Salvage therapy for acute severe ulcerative colitis during pregnancy

Abstract

Ulcerative colitis (UC) is a chronic inflammatory bowel disease with an age of onset that affects young people during the peak of their reproductive years. Management of flares of disease during pregnancy can be complex and there are few case reports of pregnant women with acute severe ulcerative colitis (ASUC). We present the case of a 31-year-old pregnant woman who at 16 weeks gestation developed ASUC in the context of primary non-response to infliximab therapy. She subsequently underwent an emergency laparoscopic colectomy after failing to respond to hydrocortisone and cyclosporine salvage therapy. Her pregnancy was further complicated by HELLP (Haemolysis, Elevated liver enzymes and Low Platelets) syndrome resulting in premature delivery at 27 weeks gestation. This case highlights the management issues involved in ASUC during pregnancy and the assessment of disease activity, use of salvage therapies, and provides a framework to approach this complex medical emergency.

Altered bowel habit and rectal bleeding in pregnancy: the importance of recognising undiagnosed inflammatory bowel disease

“…Active IBD pre‐conception and during pregnancy significantly increases the risk of adverse outcomes including stillbirth, pre‐term delivery, low birthweight and postpartum complications 3 . Women with active disease at the time of conception are more likely to have worsening disease activity during pregnancy and postpartum flare in comparison to those in remission 3,4 …”

“…Exposure to radiation during pregnancy is ideally avoided, but if there are systemic features to suggest toxic megacolon, an abdominal X‐ray is warranted 3,9 . Intestinal ultrasound is emerging as a safe modality for the evaluation of colonic disease activity, foetal viability and growth parameters, but is limited for isolated rectal or distal sigmoid disease, and for assessment of the terminal ileum beyond 20 weeks' gestation 3,10,11 . Magnetic resonance imaging without gadolinium is considered safe, but experience in UC remains scant.…”

“…In patients with moderate to severe flares of UC, disease control needs to be prioritised to achieve optimal pregnancy outcomes. Oral prednisolone or intravenous steroids may be used, 3 but exposure to steroids should ideally be minimised with a cautious but rapid wean if possible due to association with gestational diabetes and low birthweight during pregnancy 4,12 . In patients with acute severe ulcerative colitis, intravenous steroids remain first line.…”

“…In patients with acute severe ulcerative colitis, intravenous steroids remain first line. Infliximab and cyclosporin are equally effective as salvage therapy in non‐pregnant steroid refractory acute severe ulcerative colitis patients, 13 with infliximab preferred in pregnancy due to potential for cyclosporin‐induced renal impairment, need for intensive monitoring and metabolic syndrome 2,3,14 . Anti‐TNFα therapy should similarly be considered the first‐line agent in severe steroid refractory UC due to its safety profile 15 .…”

“…Owing to its teratogenic side‐effects and excretion into breast milk, methotrexate is contraindicated during pregnancy and breastfeeding. Its use should be discontinued at least 3–6 months before conception with alternative means to control disease 3,4 . Antibiotics have no established role in uncomplicated UC and should be avoided unless a specific pathogen is identified.…”