S2301 COVID-19 and Ulcerative Colitis in Pregnancy

Abstract

INTRODUCTION: Impacts of the novel Coronavirus (SARS-CoV-2) are widespread, range in severity, and vastly unknown. Inflammatory bowel disease (IBD) patients are often treated with immunosuppressive medications which can increase risk of viral infections and associated morbidity and mortality. We present a case of a pregnant patient with pan-colonic ulcerative colitis (UC) who was infected with SARS-CoV-2. CASE DESCRIPTION/METHODS: A 29-year-old female with pan-colonic UC, at 22 weeks’ gestation, presented with bloody diarrhea, fecal urgency, and incontinence. She was diagnosed in 2015 and established care with us in 2018 while on balsalazide. During initial attempt to stage her UC with a colonoscopy, she became pregnant but unfortunately had a miscarriage. Her colonoscopy revealed Mayo 1 activity in the left colon with decreased vascular pattern (Figures 1 and 2). She had a disease flare 1 year ago which resolved with transrectal 5-mesalamine. During a pre-conception planning IBD visit, given her clinical course (disease flares, lack of complete mucosal healing with moderate histological activity), targeted immune-modifying biologic was recommended. After much discussion, she elected to stay the course with close surveillance. Her current presentation was consistent with another disease flare. Evaluation revealed fecal calprotectin of 700.4mcg/gm and CRP of 14.4mg/L with negative C. diff testing. She was started on budesonide 9mg daily, however due to persistent symptoms 2 weeks later, was switched to prednisone 40mg daily with clinical response within 72 hours. One week later, she developed rhinorrhea and myalgias and tested positive for SARS-CoV-2. As she was clinically stable, she was advised to self-quarantine without need for hospitalization. Prednisone dose was immediately decreased to 20mg daily with a 4-week taper. The UC flare symptoms resolved and her viral symptoms improved after 3 weeks. She is currently back to her baseline health with no known adverse effects to her pregnancy, which is currently at 38 weeks’ gestation. With collaboration with her obstetrics team, the decision was made to proceed with vedolizumab after delivery. DISCUSSION: Pre-pregnancy IBD control is predictive of IBD-related pregnancy outcomes. Our case demonstrates treatment of an intrapartum UC exacerbation in the setting of maternal infection with SARS-CoV-2. Cautious treatment of maternal IBD is necessary. A multidisciplinary approach between IBD gastroenterology and Obstetrics is critical in safely managing these patients.Figure 1.: Decreased vascular pattern seen in the rectum on white light (left) and narrow-band imaging (right).Figure 2.: Mucosal erythema demonstrated in the sigmoid colon.