S4954 Acute Severe Ulcerative Colitis in Pregnancy Requiring Surgery (Ileostomy)

Introduction: Managing ulcerative colitis (UC) during pregnancy poses a unique challenge. Goals of treatment include adequate disease control and ensuring optimal maternal and fetal health and development. Uncontrolled UC during pregnancy is a strong predictor of poor pregnancy outcomes, including preterm birth, low birth weight, and spontaneous abortion. We describe a 29-year-old woman G3P2 with medically refractory, acute, severe UC during her second trimester of pregnancy. Case Description/Methods: A 29-year-old woman, with a 13-year history of UC presented to the inflammatory bowel disease Clinic at 14-weeks of pregnancy with a 6-month history of up to 15 loose, bloody stools daily, severe abdominal pain, and weight loss. Previous failed therapies included mesalamine, adalimumab, vedolizumab, tofacitinib, and ustekinumab. At presentation, she was on mesalamine monotherapy with markedly elevated serum inflammatory markers (erythrocyte sedimentation rate 33 mm/hr, C-reactive protein 5.3 mg/dL). A steroid taper was initiated to induce clinical remission. Due to her history of secondary loss of response to anti-tumor necrosis factor therapy and now, steroid-refractory disease, she underwent a diverting ileostomy and appendectomy at 15 weeks’ gestation, which resulted in clinical improvement. The 65-minute surgery avoided the hours-long colectomy, with an uneventful 4-day stay. She ultimately delivered a healthy 8lb 6oz (3.8 kg) fetus at full term. She declined a staged J-pouch and opted for robotic total proctocolectomy with permanent end ileostomy. Discussion: Our case highlights the value of diversion as a rescue surgical intervention for acute, severe UC. Although the typical management of medically refractory UC involves colectomy and multistage ileoanal pouch construction, in our case involving a gravid patient, a less-involved surgery was preferred to minimize both maternal and fetal surgical risks. While there have been several reports of diverting ileostomy as a safe and effective temporizing measure for medically refractory inflammatory bowel disease, to our knowledge, this is the first case describing its use in a pregnant patient. Recent reports indicate appendectomy as a potential therapeutic intervention for inducing remission in patients with UC especially in medically refractory disease. Emerging data from the PASSION study demonstrated that appendectomy resulted in clinical response in about 30% of patients with medically refractory UC. In addition, a systematic review and meta-analysis also showed that an appendectomy may reduce the risk of future colectomy.