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.