How Should IBD Medications Be Managed During Pregnancy?

Answer in brief: The priority in pregnancy is sustained IBD remission because active disease is itself a major maternal and fetal risk. Most maintenance biologics, including anti-TNF agents, vedolizumab and ustekinumab, are generally continued through pregnancy when needed for disease control. Methotrexate is contraindicated; small-molecule JAK inhibitors and S1P modulators are generally avoided. Preconception planning and multidisciplinary care are strongly recommended.

Maternal disease control supports fetal health

The 2025 global consensus reframed medication decisions around a crucial principle: undertreated active IBD can be more dangerous than continuing many effective maintenance therapies. Stopping treatment solely because of pregnancy may provoke relapse, steroid exposure, hospitalization or surgery.

Biologics are usually continued

The global consensus recommends continuing maintenance anti-TNF therapy and supports continuation of vedolizumab and ustekinumab. Combination anti-TNF/thiopurine maintenance can also be continued when clinically appropriate. Decisions about newer agents should use current product-specific data and specialist input.

Know the drugs to avoid

Methotrexate is teratogenic and must be discontinued before conception. JAK inhibitors and S1P modulators are generally avoided during pregnancy because safety data and mechanism raise concern. Thiopurines should not usually be newly initiated simply to treat an acute flare, although established maintenance therapy can be continued.

Treat active disease promptly

Pregnancy is not a reason to accept ongoing intestinal inflammation. Patients with active disease should receive effective therapy using pregnancy-compatible options, with multidisciplinary input when disease is severe.

Plan before conception

The best pregnancy starts with remission. Review medications, vaccines, nutrition, iron status and disease activity before conception; coordinate gastroenterology and obstetric care; and discuss infant vaccination implications of in-utero biologic exposure.

What trainees should remember

The safest pregnancy strategy is usually controlled IBD, not medication withdrawal. Continue effective compatible maintenance therapy, avoid known high-risk drugs, and plan pregnancy while disease is in remission.

Frequently asked questions

Should anti-TNF therapy be stopped in the third trimester?

Routine late-pregnancy discontinuation is no longer favored when it risks maternal relapse; current consensus supports continuation through pregnancy.

Can methotrexate be used during pregnancy?

No. Methotrexate is contraindicated and requires preconception discontinuation.

References and further reading

1. Thomson ABR. Clinical Pharmacology, Physiology and Pathophysiology: Gastroenterology, Hepatology, and Pancreaticobiliary Disorders. CAPstone Academic Publishers; 2024.

2. Thomson ABR. Guideline-Based Management in Gastroenterology. CAPstone Academic Publishers; 2015.

3. Mahadevan U, et al. Global Consensus Statement on the Management of Pregnancy in Inflammatory Bowel Disease. Clin Gastroenterol Hepatol. 2025;23(11 Suppl):S1-S60.