Navigating the double-edged sword: Ulcerative colitis and pregnancy-balancing maternal and fetal health: A case series

Background: Ulcerative Colitis (UC) commonly affects women during their reproductive years, complicating pregnancy when disease activity flares. Acute severe ulcerative colitis (ASUC), particularly toxic megacolon or fulminant colitis, represents a life-threatening complication that challenges obstetric and surgical decision-making due to dual maternal and fetal considerations.Case Series: We describe two contrasting presentations of ASUC in pregnant patients requiring urgent surgical intervention. The first case involved a 34-year-old woman at 36 weeks gestation with perforated toxic megacolon, initially misdiagnosed as placental abruption. She underwent emergency caesarean delivery followed by intraoperative identification of sigmoid perforation, necessitating total colectomy and ileostomy. Her postoperative course included multiple staged procedures, culminating in successful ileostomy reversal.The second case describes a 35-year-old woman at 10 weeks gestation with fulminant UC complicated by steroid-induced cytomegalovirus colitis. Despite escalated medical therapy, she required a subtotal colectomy and ileostomy at 16 weeks. She achieved a successful vaginal birth after caesarean at term and underwent restorative proctocolectomy postpartum without complications.Discussion: These cases illustrate the diagnostic and therapeutic complexity of ASUC in pregnancy, especially in settings where atypical presentations and overlapping obstetric conditions may delay definitive care. Early multidisciplinary team involvement, including gastroenterology, obstetrics, colorectal surgery, and infectious disease specialists, is essential. Surgical timing should prioritize maternal stabilisation while considering gestational age and fetal viability. Midline laparotomy is often the optimal approach in undifferentiated acute abdomen in pregnancy to accommodate both fetal delivery and abdominal exploration.Conclusion: This series emphasizes the importance of preconception counselling, prompt recognition of ASUC, and individualized, multidisciplinary care to optimise maternal and fetal outcomes. It highlights the need for increased awareness and development of standardised management strategies for IBD emergencies in pregnancy.