Author Information
Ruhil MS*, Desai G**, Hatkar PA***, Mayadeo NM****
(* Second Year Resident, ** Assistant Professor, *** Associate Professor, **** Ex-Professor, Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, India.)
Abstract
Celiac disease is a rare autoimmune disorder with multisystem involvement. It has a significant impact on the pregnancy and menstrual health. We present a case of successful pregnancy in a patient of celiac disease.
Introduction
Celiac disease is an autoimmune inflammatory condition with intestinal involvement predominantly. It gets triggered by diet containing gluten.[1] It affects around 0.5-1 % of the general population. Patients may complain of diarrhea, abdominal pain, abdominal bloating and weight loss. Late menarche, secondary amenorrhea, infertility, early menopause, recurrent pregnancy wastage and intrauterine growth restriction are other features of this disorder.[2,3] We present a case of celiac disease in pregnancy and its outcome.
Case Report
A 25 year old woman, married since 2 years, G2SA1 known case of celiac disease, came to the antenatal outpatient department at 7 weeks of gestation for antenatal registration. She had regular menstrual cycles.
At the age of 11 years, she had presented with pain in abdomen, vomiting and confusion, with normal blood pressure. Raised blood sugars (240 mg/ l) and positive urinary ketones suggested ketoacidosis, and diagnosis of type 1 diabetes mellitus was made. She was started on insulin and initiated regular follow up with endocrinologists. Menarche was at 13 years, with no problems. Around 2 years prior to current presentation, evaluation for hypothyroidism revealed positive anti-TPO and anti-TTG antibodies, suggestive of autoimmune thyroiditis. Gastroenterologists were consulted for anti-TTG positivity. She was kept on gluten free diet and duodenal biopsy was performed which showed villi with normal architecture and minimal increase in intraepithelial lymphocytes and mild lymphocytic inflammation in lamina propria. Repeat biopsy was done four months later after keeping her on gluten diet. The villi were found to be of normal architecture, there was patchy increase in intraepithelial lymphocytes and moderate lymphoplasmocytic infiltrates with eosinophils. Hence, she was diagnosed with silent celiac disease and was advised gluten free diet. She continued following up with gastroenterologists also regularly.
Around a year later, she conceived spontaneously. She was admitted in the antenatal ward for management of deranged sugar levels ranging up to 250 mg/ dl. Endocrinologists advised insulin (regular) 8-8-8-8 units and insulin (long acting) 0-0-8 units subcutaneously, with blood sugar monitoring 6 times a day. She was continued on same dose of tablet levothyroxine (25 microgram) and recent TSH value was normal (1.84 U/ L). Renal function tests and detailed neurological examination showed that there were no neurological or renal sequelae. Diabetic retinopathy was ruled out. She also developed acneiform eruptions over face and upper back, which was managed with topical medications. Upon normalization of sugars, she was discharged with antenatal care advise. Hemoglobin level was normal (10.5 mg %). There were no fetal malformations and fetal 2 D echo was normal. She was continued on gluten free diet, and dietician was consulted for specific advice.
She was readmitted at 32 weeks of gestation for evaluation of polyhydramnios (AFI of 25 cms). She was otherwise asymptomatic. Sugars (FBS 72 mg/ dl and PLBS 147 mg/ dl) and HbA1c (5.8) were within normal range. Two doses of steroids injections were given. Dinoprostone gel induction of labor was done at 38 weeks of gestation and sugars levels during labor were well maintained. Healthy female child of 3.5 kg with Apgar score of 9/ 10 was delivered by outlet forceps application in view of fetal distress in second stage of labor. After brief observation period in NICU, baby was shifted back to mother. She was discharged on day 4 of delivery with no complications.
Discussion
Celiac disease is a prototype of malabsorption syndromes and is caused by hypersensitivity to gluten, and gluten free diet is the main treatment. Malnutrition caused by the malabsorption is responsible for the intrauterine growth restriction and still birth. It is crucial for these patients and their fetuses to receive the daily amount of nutrition due to the increased metabolism during pregnancy. Our patient had been on gluten free diet and was continued on the same during pregnancy.
The deficiency of certain essential minor elements and vitamins due to malabsorption may lead to multiple complications. Supplementation of multivitamins throughout the course of pregnancy is necessary. Though newer approaches such as enzymes that can break bonds between proline and glutamine in gluten are being tried, experience in pregnancy is limited.
Celiac disease can present with wide spectrum of clinical manifestations including higher rates of infertility, recurrent abortions, intrauterine growth retardation and still births.[4,5] To screen the patients for celiac disease, the preferred test is the measurement of IgA tissue transglutaminase levels. The diagnosis is confirmed by endoscopic biopsy of small intestine.
There is higher risk of preterm births in celiac disease. Autoimmune responses resulting in increased circulatory antibodies (anti-glial and anti-endomysial) may lead to the premature delivery. Since the disease was under good control, our patient did not have a preterm birth.
Our patient had one prior spontaneous abortion, and no other major obstetric comorbidity in this pregnancy. Reproductive problems such as infertility, congenital anomalies, spontaneous abortions, abruptio placenta, still births and the development of preeclampsia are prevalent.[6] Our patient was not anemic. Iron deficiency may result in increased rates of feto-maternal morbidity and mortality and folate deficiency has been found to cause congenital malformations, abruptio placenta and preeclampsia.[7,8,9] However, this case is presented here to show that early diagnosis and appropriate management can help reduce these complications and entail good pregnancy outcome.
Conclusion
Celiac disease is a malabsorption syndrome resulting from inflammation at the mucosa of the small intestine due to nutrients including gluten, and can have implications on reproductive outcomes in women. Celiac disease can coexist with type 1 diabetes mellitus as seen in this case. Successful obstetric outcome is possible with a multidisciplinary approach involving obstetricians and other specialties. In this case, involvement of the gastroenterologists, endocrinologists and dieticians helped in the overall successful outcome.
References
- Green PH, Cellier C. Celiac disease. N Engl J Med. 2007; 357:1731–43.
- AGA Institute. AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac Disease. Gastroenterology. 2006; 131:1977-80.
- Fasano A, Catassi C. Clinical practice. Celiac disease. N Engl J Med. 2012; 20:2419–26.
- Salvatore S, Finazzi S, Radaelli G, Lotzniker M, Zuccotti GV. Prevalence of undiagnosed celiac disease in the parents of preterm and/or small for gestational age infants. Am J Gastroenterol. 2007; 102:168–73.
- Martinelli D, Fortunato F, Tafuri S, Cinzio AG, Prato R. Reproductive life disorders in Italian celiac women. A case-control study. BMC Gastroenterol. 2010; 10:89–97.
- Choi JM, Lebwohl B, Wang J, Lee SK, Murray JA, Sauer MV et al. Increased prevalence of celiac disease in patients with unexplained infertility in the United States. J Reprod Med. 2011; 56:199–203.
- Jackson JE, Rosen M, McLean T, Moro J, Croughan M, Cedars MI. Prevalence of celiac disease in a cohort of women with unexplained infertility. Fertil Steril. 2008; 89:1002–4.
- Machado AP, Silva LR, Zausner B, de A OJ, Diniz DR, de Oliveira J. Undiagnosed celiac disease in women with infertility. J Reprod Med. 2013; 58:61–6.
- Kumar A, Meena M, Begum N, Kumar N, Gupta RK, Aggarwal S. Latent celiac disease in reproductive performance of women. Fertil Steril. 2011; 95:922–7.
Citation
Ruhil MS, Desai G, Hatkar PA, Mayadeo NM. Management Of Celiac Disease In Pregnancy. JPGO 2018. Volume 5 No.3. Available from: http://www.jpgo.org/2018/03/management-of-celiac-disease-in.html