Introduction

Definition of coeliac disease

Coeliac disease happens when the body's defence system attacks itself after eating gluten, causing damage to the gut and making it difficult for the body to absorb nutrients. Signs of the condition include diarrhoea, stomach ache, and feeling bloated. Gluten is present in wheat, barley, rye, pasta and bread. Both genetic and environmental factors play a role in causing this condition.¹

Importance of managing coeliac disease during pregnancy

Pregnant women with coeliac disease must adhere to a strict gluten-free diet, attend regular check-ups, and consider taking calcium, iron, and vitamin B12 supplements. It is crucial to consult a dietitian to ensure proper nutrient intake for both the mother and the baby.²

Understanding coeliac disease

Pathophysiology

Coeliac disease occurs when the body's immune system reacts badly to specific components of gluten. This reaction can cause damage to the intestines, making them more permeable and causing inflammation. Some of the main things that happen in coeliac disease are that the cells in the intestines get shorter, the crypts in the intestines grow too much, and the villi get damaged. There's also an increase in certain types of immune cells in the intestines.³

Symptoms

The symptoms of coeliac disease can vary widely. Possible symptoms include:

• Stomach pain
• Bloating
• Gas
• Constipation
• Diarrhea
• Fatty stools

Other symptoms include weakness, fatigue, pale skin, cold hands, brittle nails, mouth sores, unintended weight loss, growth delays, muscle wasting, dental enamel defects, abnormal periods or difficulty getting pregnant, mood changes, and dermatitis herpetiformis - a chronic skin condition.⁴

Diagnosis of coeliac disease

Screening and testing

Healthcare providers use two methods to check for coeliac disease. 

First, they test a blood sample to look for gluten antibodies that harm your intestines. Then, if needed, they take a small tissue sample from your small intestine (biopsy) to check for damage under a microscope.

A gastroenterologist examines your small intestine. The endoscope is gently passed through your mouth and into the first part of your small intestine. Once coeliac disease is confirmed, your provider will test your blood for specific vitamin and mineral deficiencies. Severe deficiencies may have broad effects on your body and may require direct treatment with supplements. Typical findings include iron-deficiency anaemia, vitamin deficiency anaemia, vitamin D deficiency, and low electrolytes such as calcium.⁴

Diagnosis during pregnancy

Untreated maternal coeliac disease can lead to pregnancy complications such as low birth weight, intrauterine growth restriction (IUGR), and preterm birth. Having untreated coeliac disease during pregnancy can increase the risk of perinatal mortality and morbidity. It can also have long-term effects on the child's health. Some research based on Swedish and Danish population registries has shown that untreated coeliac disease causes a reduction in the average birth weight and an increased likelihood of the baby being small for gestational age and being born prematurely. However, this study did not find any association with treated coeliac disease. 

Additional evidence from Swedish and Danish studies has shown that undiagnosed coeliac disease can cause adverse pregnancy outcomes, including an increased risk of intrauterine growth restriction (IUGR), low birth weight, very low birth weight, and premature birth. Once again, the study did not find any associations in the treated coeliac disease group. Another study, taking into account factors such as maternal height and weight, demonstrated that women with undiagnosed coeliac disease had a significantly higher risk of delivering a baby that was small for gestational age.⁵

Nutritional management

Gluten-free diet

Cutting out gluten from your diet may seem challenging, but there are many healthy and delicious gluten-free options. Focus on naturally gluten-free food groups like fruits, vegetables, meat, poultry, fish, seafood, dairy, beans, legumes, and nuts. In supermarkets, you can also find gluten-free grains like quinoa, rice, and millet. Always read labels carefully and stick to fresh, minimally processed foods. It's important to choose grains tested for gluten presence and to opt for naturally gluten-free beverages.⁶

Nutritional requirements in pregnancy

It is crucial to remember the following guidelines for healthy eating during pregnancy:

• Make sure to eat regular meals and snacks and only go for a short time without eating. Base your meals on a variety of food groups and consider adding more protein and wholegrain carbohydrates for extra energy
• Stay hydrated by drinking at least 1900ml of fluids daily. This should be even more if you're feeling nauseous, in hot weather, or exercising
• Keep good food hygiene habits by washing your hands after handling raw meats and storing them separately from cooked foods to prevent cross-contamination

Furthermore, it is essential to avoid certain foods due to their potential risks to your baby:

• Avoid raw shellfish, raw or undercooked meats, unpasteurized dairy products, and raw or undercooked eggs without the Lion Code
• Be cautious with soft-ripened, blue-veined cheeses, unpasteurised dairy products, all types of pâté, and soft-serve ice cream from vans or kiosks
• Limit your consumption of certain fish, such as shark, marlin, swordfish, and tuna, and avoid excessive vitamin A and caffeine intake

It is imperative to avoid alcohol and smoking during pregnancy altogether, as these can cause serious harm to the unborn baby. Physical activity is essential, and pregnant individuals should aim for at least 30 minutes of moderate-intensity daily activity.⁷

It's important to take folic acid and vitamin D supplements during pregnancy. These are available at pharmacies, supermarkets, and with a GP prescription. Additionally, specific individuals may qualify for free vitamins through the Healthy Start scheme. A healthy diet rich in folate and iron is also essential during pregnancy.⁸

Monitoring and follow-up

Before you try to get pregnant, it's important to make sure your body is healthy and your coeliac disease is under control. Having normal lab results, or results close to your doctor's recommendations, is crucial. You should also start taking a gluten-free prenatal vitamin and mineral supplement when you're planning to get pregnant.

During pregnancy, it's essential to focus on getting enough of certain nutrients like iron, folic acid, calcium, vitamin D, and omega-3 fatty acids. It's also a good idea to eat a variety of seafood with low mercury levels and avoid high-mercury fish.

Your doctor will talk to you about how many calories you need, how much protein you should eat and how to get enough healthy fats, fibre, and fluids. They'll also discuss any vitamins, minerals, or other supplements you might need based on your lab results, diet and medical history. Women in need of prenatal and pregnancy counselling should seek advice from physicians and registered dietitians with expertise in coeliac disease.

Those newly diagnosed with coeliac disease should take the following lab:

• CBC (complete blood count)
• Iron studies (with ferritin preferred)
• Vitamin D
• Folate
• B12
• IgA-tTG (coeliac antibody)
• TSH
• Bone mineral density test (BMD), typically performed 12 months after starting the GFD
• Other labs as needed, such as testing for fat-soluble vitamins (A, E, and K), zinc, selenium, magnesium and more, based on individual requirements⁹

Managing complications

A study from Italy looked at how coeliac disease can impact women's ability to have children.

The study found that untreated coeliac disease was linked to various problems with having children, like trouble getting pregnant, recurrent miscarriages, and babies not growing properly in the womb. However, when women with coeliac disease started eating a gluten-free diet, these problems went away.

The study also looked at how coeliac disease might be causing these problems. It is suggested that certain nutrients vital for pregnancy, like zinc and folic acid, might not be adequately absorbed in women with coeliac disease. Additionally, the study proposed that the immune system in women with coeliac disease might be causing damage to the developing pregnancy, which could be related to specific antibodies found in coeliac disease.

Overall, the study showed that untreated coeliac disease can affect a woman's ability to have children, but following a gluten-free diet can help to eliminate these issues. However, more research is needed to understand how coeliac disease affects reproductive health.¹⁰

Psychological and emotional support

After being diagnosed, people experience both good and challenging times psychologically. Dealing with a gluten-free diet was not easy and caused psychological struggles like heightened anxiety and depression. Adults with coeliac disease might need ongoing medical check-ins and special psychological assistance. The diet also brought financial challenges for some and impacted family relationships. On top of that, there's a stigma around coeliac disease, highlighting the need for more public understanding and support groups.¹¹

Postpartum considerations

After giving birth, it is essential for women diagnosed with coeliac disease to maintain a strictly gluten-free diet. Studies have shown that not following a gluten-free diet can lead to shorter breastfeeding duration for women with coeliac disease. Also, there's some research suggesting that breastfeeding, especially when introducing gluten to the baby's diet, might help protect the child from developing coeliac disease. However, there's still uncertainty about whether breastfeeding permanently lowers the risk of coeliac disease or just delays its onset, as the study didn't follow patients for a long time. So, more research and long-term monitoring are needed to fully understand the impact of breastfeeding on the risk of developing celiac disease.¹²

Summary

Coeliac disease is when your body's immune system reacts to gluten, damaging your gut and affecting how your body absorbs nutrients. When you're pregnant, it's essential to take care of your coeliac disease to avoid issues such as having a low-birth-weight baby, giving birth too early and having a baby with intrauterine growth restriction (IUGR).

To manage your coeliac disease during pregnancy, it's crucial to stick to a strict gluten-free diet and go for regular medical check-ups. You need to make sure you're eating foods that are naturally free from gluten, stay away from foods that could pose a risk, and take supplements like folic acid and vitamin D. It's also essential to get support for your mental well-being and to take care of yourself after giving birth, by sticking to a gluten-free diet and considering how breastfeeding fits into your plans. When you manage your celiac disease properly, you increase the chances of having a healthy pregnancy and reduce the risk of complications for both you and your baby.