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Evaluation and management of rectal bleeding in pregnancy

Ralley Prentice, Aysha Al‐Ani, Tiffany Cherry, Julia Dixon‐Douglas, Jade Eccles‐Smith, Julia Matheson, Jeanne Tie, Iniyaval Thevathasan, Jacob J McCormick and Britt Christensen
Med J Aust 2021; 215 (8): . || doi: 10.5694/mja2.51267
Published online: 4 October 2021

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.
  • Ralley Prentice1,2
  • Aysha Al‐Ani3
  • Tiffany Cherry3
  • Julia Dixon‐Douglas4
  • Jade Eccles‐Smith5
  • Julia Matheson3
  • Jeanne Tie4,6
  • Iniyaval Thevathasan5
  • Jacob J McCormick3,4
  • Britt Christensen3

  • 1 Monash Health, Melbourne
  • 2 St Vincent’s Hospital Melbourne, Melbourne, VIC
  • 3 Royal Melbourne Hospital, Melbourne, VIC
  • 4 Peter MacCallum Cancer Centre, Melbourne, VIC
  • 5 Royal Women's Hospital, Melbourne, VIC
  • 6 University of Melbourne, Melbourne, VIC



Competing interests:

Britt Christensen has received speaking fees from Abbvie, Jannsen, Pfizer, Takeda and Ferring Pharmaceuticals, and research grants from Janssen and Ferring Pharmaceuticals, and has served on the advisory boards of Gilead and Novartis.

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