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Cyclosporin has been established in the management of steroid resistant severe ulcerative colitis. We read the letter by Dor and Blanshard (Gut 2003;52:1070-a) regarding the severe side effects of cyclosporin used in a patient with steroid resistant severe ulcerative colitis after undergoing emergency Caesarean section. We would like to report our experience of a pregnant patient with steroid resistant severe distal ulcerative colitis in whom remission was induced with cyclosporin. She delivered a healthy baby at 34 weeks.
A 36 year old woman presented for the first time with a five week history of bloody diarrhoea and mucus discharge in the 12th week of her first pregnancy. Ulcerative colitis was confirmed on flexible sigmoidoscopy and histology. She was started on mesalazine (Pentasa) 1 g twice daily orally and Pentasa enema was added subsequently. She failed to respond well to oral prednisolone (40–60 mg daily) for five weeks or to subsequent intravenous prednisolone given for a further two and a half weeks. Azathioprine (oral 150 mg daily) was also added. Repeat sigmoidoscopy confirmed severe distal colitis with ulceration. At the 23rd week of pregnancy, she was started on intravenous cyclosporin (2 mg/kg) with careful monitoring of serum levels. Significant improvement was noted in two weeks, after which cyclosporin was changed to the oral route. Steroids were gradually tapered to 2.5 mg daily. At 34 weeks she underwent an emergency Caesarean section because of antepartum haemorrhage and a healthy baby girl (birth weight 2.07 kg) was delivered. Two weeks later, cyclosporin was weaned off after minimal rise of serum creatinine that coincided with high serum cyclosporin levels. Her serum creatinine normalised four weeks later. She and baby remained well on azathioprine and mesalazine 14 weeks after delivery.
Intravenous cyclosporin induced remission in our pregnant patient who had failed to respond to high dose oral and intravenous prednisolone. Colectomy and the associated potential complications in pregnancy were avoided. There is only one other case report in the literature1 where cyclosporin was used in similar circumstances. While we would agree that cyclosporin should be used cautiously in pregnancy, our positive experience, and that of Bertschinger and colleagues,1 suggests that cyclosporin may induce remission and avoid colectomy during pregnancy.
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