Evaluation and management of rectal bleeding in pregnancy

Abstract

Summary Rectal bleeding occurs in about 40% of pregnant women, and is predominantly attributed to benign perianal pathology (haemorrhoids or anal fissures). More sinister causes of rectal bleeding may be heralded by key red flag clinical and biochemical features. These features should be evaluated in all women with rectal bleeding. Imaging investigations or flexible sigmoidoscopy may be warranted. The latter can be performed safely by experienced operators in pregnant women. Women with evidence of haemodynamic compromise, elevated inflammatory markers, significant anaemia, signs of intestinal obstruction or compromise to the fetus should be evaluated urgently. Providers must be mindful of the changes in normal ranges for common haematological and biochemical parameters in pregnancy compared with the non‐pregnant state. Faecal calprotectin is an established tool for identification of intestinal inflammation and is valid in pregnancy. An elevated faecal calprotectin level (≥ 50 µg/g) signifies a need for further diagnostic evaluation. Inflammatory bowel disease may present initially, or with worsening disease activity, in pregnancy. Expedient diagnosis with the use of faecal calprotectin, sigmoidoscopy with or without intestinal ultrasound, exclusion of alternative or compounding infective aetiologies, and institution of appropriate therapy are critical. Medical therapies for management of inflammatory bowel disease can be safely instituted in pregnancy. Colorectal cancer incidence is increasing in younger age groups, but fortunately remains rare. When diagnosed in pregnancy, colorectal cancer can be successfully and safely managed with a collaborative multidisciplinary team approach. Early diagnosis is key to optimising outcomes.

Preconception, antenatal and postpartum management of inflammatory bowel disease

“…8 Biochemical assessment is particularly important, as symptoms of active IBD are difficult to differentiate from those that can occur as a consequence of other pregnancy complications, such as haemorrhoids. 7,27 Furthermore, routine inflammatory markers are affected by pregnancy and must be interpreted with consideration for appropriate pregnancy reference ranges. 27 Contrastingly, faecal calprotectin remains accurate in pregnancy and can additionally be used to evaluate those with symptoms potentially attributable to new-onset IBD, such as rectal bleeding and diarrhoea.…”

“…27 Contrastingly, faecal calprotectin remains accurate in pregnancy and can additionally be used to evaluate those with symptoms potentially attributable to new-onset IBD, such as rectal bleeding and diarrhoea. 7,28 In the latter context, a faecal calprotectin ≥50 µg/g should prompt expedient gastroenterological referral for consideration of endoscopy or imaging. 7 • 2-5 mg daily of folate is needed in the setting of extensive ileal disease, in those on a fibre-restricted diet and in those taking sulfasalazine for three months prior to conception and in the first 12 weeks of pregnancy.…”

“…8 Emergency review is required for individuals with acute severe colitis (>6 bloody bowel actions per day and pulse >90 bpm, temperature >37.8 °C, haemoglobin <105 g/L or C-reactive protein >30 mg/dL), suspected intestinal obstruction or perforation or perianal abscess. 7,8…”

“…4,5 Furthermore, onset of IBD in pregnancy is occasionally encountered. 6,7 Accordingly, the aim of this article is to provide an evidence-based review of the approach to and management of patients with IBD prior to, during and following pregnancy.…”

Surgery in Pregnancy

“…Patients presenting with obstruction can be temporized with a diverting stoma. Neoadjuvant chemotherapy options during pregnancy include 5FU with .50 case reports (57) and FOL-FOX with very limited safety data available (52,56). There were 8 reports of FOLFOX exposure in utero, and only 1 infant was born with an abnormality (permanent hypothyroidism) (56).…”