Jump to comment:

• Prevention of abortion by cyclosporine treatment of fulminant ulcerative colitis during pregnancy
  Sieglinde Angelberger
  Published on: 28 February 2006

• Published on: 28 February 2006

  Prevention of abortion by cyclosporine treatment of fulminant ulcerative colitis during pregnancy

  • Sieglinde Angelberger, MD
  • Other Contributors:
    • Walter Reinisch, Clemens Dejaco

  Dear Editor,

  Cyclosporine (CsA) is an established treatment in severe, intravenous- corticosteroid-resistant ulcerative colitis (UC). Although one third of UC patients relapse during pregnancy, experience with CsA use during this period is limited to a few case reports.[1][2] Most of the available data on CsA administration and pregnancy outcome have been obtained from the transplantation literature.[3] We read the...

  Show More

  Dear Editor,

  Cyclosporine (CsA) is an established treatment in severe, intravenous- corticosteroid-resistant ulcerative colitis (UC). Although one third of UC patients relapse during pregnancy, experience with CsA use during this period is limited to a few case reports.[1][2] Most of the available data on CsA administration and pregnancy outcome have been obtained from the transplantation literature.[3] We read the letter of Jayaprakash et al. who described the case of a patient with fulminant corticosteroid-resistant distal UC successfully treated with CyA and delivering a healthy baby.[2]

  Herein we report the dramatic case of a 21-year-old primigravida with the diagnosis of UC since April 2000 who experienced a fulminant flare at the end of her first trimester despite immunosuppressive treatment and whose pregnancy could only be preserved by i.v. CsA therapy. At time of conception in June 2003 the patient was in stable clinical remission, receiving 40mg/d of thioguanine, 2g/d of mesalamine and 50mg/d of sertraline due to chronic active disease resistant to azathioprine. In the 13th gestational week the patient was admitted to hospital because of a fulminant relapse of ulcerative colitis despite 50 mg oral steroids which had been self-administered for 1 week. At admission laboratory tests showed C-reactive protein level of 9.36mg/dl and hemoglobin of 8.9g/dl. Thioguanine was discontiunued and after the patient had failed to respond to intravenous prednisolone at a dose of 75 mg for 9 days abortion was discussed but declined by the patient. Therefore intravenous cyclosporine at a dosage of 2mg/kg/d was started. Careful monitoring of creatinine and serum CsA levels leading to levels of 200-300 ng/ml was done and repeated sonography of the foetus was performed. Erythrocyte concentrates were required due to progressive anemia. Induction of response was delayed resulting in an unusual long term CsA treatment period of 3 weeks. The symptoms of UC improved, CyA was switched to oral administration (100mg b.i.d.) and the patient was discharged after 5 weeks, although complete remission was never achieved. Besides the occurrence of hypertrichosis CsA was well tolerated by the patient. In the 29th gestational week, a cesarean section was necessary because of premature rupture of fetal membranes and growth retardation. The patient delivered a female baby with a birth weight of 893g and a length of 35 cm (APGAR: 9/10/10). Typical problems of preterm births such as respiratory distress syndrome, acute enterocolitis necroticans, sepsis and anemia were successfully handeled at the ICU and the girl had a normal growth and development further on. Echocardiography detected a peripheral pulmonary artery stenosis and a small ASD II which regressed and spontaneously occluded after 10 months of birth, respectively. Two small hemangiomas on the head and back were also found but became smaller in size. After discontinuation of cyclosporine postpartum symptoms of UC deteriorated the mother’s condition beyond control by conservative measures. Colectomy with ileostomy was performed in June 2004. Currently the patient is pregnant again, and mother and foetus are in good health.

  While standard medication like 5-ASA, azathioprine / 6-mercaptopurine, and corticosteroids are considered to be safe in the treatment of ulcerative colitis during pregnancy, administration of CsA is discussed controversially. Intravenous CsA considerably improved symptoms of UC in our patient without major toxicity. The premature delivery with all its consequences could be related to deterioration of UC or CsA therapy, as both reported in literature, whereas the role of thioguanine still remains unclear. However, due to CsA treatment the pregnancy could be prolonged and the foetus reached a gestational age which allowed an alive delivery. Acute colectomy, which is associated with a tremendous maternal and fetal risk, could be avoided.[4] On account of this positive experience and the available data so far we believe that CsA treatment should be considered as last medical resort to prevent medical abortion in fulminant UC during pregnancy.

  References

  1 Bertschinger P, Himmelmann A, Risti B, et al. Cyclosporine treatment of severe ulcerative colitis during pregnancy. Am J Gastroenterol 1995;90(2):330.

  2 Jayaprakash A, Gould S, Lim AG, et al. Use of cyclosporin in pregnancy. Gut 2004;53(9):1386-7.

  3 Armenti VT, Ahlswede KM, Ahlswede BA, et al. National transplantation Pregnancy Registry--outcomes of 154 pregnancies in cyclosporine-treated female kidney transplant recipients. Transplantation 1994;57(4):502-6.

  4 Willoughby CP, Truelove SC. Ulcerative colitis and pregnancy. Gut 1980;21(6):469-74.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top