Beyond the drug maze: Ustekinumab in ulcerative colitis for a successful pregnancy

Management of ulcerative colitis (UC) during pregnancy poses considerable therapeutic challenges, particularly when patients require biologic therapy and the safety profile in gestation is uncertain. We present the case of a 30-year-old woman with moderate-to-severe UC (E2 disease) who was initially well controlled on tofacitinib but discontinued the drug in view of conception planning. The patient was subsequently treated with steroids and azathioprine; however, therapy was complicated by drug-induced leukopenia, leading to its withdrawal. This was followed by initiation of adalimumab, yet the patient continued to experience an active disease flare, and during this period, the patient suffered a first-trimester spontaneous abortion. Endoscopy at that time revealed deep ulcerations consistent with severe colitis. Given her limited therapeutic options, ustekinumab (UST) was introduced as rescue therapy, and within weeks the patient achieved biochemical and clinical remission. Encouragingly, the patient conceived again while on maintenance UST and her antenatal course was uneventful, with serial scans confirming normal fetal growth. The patient delivered a healthy neonate through elective cesarean section (appearance, pulse, grimace, activity, respiration (APGAR) 9/9, birth weight 3.2 kg) without evidence of malformations. This case underscores the growing evidence supporting UST as a potential therapeutic option in women with refractory UC during pregnancy when alternatives fail.