Conditional, Very Low)
  • Consensus Statements: Endoscopy during pregnancy among women with IBD is low risk but should only be performed if it may change management. If cross-sectional imaging is needed during pregnancy, intestinal ultrasound and MRI without gadolinium are preferred to CT. Fecal calprotectin is useful for monitoring disease activity in pregnant women with IBD.

Management of Pregnancy

  • We suggest that pregnant women with IBD take low-dose aspirin by 12–16 weeks gestation to prevent preterm preeclampsia. (Conditional, Low)
  • We suggest that pregnant women with Crohn's disease and active perianal disease undergo Cesarean delivery. (Conditional, Very Low)
  • We suggest that pregnant women with IBD and prior ileal pouch anal anastomosis consider Cesarean delivery. (Conditional, Very Low)
  • Consensus Statements: Pregnancies for women with IBD should be considered as high risk for complications. Women with current or past history of rectovaginal fistulas should deliver by Cesarean delivery. Women with IBD should be assessed early in pregnancy or preconception for nutritional status, weight gain, and micronutrient deficiency.

Medications in Pregnancy

  • For women with IBD who are pregnant or attempting conception, we recommend continuing maintenance 5-ASA therapy. (Strong, Low)
  • In women with IBD who are pregnant or attempting conception, we suggest continuing maintenance sulfasalazine therapy. (Conditional, Very Low)
  • In women with IBD who are pregnant, we suggest use of corticosteroid therapy when clinically necessary with appropriate monitoring. (Conditional, Low)
  • In women with IBD, we recommend discontinuing maintenance methotrexate therapy prior to conception. (Strong, Very Low)
  • In women with IBD who are pregnant or attempting conception, we suggest continuing maintenance thiopurine therapy as data does not demonstrate an increased risk of congenital malformations or infant infections. (Conditional, Very Low)
  • In women with IBD who are pregnant or attempting conception, we recommend continuing maintenance anti-TNF therapy throughout pregnancy. (Strong, Low)
  • In women with IBD who are pregnant or attempting conception, we suggest continuing maintenance combination therapy with an anti-tumor necrosis factor and thiopurine therapy throughout pregnancy. (Conditional, Very Low)
  • In women with IBD who are pregnant or attempting conception, we suggest continuing maintenance vedolizumab therapy throughout pregnancy. (Conditional, Low)
  • In women with IBD who are pregnant or attempting conception, we suggest continuing maintenance ustekinumab therapy throughout pregnancy. (Conditional, Low)
  • Consensus Statements: Women with IBD who are pregnant and with active disease should start or optimize the same appropriate therapies as in nonpregnant patients, except for thiopurines, methotrexate, JAK inhibitors, and S1P receptor modulators. 

    In women with IBD who continue thiopurines during pregnancy, precaution should be taken for intrahepatic cholestasis by measurement of liver enzymes, metabolite levels, and consideration of split dosing. Women with IBD who are pregnant and have infections, fistula, or pouchitis that require antibiotics may take an appropriate course of a low-risk antibiotic. 

    Women with IBD may initiate or continue calcineurin inhibitors (cyclosporine and tacrolimus) during pregnancy with careful monitoring if there are no viable alternate treatment options available. Women with IBD who are pregnant or attempting conception should continue biosimilars to existing biologics. 

    Women with IBD who are pregnant or attempting conception should continue anti-interleukin (IL)-23 therapy throughout pregnancy (mirikizumab, risankizumab, guselkumab). Women with IBD should discontinue ozanimod at least 3 months prior to conception unless there is no effective alternative therapy to maintain maternal health. 

    Women with IBD should discontinue etrasimod at least 1–2 weeks prior to conception unless there is no effective alternative therapy to maintain maternal health. Women with IBD should discontinue tofacitinib at least 4 weeks prior to conception unless there is no effective alternative therapy to maintain maternal health. 

    Women with IBD should discontinue upadacitinib at least 4 weeks prior to conception unless there is no effective alternative therapy to maintain maternal health. Women with IBD should discontinue filgotinib at least 4 weeks prior to conception unless there is no effective alternative therapy to maintain maternal health.

Medications During Lactation

  • We recommend breastfeeding as it is not associated with an increased risk of disease exacerbation in women with IBD. (Strong, Very Low)
  • We suggest counseling that infants born to mothers on anti-TNF therapy who breastfeed have no increased risk of infection in the first 12 months of life. (Conditional, Very Low)
  • Consensus Statements: Mothers with IBD currently on 5-ASA/sulfasalazine may breastfeed. Mothers with IBD currently on thiopurines may breastfeed. Mothers with IBD currently on corticosteroids may breastfeed. Mothers with IBD currently on anti-TNF agents (infliximab, adalimumab, golimumab, certolizumab) may breastfeed. 

    Mothers with IBD currently on anti-integrins (vedolizumab, natalizumab) may breastfeed. Mothers with IBD currently on anti-interleukin-12/23 and anti-interleukin-23 agents may breastfeed (ustekinumab, risankizumab, mirikizumab, guselkumab). Mothers with IBD currently on biosimilars may breastfeed. 

    Mothers with IBD currently on S1P receptor modulators (etrasimod or ozanimod) should not breastfeed. Mothers with IBD currently on JAK inhibitors (tofacitinib, upadacitinib, filgotinib) should not breastfeed.

Pregnancy Adverse Events

  • We suggest counseling that women with IBD as compared with women without IBD have an increased risk of adverse pregnancy outcomes including low birth weight and preterm delivery. (Conditional, Very Low)
  • We suggest counseling that women with IBD with moderate to severe disease activity have an increased risk of spontaneous abortion as compared with women without IBD or women with mild IBD. (Conditional, Very Low)
  • We suggest counseling that pregnant women with IBD have an increased risk of VTE during pregnancy as compared with pregnant women without IBD. (Conditional, Low)
  • We suggest counseling that pregnant women with IBD have an increased risk of VTE during the postpartum as compared with pregnant women without IBD. (Conditional, Low)
  • Consensus Statement: Controlling disease activity during pregnancy among women with IBD is critical to reduce adverse outcomes.

Delta and Neonatal Adverse Events

  • We suggest counseling that children born to women with IBD have an increased rate of neonatal intensive care unit admissions and hospitalizations in the first year of life compared with children born to women without IBD. (Conditional, Very Low)
  • We suggest counseling that children born to women with active IBD have an increased rate of small for gestational age and low birth weight compared with children born to women with inactive IBD. (Conditional, Very Low)
  • We suggest counseling that children born to women treated with anti-tumor necrosis factor therapy, ustekinumab, or vedolizumab during pregnancy have no increased risk for early childhood malignancy. (Conditional, Very Low)
  • We suggest counseling that children born to women treated with anti-tumor necrosis factor therapy, ustekinumab, or vedolizumab during pregnancy have no increased risk for early childhood developmental delay. (Conditional, Very Low)
  • We suggest counseling that children born to women treated with thiopurine therapy during pregnancy have no increased risk for early childhood developmental delay. (Conditional, Very Low)
  • Consensus Statement: None given.

Vaccines

  • We recommend that inactive vaccines be provided to children born to mothers with IBD on anti-TNF agents. (Strong, Very low)
  • We suggest that live rotavirus vaccine may be provided in children with in utero exposure to biologics. (Conditional, Very Low)
  • We recommend that live Bacillus Calmette-Guérin vaccine be avoided in the first 6 months of life in children with in utero exposure to anti-TNF therapy due to risk of disseminated tuberculosis and associated mortality. (Strong, Very Low)
  • Consensus Statements: Inactive vaccines should be given on schedule to infants of women with IBD regardless of in utero IBD medication exposure. Children exposed to JAKis or S1P receptor modulators in utero may receive live vaccines after 1 month of age. Live vaccines can be given to infants of mothers breastfeeding while on biologics.

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