US supreme court decision: the gastroenterological perspective.

Recent US supreme court decision in the matter of Dobbs v. Jackson Women’s Health Organization will have a tremendous effect on medical practice in upcoming years. Naturally, Obstetrics and Gynecology is the prime influenced medical field. However, this decision will have a wide range of effects on all modalities and medical disciplines. Gastroenterologists will have to face some critical issues while making therapeutic recommendations for patients with childbearing potential.

As the right to perform a legal abortion will be restricted, the price of an unplanned pregnancy might become unacceptably high for the patient, including birth defects and the risk of internal injuries, aggressive infections, and maternal death in cases of attempts to perform illegal procedures.

One of the most relevant issues is the therapeutic approach to chronic disease patients, the most common in the field is inflammatory bowel disease (IBD).

As the incidence and prevalence of IBD rises significantly in recent years, and since the diseases affect both genders equally and tend to affect patients during their reproductive years, we are now facing a new set of considerations while trying to make therapeutic decisions.

The first point is the use of potentially teratogenic therapies while treating patients with childbearing potential. To date, most medications are considered safe. Only methotrexate, tofacitinib, and the newly FDA-approved upadacitinib are potentially harmful to the fetus. Current medical practice is to inform patients about the potential risk and emphasize the importance of strict birth control.

However, things can go wrong, and patients might experience unplanned pregnancies. Furthermore, methotrexate has also paternal teratogenicity, and patients are instructed to stop treatment at least 3 months prior to conception. Therefore, in the light of the Supreme Court decision – should we completely avoid these medications in patients with childbearing potential?

Another critical issue is the use of investigational drugs. Currently, there are many new therapeutic IBD treatments in the pipeline and most of them are presently under clinical trials. Clinical trials are usually offered to patients who have severe disease, after failure of previous treatments. Since the effect of these investigational therapies on the fetus is unknown, patients with reproduction potential are instructed to maintain strict birth control measures and the occurrence of pregnancy is monitored frequently during the study. However, pregnancies do occur even during clinical trials. Therefore, again – this raises the question – should we avoid including patients with reproduction potential in clinical trials? Obviously, excluding these patients will have a major effect on future clinical trials and the development of new therapeutic options.

A different point is the efficacy of oral contraceptives in patients with decreased bowel absorption. This can affect not only IBD patients but also many other patients suffering from malabsorption. These patients should be aware of the risk, and a different birth control method should be considered.

Other aspects include management of patients with chronic disease exacerbation during pregnancy – this involves not only IBD, but also patients with chronic liver disease and other chronic conditions – what should be our treatment limitations? In case the prognosis of the mother is deeply affected by the pregnancy – what should be the choice?

All these questions, and probably many others, will apparently become very acute and bothersome in the light of the recent Supreme Court’s reversal of Roe v. Wade decision, and will necessitate applying of a new set of considerations, which are far beyond the current medical practice.