It’s a decision women probably thought they’d never have to make: to get a newly developed vaccine while pregnant with a chronic illness in the middle of a pandemic, or not. As a mom of two toddlers living with Crohn’s disease, with baby No. 3 due in July, the decision is weighing heavily on me. And I find that the decision is reminiscent of life with an inflammatory bowel disease (IBD). Whether it’s starting a new medication or going through a procedure, I’ve been weighing the risk and benefits of my health choices since being diagnosed with Crohn’s disease in 2005.
I’m currently in my second trimester, and live in Missouri where all pregnant women are now eligible to receive the COVID vaccine. I’ve had conversations with my gastroenterologist, my ob-gyn, and my maternal fetal medicine doctors. I expressed my concerns to them that I’m a bit nervous to receive the vaccine while pregnant. I also let my care team know that as a stay-at-home mom who has been keeping a low profile since March 2020, I don’t feel I’m at high risk for exposure. Each physician on my care team understood my hesitation and given my personal situation, they agreed it would be okay for me to wait to get the vaccine until my baby boy arrives this summer.
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Even given this go-ahead, I still grapple with the dilemma daily and wonder if I’m making the best decision for myself and for my unborn child. For additional guidance, I turned to Uma Mahadevan, MD, a gastroenterologist and codirector of the Colitis and Crohn’s Disease Center at the University of California in San Francisco. Dr. Mahadevan has a special interest in pregnancy and fertility in IBD. Currently, she leads the U.S. Pregnancy in Inflammatory Bowel Disease and Neonatal Outcomes (PIANO) study, which looks at pregnancy outcomes and drug safety in women with IBD on immunosuppressive and biologic medications. I am participating in the PIANO registry right now and grateful for all the research being done on pregnant women with IBD who are bringing babies into this world.
I asked Mahadevan how she’s navigating conversations with her patients regarding the COVID-19 vaccine. “This comes up frequently now that the vaccines are available,” she said. “Pregnant women overall are at increased risk of severe illness from COVID-19 (intensive care unit stay, need for mechanical ventilation and death) compared with the general population. While IBD itself does not seem to increase risk, pregnancy does,” she said. “The American College of Obstetrics and Gynecology (ACOG), Advisory Committee on Immunization Practices (ACIP) and the CDC all recommend that pregnant and lactating women should be offered the vaccine.”
Ideally women should get vaccinated prior to pregnancy, but if that did not happen, pregnant women have the choice of whether to get vaccinated. Whether you’re on immunosuppressant medication like me, or you’re not, Mahadevan believes all women should get vaccinated.
“The recent International Organization for the Study of Inflammatory Bowel Disease (IOIBD) statement published in GUT recommends that all IBD patients get vaccinated regardless of medication being used, timing of medication, and disease activity,” she said. “It’s believed steroids may diminish response to the vaccine.”
“If pregnant women with IBD already have more adverse pregnancy outcomes than the general population and you add in the increased events with COVID, then the risks of the vaccine are outweighed by the benefit to the patient by protecting them from COVID,” explained Mahadevan. “The vaccines available now are inactive, meaning a patient on immunosuppression and who is pregnant should be able to get them just like they get the influenza and TDAP vaccines.”
The Science and the Safety
Speaking of immunosuppression, I have been taking Humira injections since 2008. I’ve followed doctors’ orders with all my pregnancies to stay on my medication until 37 weeks. Even though I know I’m doing what’s best for my and my baby’s health, I wrestle with guilt and worry about injecting a biologic medication into my body while there’s a life growing inside. My son will already be immunocompromised the first six months of his life, because of my medication. Knowing that makes me hesitant to add anything extra or an additional variable into my body.
“Nothing is 100 percent safe and there is a lot of misinformation out there,” Mahadevan said. “As when choosing medications for IBD, choosing to vaccinate means understanding the risk of the disease (COVID) to your pregnancy versus the risk of vaccination. Talk to your doctor, particularly your maternal fetal medicine specialist or your IBD gastroenterologist, who should be the best equipped to answer your questions.”
While Mahadevan is of the belief that everyone should get vaccinated when it is their turn so we can return to normal life sooner than later, she understands a stay-at-home mom like me is at lower risk for COVID-19 than someone who is working in healthcare or in an office. She recommends pregnant women who choose to wait to get the vaccine to social distance and isolate more strictly than the average person given the increased risk.
Breastfeeding and the COVID-19 Vaccine
The other hot button issue is if mothers feel comfortable getting vaccinated during breastfeeding, since lactating women were not included in clinical trials. According to the CDC, it is an appropriate time to do so. If not, postpartum mothers are recommended to isolate during the newborn period, as newborns seem to be at higher risk for bad outcomes from COVID-19 compared with those who are 1 year or older, Mahadevan said.
When receiving the vaccine, the mRNA protein particles get absorbed into our muscle cells at the injection site, making it unlikely to get into breast milk. Any small mRNA particles that reach the breast milk would likely be digested. According to the Academy of Breastfeeding Medicine, there is no need to avoid initiation or discontinue breastfeeding in patients who receive a COVID-19 vaccine. When a person gets vaccinated while breastfeeding, their immune system will form antibodies against COVID-19. Those antibodies can then be passed through breast milk to the baby.
Personally, I plan to breastfeed and get the vaccine after delivery. I feel a lot more at ease knowing my son will be out of my body, but still able to receive the nourishment and benefits of boosting his immune system. I continued my Humira injections while nursing my daughter, and plan to do the same with this baby. I’ll also be submitting samples of my breastmilk to the PIANO study and look forward to learning more about how my medication and the vaccine shows up exposure-wise in my breast milk.
If you’re pregnant and have IBD and are interested in contributing to science, you can participate in the PIANO registry. You can do so by emailing piano@ucsf.edu. The registry is also tracking COVID-19 vaccine response in pregnant women. If you’re an IBD mom who gets vaccinated in pregnancy your cord blood can help paint a clearer picture of how the antibodies are transferred.The SECURE IBD Registry is also tracking all IBD patients who get COVID.
