New‐onset ulcerative colitis in pregnancy associated to toxic megacolon and sudden fetal decompensation: Case report and literature review

Abstract

Ulcerative colitis (UC) is a chronic inflammatory disease rarely arising during gestation. Because the available information is based on case reports or small retrospective studies, diagnosis may be difficult and treatment is still controversial. A case of toxic megacolon developing in late pregnancy associated to a sudden fetal decompensation is described. Diagnostic and clinical topics of acute UC onset in pregnancy are debated.A primipara, 34 years old, 33/0 weeks of gestation, was admitted with a diagnosis of preterm labor, associated to acute bloody diarrhea (up to 10 daily motions) and cramping abdominal pain. A diagnosis of new‐onset early‐stage UC was made by sigmoidoscopy. An intensive care regimen including hydrocortisone, antibiotics and parenteral nutrition was immediately started. Magnetic resonance imaging of maternal abdomen, fostered by the worsening patient conditions, evidenced dilatation of the entire colon and a severely hampered of fetal muscular tone.Toxic megacolon complicated by superimposed Clostridium difficile infection was associated to a sudden fetal decompensation diagnosed by chance during maternal abdominal magnetic resonance imaging. An emergency cesarean section was mandatory. According to a senior surgeon's decision, total colectomy was not immediately performed following cesarean section with reference to the absence of colonic perforation. We obtained a good short‐term maternal outcome and an uncomplicated neonatal course. Counseling of those patients must be focused on timely and multidisciplinary intervention in order to improve the course of maternal disease and to prevent fetal distress.

Megacolon in Primigravida During Second Trimester: A Case Report

“…The first-time attack of UC is rather uncommon during pregnancy but not completely unheard of. Like our case, Brunelli R and colleagues and Orabona R and his colleagues also described similar cases [8,10].…”

“…Although an MRI scan is a safer option in pregnant women compared to CT scans, in our case, as per the recommendation of the multidisciplinary team, a contrast-enhanced CT scan was performed for better evaluation of the condition (intestinal perforation, if any). Similar to our case, Brunelli R and colleagues described a case of toxic megacolon and sudden onset of fetal decompensation in a pregnant woman who was diagnosed with new-onset UC during the third trimester [8].…”

Management of Pregnant Women Hospitalized with a Flare of Inflammatory Bowel Disease

“…New-onset IBD is rare in pregnancy. Evidence for this is mostly based on case reports and small case series [7,[10][11][12][13][14][15][16][17][18][19]. It has however been associated with significantly poor outcomes including miscarriage, intrauterine death, abortion, Cesarean section, preterm delivery, fetal retinopathy, and toxic megacolon.…”

“…Many of these reported cases are outdated, and one can presume that there are better outcomes due to improvements in IBD therapy and more coordination between multidisciplinary teams; however further studies in this regard are needed. As per Brunelli et al, it is felt that prevention of complications from new-onset IBD during pregnancy can be limited by early flexible sigmoidoscopy in patients with bloody diarrhea [19,20], intense fetal monitoring, and an awareness that fever in pregnancy may be blunted due to decreased maternal core temperature [21], increased levels of placenta-derived anti-inflammatory factors, and altered brain sensitivity to fever inducing prostaglandins [22].…”