Fecal Calprotectin in Pregnancy

To the Editor: Active inflammatory bowel disease (IBD) is associated with adverse pregnancy outcomes, necessitating close monitoring of these higher risk pregnancies. However, there have been limitations in the available evidence to support the use of traditional noninvasive methods of monitoring activity beyond symptoms in pregnancy.1 Although fecal calprotectin does not seem to change from the physiological changes of pregnancy2 and in a small study of 17 patients correlated with symptom based disease activity,3 two larger studies of 33 and 75 patients respectively found that fecal calprotectin during pregnancy correlated poorly with disease activity.4,5 We thank Julsgaard et al for their addition to the small number of studies to date considering objective disease monitoring in pregnant women with IBD. Their publication, titled “Fecal Calprotectin Is Not Affected by Pregnancy: Clinical Implications for the Management of Pregnant Patients with Inflammatory Bowel Disease”3 provides evidence that pregnancy alone does not affect fecal calprotectin (FC), contrasting the potential variations due to the physiological change in pregnancy seen with the use of other biomarkers, such as C-reactive protein and albumin.4 It is essential that disease monitoring continues to occur in pregnancy, particularly given the potential detrimental impact of disease activity on maternal and fetal outcomes.5 Furthermore, as it is not appropriate to perform repeated endoscopic assessment during pregnancy, FC may be even more important than in the nonpregnant patient, whereas it also enables ongoing management with a treat-to-target strategy. Accordingly, at the Vancouver IBD and pregnancy clinic, all patients are monitored during their pregnancy with routine FC with an additional calprotectin performed at the time of an increase in symptoms or de-escalation of medical therapy. For example, during her second trimester, a patient developed nonspecific abdominal pain on the background of ceasing her adalimumab in the first trimester. As we had a normal FC in early pregnancy, when her repeat FC was reported at >1000 μg/g we were able to better inform her on reinitiating her biologics during pregnancy. Further support for our proactive strategy of noninvasive disease activity monitoring during pregnancy has been provided by the findings of Julsgaard et al in their multicenter, international prospective observational study which assessed FC in women during pregnancy with or without IBD. FC concentrations were correlated with CRP, clinical activity indices and physician global assessment. A statistically significant difference was found between the median FC in the control and IBD groups, whereas unlike for CRP, a correlation was also shown in women with active disease compared to those in sustained remission. Although there remains a need for further confirmatory studies, such results have provided more evidence for the use of FC during pregnancy, which we believe to be an integral component in the management of IBD in pregnancy.

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