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Background
Acute severe ulcerative colitis occurs in 20% of patients during the course of their disease. 1 A third of patients do not respond to first line therapy with hydrocortisone and fifty percent of patients do not respond to cyclosporine or infliximab salvage therapy. 2 Up to thirty percent of patients require emergency colectomy within 3 months of their admission. 1 The risk of a significant flare of ulcerative colitis is increased especially after delivery but can occur at any time during pregnancy. 2 3 A severe flare of UC during pregnancy poses significant risks to both mother and fetus. 4 5 Active disease in pregnancy is the biggest driver of adverse outcomes such as an increased incidence of stillbirth, preterm delivery and postpartum complications for both the mother and neonate. 6-8
The literature regarding the optimal management of ASUC during pregnancy is limited. There are few case reports describing the outcomes of salvage therapy and surgery for refractory ulcerative colitis in pregnancy. Although surgery should only be undertaken in an emergency situation for ASUC during pregnancy we sought to provide a framework for the management considerations associated with this medical emergency during pregnancy to minimise the risk to the mother and baby.
Case presentation
A 31year old woman G1P0 (16/40) with a 3year history of chronic active ulcerative colitis refractory to aminosalicylate (4g/day), azathioprine (150mg/day) and infliximab induction therapy (administered at weeks 0,2 and 6) presented to antenatal clinic at 16 weeks gestation with a flare of disease activity which was characterised by increased stool frequency up to 10 bowel actions per day, bloody diarrhoea, 'crampy abdominal pain', fevers and chills. She had lost 10kg of weight over the preceding 2years. There was no significant past history nor was there a family history of inflammatory bowel disease (IBD). On presentation she was febrile to 38 degrees Celsius, with a PR 90 bpm and a BP 102/70. She appeared cachectic. Abdominal and cardio-respiratory examination were unremarkable. Fundal height was 16cm and the fetal heart rate was auscultated at 140 beats per minute.
Investigations
On admission routine blood tests indicated: severe anaemia - Hb 52 (115-165g/L); leucopenia - white cell count 2.6 (4.0-11×10*9/L); Platelets 289 (150 - 400), and; hypoalbuminaemia - albumin - 17 (35-52g/L); C-Reactive...