Editorial: Mitigating the Risk of Adverse Pregnancy Outcomes in Women With Inflammatory Bowel Disease and Chronic Liver Disease—Authors' Reply

We thank Chung and Nayagam for their thoughtful editorial and for highlighting the clinical urgency and practical steps towards safer pregnancies for women living with inflammatory bowel disease (IBD) and chronic liver disease (CLD) [1]. Their emphasis on integrated, multidisciplinary, preconception-to-postpartum care aligns with our study's aims and conclusions [2]. Using a nationally representative U.S. cohort of 21.3 million delivery hospitalisations, we found that coexisting IBD and CLD confer compounded risk beyond either condition alone, including higher odds of preterm birth, hypertensive disorders of pregnancy, and perinatal mood disorder [2]. These associations, which persisted after multivariable adjustment, can inform risk-based guidelines for pregnant patients with coexisting IBD and CLD. We agree that intrahepatic cholestasis of pregnancy (ICP) is a critical missing variable. As noted in our limitations, ICP was not included as a maternal outcome due to the absence of an ICP-specific ICD-10 code during our study period 2016–2022, with an official ICP code ‘O26.64’ introduced only in October 2023 following patient advocacy [3]. Thus, any cholestasis-mediated associations may be underestimated in our cohort of patients with coexisting IBD and CLD, predominantly primary biliary cholangitis and primary sclerosing cholangitis, in whom the predominant obstetric risk is often comorbid ICP. We anticipate that future work will leverage the new code, along with prospective registries and linkage to bile-acid measurements, to clarify the impact of ICP on pregnancy outcomes in coexisting IBD and CLD. Regarding preeclampsia prevention, we endorse daily low-dose aspirin (LDA) for pregnant patients with IBD aligning with recent global guidelines [4], whereas no CLD-specific recommendation exists. Although LDA exposure could not be estimated in the National Inpatient Sample, recent studies suggest that LDA use is not associated with increased IBD disease activity during pregnancy, supporting its safety [5, 6]. Future work should evaluate physician adherence to risk-based guidelines [7] and real-world recommendation of LDA in this population. We also echo the call for integrated care across gastroenterology, hepatology, obstetrics, and maternal-fetal medicine [8]. The editorial's proposed strategy in figure 1 outlines actionable steps for risk reduction, including mental health and variceal screening [1]. In our study, women with IBD + CLD had a significantly higher risk of perinatal mood disorders than those with either condition alone [2], and prior work shows elevated risks of mood and anxiety disorders in IBD, particularly postpartum [9]. These observations highlight the need to identify risk factors for perinatal mood disorders in this high-risk population and to test targeted interventions to optimise maternal mental health. Consistent with the elevated risk of portal hypertensive complications we observed [2], structured evaluation for varices during pregnancy should be considered in those with portal hypertension, with timing coordinated by multidisciplinary teams [10]. In conclusion, we appreciate the opportunity to continue this dialogue. We hope our findings, together with the editorial's insights, bring about integrated multidisciplinary care and inform studies to improve outcomes for pregnant patients with coexisting IBD and CLD. Jessica D. Lee: data curation, formal analysis, investigation, methodology, visualization, writing – original draft. Konstantinos Papamichael: methodology, formal analysis, writing – review and editing. Lauren T. Grinspan: writing – review and editing. Adam S. Cheifetz: writing – review and editing, methodology. Melissa Spiel: methodology, writing – review and editing. Tatyana Kushner: methodology, supervision, writing – review and editing. Loren G. Rabinowitz: conceptualization, methodology, supervision, writing – review and editing. This article is linked to Lee et al. papers. To view these article, visit http://doi.org/10.1111/apt.70425 and https://doi.org/10.1111/apt.70444. The data that support the findings of this study are available from Healthcare Cost and Utilisation Project. Restrictions apply to the availability of these data, which were used under licence for this study. Data are available from the author(s) with the permission of Healthcare Cost and Utilisation Project.