Celiac disease (CD) is an immune mediated condition that results from a reaction to dietary gluten and primarily affects the small intestine. Genetically predisposed individuals develop a chronic inflammatory state of the small intestine which leads to malabsorption. The disease is mediated by HLA DQ2 or DQ8 haplotypes, which bind the gliadin peptides of gluten, present the peptides to CD4+ T lymphocytes and trigger cytokine and B lymphocyte responses.1

The prevalence of CD in the United States is approximately 1% and can reach up to 4-5% in at-risk groups.2 Serologic study of asymptomatic elderly patients in the United Kingdom revealed a 1% prevalence rate of CD. The diagnosis of CD can be challenging in those without the classic malabsorptive symptoms of chronic diarrhea and bloating. Patients with silent CD vary in their presentation. In some cases, the diagnosis is made after a patient presents with iron deficiency anemia, osteoporosis, or an incidental finding of duodenal villous atrophy on endoscopy.3,4 Additionally, undiagnosed CD can increase long term risk of lymphoma, infertility, miscarriage, and complications in pregnancy.5,6 Mothers with untreated active CD are at higher risk of preterm labor, small for gestational age, or low birthweight infants.6 This case reinforces the importance of recognizing atypical presentations of CD in pregnancy to prevent maternal and fetal complications due to active disease.