Case History/examination:
A woman in her 20s with left-sided UC (Montreal E2) treated with
tofacitinib 10mg twice daily presented to our clinic after having a
positive pregnancy test. Her beta-human chorionic gonadotropin level was
18477 IU/L; an ultrasound confirmed pregnancy with a gestational age of
six weeks.
She was diagnosed with UC at the age of 8 years and was initially
treated with mesalazine until adolescence. Azathioprine was added due to
active colitis following the transition to the adult IBD clinic but was
ceased after the development of acute pancreatitis. She developed severe
allergic reactions to both infliximab and adalimumab. She responded well
to intravenous vedolizumab 300mg 8-weekly. However, the patient stopped
attending vedolizumab infusions due to poor venous access in 2018 before
the availability of subcutaneous vedolizumab. Six months after
non-adherence, she presented with acute severe UC that failed to respond
to intravenous hydrocortisone 100mg 4 times daily. She responded to
intravenous ciclosporin 4mg/kg infusions but was complicated by a
seizure necessitating ciclosporin cessation. Tofacitinib 10mg twice
daily was initiated, which led to significant clinical improvement. When
tofacitinib dose was reduced to 5mg twice daily, she relapsed with an
increase of faecal calprotectin to 907ug/g. Flexible sigmoidoscopy
showed Mayo 1 left-sided colitis. Tofacitinib dose was increased to 10mg
twice daily, which recaptured remission. The patient was in a stable
relationship and was advised against pregnancy whilst taking
tofacitinib, and she agreed to use contraception.
Six months into maintenance treatment on tofacitinib, the patient
performed a pregnancy test due to amenorrhea, which returned a positive
result. First-trimester ultrasound confirmed the gestational age of 6
weeks.