Steroid-Refractory Warm Autoimmune Haemolytic Anaemia Complicating Ulcerative Colitis in Pregnancy: A Case Report and Management Considerations

Autoimmune haemolytic anaemia (AIHA) arising in pregnancy is an exceptionally rare condition, and its concurrence with active ulcerative colitis (UC) presents considerable diagnostic and therapeutic complexity. We describe a 30-year-old primigravida who presented at 12 weeks' gestation with severe symptomatic anaemia (haemoglobin 4.4 g/dL), serologically confirmed warm AIHA (strongly positive direct antiglobulin test, IgG-mediated), and concurrent gastrointestinal haemorrhage attributable to an acute flare of UC. High-dose corticosteroid therapy failed to achieve a durable response, and the patient developed steroid-refractory disease characterised by recurrent haemolytic episodes necessitating repeated red cell transfusion. Infliximab was initiated for refractory colitis but was rendered ineffective by the development of anti-drug antibodies. Subsequent therapeutic escalation comprised intravenous immunoglobulin, rituximab, azathioprine, and darbepoetin alfa; vedolizumab was later introduced to achieve intestinal remission. Following rituximab administration, haemoglobin stabilised progressively, transfusion dependence resolved, and haemolysis indices normalised, notwithstanding persistent direct antiglobulin test positivity. By 32 weeks' gestation, haemoglobin had risen to above 10 g/dL with complete clinical remission of haemolysis. Delivery was expedited at 35 weeks' gestation by caesarean section owing to superimposed pre-eclampsia; no haemolytic relapse was observed in the peripartum period. The neonate was admitted to the neonatal intensive care unit for three weeks due to respiratory distress syndrome but demonstrated no evidence of haemolysis or neonatal alloimmune or autoimmune complications. This case illustrates that UC-associated, steroid-refractory AIHA in pregnancy, whilst rare, is amenable to successful management through timely escalation to biologic and immunosuppressive therapy, judicious use of erythropoiesis-stimulating agents to minimise transfusion burden, and close multidisciplinary collaboration between haematology, gastroenterology, and maternal-foetal medicine, with favourable maternal and neonatal outcomes achievable.