Perinatal Outcome and Long-Term Gastrointestinal Morbidity of Offspring of Women with Celiac Disease

Pregnancy outcomes in women with Celiac disease in Northeast Iran: a regional retrospective cohort study

PURPOSE

To investigate the odds and associations of pregnancy outcomes with exposure to biopsy-confirmed celiac disease (CD) in Northeast Iran.

METHODS

In this regional retrospective cohort study, pregnancy records of all women with celiac disease who visited Celiac Disease Clinic of Imam-Reza Hospital from 2017 to 2023 (exposed group) and a sample of women without CD (unexposed group) were extracted using the Electronic Health Record of Mashhad University of Medical Sciences called "Sina". The unexposed group was randomly selected of the database and matched to exposed group on age, location of residence, socioeconomic factors. Our exclusion criteria included age ≥ 45, presence of concomitant disorders, history of non-obstetric uterine surgery, induction of pregnancy through assisted reproductive technology, and any concurrently ongoing pregnancy at the time of study. Pregnancy outcomes evaluated in this study included normal delivery, miscarriage, preterm labor, preeclampsia, and stillbirth. Adjusted odds ratios were calculated using logistic regression adjusted for confounders.

RESULTS

Ninety pregnancy records of women with CD and 270 pregnancies of women without CD were included in this study. Low neonatal birthweight (i.e. under 2500 g) had no significant association with CD (aOR = 0.99, 95% CI = 0.92-1.06), as well as postpartum hemorrhage (aOR = 1.12, 95%CI = 0.91-1.38), fetal anomaly (aOR = 0.89, 95%CI = 0.69-1.15), miscarriage (aOR = 1.00, 95%CI = 0.91-1.10), ectopic pregnancy (aOR = 0.94, 95%CI = 0.73-1.20), preterm labor (aOR = 1.00, 95%CI = 0.92-1.10), gestational diabetes mellitus (aOR = 1.07, 95%CI = 0.98-1.16), gestational hypertension (aOR = 0.99, 95%CI = 0.89-1.11), and gestation hypothyroidism (aOR = 0.95, 95%CI = 0.82-1.11). However, we found significantly lower odds of preeclampsia in pregnancies affected by CD (aOR = 0.83, 95%CI = 0.69-0.99).

CONCLUSION

Celiac disease was not associated with increased odds of low neonatal birthweight, postpartum hemorrhage, fetal anomaly, miscarriage, ectopic pregnancy, preterm labor, gestational diabetes mellitus, gestational hypertension and gestational hypothyroidism. Preeclampsia had significantly lower odds in pregnancies affected with CD.

Associations between Celiac Disease, Extra-Gastrointestinal Manifestations, and Gluten-Free Diet: A Narrative Overview

Millions of children and adults worldwide suffer from undiagnosed and untreated celiac disease (CeD). The clinical picture of CeD is highly heterogeneous and comprises manifestations that can affect almost the whole body. This narrative overview is aimed at characterizing diseases and complaints that are associated with unrecognized CeD and that frequently involve sites other than the gastrointestinal (G.I.) tract, i.e., dental, otorhinolaryngological, and ocular complications; skin and hair abnormalities; afflictions of the bones, joints, and muscles; cardiovascular affectations; kidney diseases; neuro-psychiatric disorders; and gynecological-obstetrical manifestations. The association between CeD and extra-GI manifestations is frequently overlooked, which leads to a delay in diagnosis. Most CeD-mediated disorders can be treated with a strict gluten-free diet (GFD), but some of them are irreversible unless CeD is diagnosed in time. Some manifestations can be classified as risk factors for CeD, and CeD screening tests for affected patients should be selectively considered. Apart from gastroenterologists, specialists in other medical disciplines can play an important role in identifying people with unrecognized CeD and may help prevent its progress and long-term complications. Further comprehensive investigations are necessary to clarify the pathogenesis of extra-GI manifestations and the effect of a GFD.

Fetal Biometric Assessment and Infant Developmental Prognosis of the Tadalafil Treatment for Fetal Growth Restriction

Background and Objectives: Tadalafil is expected to treat fetal growth restriction (FGR), a risk factor for stillbirth and neonatal morbidity. This study aimed to evaluate the fetal biometric growth pattern of fetuses with FGR treated with tadalafil by ultrasonographic assessment. Materials and Methods: This was a retrospective study. Fifty fetuses diagnosed with FGR and treated by maternal administration of tadalafil and ten controls who received conventional treatment at Mie University Hospital from 2015 to 2019 were assessed. Fetal biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL), and estimated fetal weight (EFW) at the start of treatment and at two weeks and four weeks of treatment were mainly assessed by ultrasound examination. The Wilcoxon signed-rank test was used to assess the measures. The Kyoto Scale of Psychological Development (KSPD) was used to assess the developmental prognosis on tadalafil-treated children at 1.5 years of corrected age (CA) and 3 years old. Results: The median gestational age at the start of treatment was 30 and 31 weeks in the tadalafil and control groups, respectively, and the median gestational age at delivery was 37 weeks in both groups. The Z-score of HC was significantly increased at 4 weeks of treatment (p = 0.005), and the umbilical artery resistance index was significantly decreased (p = 0.049), while no significant difference was observed in the control group. The number of cases with an abnormal score of less than 70 on the KSPD test was 19% for P-M, 8% for C-A, 19% for L-S, and 11% for total area at 1.5 years CA. At 3 years old, the respective scores were 16%, 21%, 16%, and 16%. Conclusions: Tadalafil treatment for FGR may maintain fetal HC growth and infants' neuro-developmental prognosis.

Adverse pregnancy outcomes in women with celiac disease: a systematic review and meta-analysis

Background

The aim of this meta-analysis was to evaluate the risk of adverse pregnancy outcomes in women affected with celiac disease (CD), and to further estimate the impact of early disease diagnosis and subsequent adherence to a gluten-free diet (GFD) on obstetric complications.

Methods

A systematic search for English language observational studies was conducted in Medline, Scopus, and the Cochrane Library, from inception till April 2022, to identify relevant studies reporting on the incidence of adverse pregnancy outcomes in women with CD. Odds ratios (OR) and relative risks (RR) with 95% confidence intervals (CIs) were used to combine data from case-control and cohort studies, respectively. The quality of the included studies was assessed using the Newcastle-Ottawa scale.

Results

In total, 14 cohort and 4 case-control studies were included and our analysis demonstrated that the risk for spontaneous abortion (RR 1.35, 95%CI 1.10-1.65), fetal growth restriction (RR 1.68, 95%CI 1.34-2.10), stillbirth (RR 1.57, 95%CI 1.17-2.10), preterm delivery (RR 1.29, 95%CI 1.12-1.49), cesarean delivery (RR 1.10, 95%CI 1.03-1.16) and lower mean birthweight (mean difference -176.08, 95%CI -265.79 to -86.38) was significantly higher in pregnant women with CD. The subgroup analysis demonstrated that only undiagnosed CD increased risk for fetal growth restriction, stillbirth, preterm delivery and lower mean birthweight, whereas early diagnosis of CD was not linked to any adverse pregnancy outcomes.

Conclusions

Undiagnosed CD is associated with a higher risk of adverse pregnancy outcomes. Early CD diagnosis and appropriate management with GFD may ameliorate these associations.

Tadalafil treatment for fetuses with early-onset growth restriction: a protocol for a multicentre, randomised, placebo-controlled, double-blind phase II trial (TADAFER IIb)

INTRODUCTION

TheTADAlafil treatment for Fetuses with early-onset growth Restriction: multicentrer, randomizsed, phase II trial (TADAFER II) study showed the possibility of prolonging the pregnancy period in cases of early-onset fetal growth restriction; however, it was an open-label study. To establish further evidence for the efficacy of tadalafil in this setting, we planned a multicentre, randomised, placebo-controlled, double-blind trial.

METHODS AND ANALYSIS

This trial will be conducted in 180 fetuses with fetal growth restriction enrolled from medical centres in Japan; their mothers will be randomised into three groups: arm A, receiving two times per day placebo; arm B, receiving one time per day 20 mg tadalafil and one time per day placebo and arm C, receiving 20 mg two times per day tadalafil. The primary endpoint is the prolongation of gestational age at birth, defined as days from the first day of the protocol-defined treatment to birth. To minimise bias in terms of fetal baseline conditions and timing of delivery, a fetal indication for delivery as in TADAFER II will be established in this trial. The investigator will evaluate fetal baseline conditions at enrolment and decide the timing of delivery based on this indication.

ETHICS AND DISSEMINATION

This study has been approved by Mie University Hospital Clinical Research Review Board on 22 July 2019 (S2018-007). Written informed consent will be obtained from all mothers before recruitment. Our findings will be widely disseminated through peer-reviewed publications.

TRIAL REGISTRATION

jRCTs041190065.

Association Between Mode of Delivery of the Breech Fetus and Hospitalizations Due to Inflammatory Bowel Disease During Childhood

BACKGROUND AND GOALS

While evidence suggests short-term benefits in neonatal morbidity and mortality from cesarean delivery of the fetus in breech presentation, the long-term implications for the offspring are less clear. To assess the implications of the mode of delivery on offspring's health, we have evaluated the long-term gastrointestinal (GI) morbidity of offspring with a breech presentation delivered in either way.

MATERIALS AND METHODS

A population-based retrospective cohort study including singleton deliveries in breech presentation occurring between 1991 and 2014 at a tertiary referral hospital. Incidence of hospitalizations of the offspring up to the age of 18 years involving GI morbidity was compared between those delivered via cesarean section or vaginally. A Kaplan-Meier survival curve compared cumulative GI morbidity. A Weibull parametric survival model controlled for confounders while accounting for repeated occurrence of mothers and dependence among siblings.

RESULTS

Overall, 86.9% (n=6376) of the 7337 fetuses in breech presentation, were delivered abdominally. Hospitalizations involving GI morbidity were higher in offspring delivered by cesarean section, specifically due to inflammatory bowel disease (IBD). Kaplan-Meier survival curve revealed the higher cumulative incidence of total GI morbidity and IBD specifically in the cesarean delivery group (P<0.001 and P=0.004, respectively). Using a Weibull parametric while controlling for relevant confounders, cesarean delivery emerged as an independent risk factor for long-term IBD-related morbidity of the offspring delivered in breech presentation (adjusted hazard ratio=3.18, 95% confidence interval: 1.47-6.87, P=0.003).

CONCLUSION

Cesarean delivery is associated with higher rates of hospitalizations due to IBD and total GI morbidity during childhood in term singleton in breech presentation.

Assessment of the value of measuring soluble fms-like tyrosine kinase-1 and placental growth factor levels following administration of tadalafil to treat fetal growth restriction

PURPOSE

The aim of this study was to measure the blood levels of soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) before and after tadalafil treatment in patients with fetal growth restriction.

MATERIALS AND METHODS

Maternal blood was collected from 13 women before and 2 weeks after tadalafil administration in the TADAFER II trial. The tadalafil treatment was conducted in addition to the conventional FGR treatment. As a control, maternal blood was also collected from 11 women before and 2 weeks after conventional treatment for fetal growth restriction. Blood sFlt-1 and PlGF were measured and the sFlt-1/PlGF ratio was calculated. Student's t-test was used to statistically analyze differences in the sFlt-1 and PlGF levels, and in the sFlt-1/PlGF ratios.

RESULTS

In both treatment groups, the levels of sFlt-1 and PlGF before and after treatment were not significantly different from each other. The sFlt-1/PlGF ratio was 2.0 ± 1.0 before and 17.6 ± 11.3 after treatment in the control group (p=.04). The sFlt-1/PlGF ratio was 2.2 ± 1.1 before and 22.2 ± 10.6 after tadalafil treatment in the tadalafil group (p=.06). The sFlt-1/PlGF ratios before and after tadalafil treatment were significantly increased in the control group. In both treatment groups, the sFlt-1/PlGF ratios before and after treatment were less than 38.

CONCLUSIONS

We conclude that the levels of sFlt-1 and PlGF were not significantly different as a result of tadalafil treatment. Further studies are needed to understand the mechanism of action of tadalafil in the treatment of fetal growth restriction.

Mode of delivery and long-term gastrointestinal-related hospitalization of the offspring

OBJECTIVE

We set out to ascertain a possible association between mode of delivery (cesarean vs. vaginal delivery) and gastrointestinal hospitalization of the offspring.

STUDY DESIGN

A population based cohort analysis including all uncomplicated singleton deliveries occurring between the years 1991-2014 at a tertiary medical center was performed, comparing long-term gastrointestinal hospitalization of offspring, according to mode of delivery. Multiple gestations, fetuses with congenital malformations and perinatal deaths were excluded, as were cases of urgent cesarean delivery and pregnancy complications. Gastrointestinal hospitalizations (up to age 18 years) were defined using predefined ICD9 codes, as recorded in hospital records. A Kaplan Meier survival curve was constructed to compare cumulative incidence of first gastrointestinal hospitalizations. A Cox proportional hazard model was used to control for confounders.

RESULTS

During the study period 139,232 deliveries met the inclusion criteria; 13,242 (9.5%) of which were elective cesarean deliveries, and the remaining 125,990 (90.5%) were delivered vaginally. Cesarean delivery was associated with more offspring hospitalizations for gastrointestinal morbidity (p < .001). The Kaplan Meier survival curve demonstrated higher cumulative incidence of gastrointestinal hospitalizations in the cesarean delivery group (log rank test p < .001). Utilizing a Cox proportional hazards model to control for confounders, cesarean delivery was found to be an independent risk factor for long-term gastrointestinal hospitalization of the offspring (adjusted HR 1.409, 95%CI 1.306-1.521, p < .001). Specifically, inflammatory bowel disease was more common among offspring following cesarean delivery aHR 1.386 95% CI 1.215-1.582 p < .001.

CONCLUSION

Elective cesarean delivery is an independent risk factor for long-term gastrointestinal-related hospitalization of the offspring.

Maternal celiac disease and the risk for long-term infectious morbidity of the offspring

PROBLEM

Celiac disease is an autoimmune disease, patients with celiac have increased risk for infections, and offspring of celiac mothers have increased morbidity. The aim of the study was to assess long-term infectious morbidity among offspring of pregnant women with celiac disease.

METHOD OF STUDY

A population-based cohort study was conducted, including all singleton deliveries between the years 1991-2014 at a tertiary medical center. The offsprings were subdivided into two groups: offsprings of mothers with and without celiac disease. Data on demographics, maternal, perinatal, and long-term hospitalizations for infectious morbidity were compared between the two groups.

RESULTS

During the study period there were 210 (0.09%) deliveries of mothers with celiac, and they were compared to 242170 (99.91%) deliveries of non-celiac mothers. Cumulative infectious morbidity was significantly higher in offspring of mothers with celiac compared to offspring of mothers without celiac (Kaplan-Meier, log-rank p = .004). Specifically, among the offspring of mothers with celiac significantly higher rates of bacteremia was noted (1.0% vs. 0.1%; p = .001), and infections of the central nervous system (1% vs. 0.2%; p = .028). In the Cox multivariable model which accounted for confounding variables, being born to mothers with celiac disease was associated with significantly increased risk for long-term infectious morbidity of the offspring (adjusted HR = 1.6, 95% CI 1.165-2.357, p = .005).

CONCLUSIONS

Maternal celiac disease is an independent risk factor for long-term infectious morbidity for the offspring.