gastrointestinal disorders with pregnancy amr nadim, md ass. prof. of obstetrics and gynecology ain...
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Gastrointestinal Disorders with Pregnancy
Amr Nadim, MD
Ass. Prof. of Obstetrics and Gynecology
Ain Shams faculty of Medicine
Topics to be covered...
• Hepatic Disorders– Intrahepatic Cholestasis
– Chronic Liver Diseases
– Viral Hepatitis
• Hepatitis A
• Hepatitis B
• Hepatitis C and others
Topics to be covered...• Gastrointestinal Diseases
– Gastroenteritis
– Nausea and Emesis gravidarum- Hyperemesis gavidarum
– Gastroesophageal Reflux
– Peptic Ulcer
– Inflammatory Bowel Disease
Guidelines for Managing Gastrointestinal Problems with Pregnancy
• Many are due to physiologic changes and are self -limiting
• most of the problems could be managed by dietary measures and reassurance.
• The decision to continue or to modify treatment for a pre-existing condition should take into account the benefit/risk ratio for mother and fetus
• A decision to treat in the first trimester should be considered exceptional
Dietary habits in pregnancy
• Dietary craving:– Towards peculiar tastes– Pica: e.g geophagia but also to chalk, clay, ice
• Dietary aversions– towards meat, fish, fatty food, etc….
• The occurrence of such food habit bears nothing in common with nausea and vomiting.
Disorders of the Oral Cavity• Aphthous stomatitis:
– Vitamin B12 or folic acid deficiency– May herald onset of GIT, collagen disorders or blood diseases– Treatment is symptomatic+topical steroids and local
anesthetics and that of the cause
• Hyperplastic gingivitis:– Related to elevated hCG and sex hormones.
• Dental caries (1.5-2 times non pregnant):
– Increased acidophilic organisms under E+P predominance– Calcium deficiency is no more incriminated
Gastro-esophageal DisordersReflux
• Dyspepsia and heartburn are distressing symptoms that occur in 70% of pregnant women starting from the first trimester.
• In pregnancy there is drop of the “Barrier Pressure” : [LOSP] - [Intragastric Pressure]
• Lowering of LOSP is due to the effect of E+P
• Heartburn is more severe after meals and is aggravated in the recumbent position
Reflux• General measures:
– Elevation of the head of the bed, small meals, reduced fatty and spicy diet, avoidance of smoking, caffeine and chocolate, refraining from meals or liquids other than water within 3 hours from going to bed.
– OTC antacids:• Avoid Na bicarbonate and particulate antacids
• 10-15 ml after meals and at bed time
– Sucralfate 1g. Tds– Cimetidine 400 mg after the evening meal– Ranitidine- Famotidine– Domperidone (Motilium) may raise the LOSP
Emesis GravidarumEmesis GravidarumMorning sickness: Morning sickness: does not influence health
• Unknown etiology.– Elevated levels of Gonadotropins and progesterone– Elevated level of T4: occult thyrotoxicosis (GTT or else)– Beta-endorhins secreted by the placenta and binding to opioid
receptors at the vomiting center– bla bla bla!!!
• Is encountered in 50-85% of pregnancies. Most frequently 6-8 weeks but in 20% may continue into the second and third trimester.
Hyperemesis GravidarumHyperemesis GravidarumVomiting occurring before the 20th week and requiring admission to the hospital
• Affects 0.5 to 10 per 1000 pregnancies.
• Peak incidence between 8th and 12th weeks.
• Multifactorial etiology: Hormonal, neurological, psychological, metabolic and toxic factors…
• Beware of molar pregnancy and Hyperthyroidism.
• Laboratory data:– Ketonuria, increasaed urine sp. Gravity, increased Ht.– Hyponatremia, hypokalemia, metabolic alkalosis– Alteration of Kidney and liver function tests.
TreatmentShould be tailored to suit individual cases.
• General measures:– Small, frequent meals.– Avoiding spicy and greasy diet.– Vitamins (including thiamine supplementation).– Nutritional consultation
• Initial therapy : oral therapy with oral or rectal antiemetics.
• Hospitalization:– Intractable emesis– Hypovolemia and/or electrolyte imbalance.– Laboratory anomalies.
AntiemeticsThe FDA has approved no drug for treatment of nausea and vomiting during pregnancy.• Pyridoxine(vitamin B6), 25mg tds• Phospharylated carbohydrate solution.• Doxylamine• Metoclopropmide (Primpran-Plasil)• Promethazine (Phenargan)• Chlorpromethazine• Ondasterone (Zofran): 4-8 mg tds• Methylpednisolone
Peptic Ulcer Disease
• Is of rare occurrence during pregnancy
• Some are reporting improvement of their symptoms.
• Dietary recommendations
• Avoidance of NSAIDs
• Antacids and H2 receptor antagonists
• Serious complications are rare …However if occurring they should be managed as the non pregnant patient
Inflammatory Bowel Disease Ulcerative Colitis - Crohn’s Disease
• Disease of young adults:– UC: 15-30 years and CD: 20-35 years– The fertility rate is unaffected in UC but reduced in CD because
of pelvic adhesions resulting from the inflammatory process.
• Medical Management:– Sulfazaline and Corticosteroids are safe – Folate supplementation is a must– The use of 6-mercaptopurine or azathiopine or ciprofloxacine
should be reserved to individual cases
IBD...• Surgical Intervention:
– As for non pregnant ladies
• Effect on the outcome of pregnancy:– There is increased fetal loss if:
• Manifest for the first time during pregnancy
• Colonic rather than small bowel disease.
• Uncontrolled and requires surgery
• How to deliver?– Vaginal delivery unless perineal scarring
– Active perineal disease may render episiotomy healing difficult
– Difficult intraperitoneal adhesions are expected in CS
GastroenteritisGastroenteritisViral , Bacterial or Parasitic
• Nausea, vomiting, cramping ands diarrhea with headaches , myalgia and low grade fever.
• Symptoms last for 48 hrs.
• Treatment is supportive:– Keep patients hydrated with adequate electrolyte
balance and place the bowel at rest.– Bowel rest.
• Intrahepatic Cholestasis
• Most common disorder unique to pregnancy of Variable incidence
• Increased risk of prematurity and IUFD
• Recurrent in 70% of the cases
– C/O: • Pruritis
• Jaundice in 50% of cases
• No Fever, Emesis, nor nausea
• D.D. Viral Hepatitis, Gall bladder Disease.
Laboratory Investigations
– Alk. Phosphatase +++
– Moderate Serum Transferases. – Bilirubin (Direct , rarely > 5 mg/dl– Bile acids up to 10 folds.
• Diagnostic criteria: Pruritis + Increased bile acids and salts
– Management• Cholestyramine: 8-6 g /day (3-4 divided doses)
– Weekly Check PT; if prolonged give vit K(10 mg/day).
• Diphenhydramine
• Dexamethazone
• Phenobarbitone
– Tests for Fetal well being– Terminate pregnancy when maturity is achieved
– Usually the condition subsides 2 days after delivery
– Be cautious for postpartum use of COCs
Hepatitis B VirusHepatitis B VirusParenteral exposure - STD - Vertical transmission
• Maternal Infection: – HBV prodrome of arthralgia, myalgia, ±jaundice,
fever , nausea & vomiting
• Fetal infection; HBeAg carries a risk of 85 to 90% risk of chronic HBV and associated sequelae.
• Morbidity and mortality: – No worsening of the disease with pregnancy– No CFM, IUFD, abortions or IUGR
Hepatitis B VirusHepatitis B VirusHepatitis Markers
– HBsAg: denotes carrier or infective status– HBeAg: High infectivity– Anti-HBcAg: partial convalescence.– Anti-HBsAg: immunity or recovery
• The risk of fetal transmission is highest in HBeAg +ve mothers at the time of delivery
Hepatitis B VirusHepatitis B VirusManagement
• The US CDC recommend universal screening of pregnant women for HBV.
• HBIG interrupt vertical transmission in 90% of cases:– 5ml of HBIG administered as soon as exposure is suspected.– 0.5 ml of HBIG given to the newborn in 12 hrs from delivery
to be followed by the standard 3 doses of the vaccine.
• Recombinant Hepatitis B Vaccination...
Hepatitis C Hepatitis C
• Persistent disease is common.
• In utero transmission: 50% higher than HBV.– To date there is no teratogenic Syndromes.– There is however a risk for acute hepatitis or chronic carrier
state.
• Antibody to HCV - PCR for HCV-RNA
• Prevention of vertical transmission by HCIG is equivocal.
• Exposed newborns; 0.5ml HCIG followed by another dose 4 weeks later.
Chronic Liver DiseaseChronic Liver Disease
• Chronic active hepatitis: – Responds to immunosuppression with corticosteroids.
– Increased risk of stillbirths, ,prematurity and PE.
• Liver cirrhosis:– Infertility is common.
– High perinatal loss and poor maternal outcome.
• Budd-Chiari Syndrome:– May occur due to the hypercoagulable state of pregnancy.
– Abdominal pain + Hepatomegaly & ascitis of abrupt onset.
Acute AppendicitisThe most common surgical complication in pregnancy
• A high suspicion index is needed…the classical signs are often absent.
• Patients present with anorexia, nausea, vomiting, fever, abdominal pain(site depending on the GA).
• DD:– Ectopic pregnancy– Pyelonephritis (Most common misdiagnosis)– Acute Cholecystitis– PID– Adnexal Torsion
Appendicitis...
• Therapy:– Laparoscopy– Laparotomy: There acceptable negative laparotomy rate is 20-
35%.– Antibiotics
• Complications include: preterm labor, abortion. If the delay is more than 24 hours the maternal and fetal morbidity is increased
Mortality may approach 5% in case of surgical delay
Acute CholecystitisSecond most common surgical complication of pregnancy.
• 3.5% of all pregnant women have gall stones
• C/O:– Abrupt onset of right upper quadrant pain, nausea, vomiting , anorexia,
intolerance to fatty food
• Investigations:– U/S– CBC, serum lipases and amylases
• Treatment:– Conservative– ERCP– Surgical
Acute pancreatitis1 per 1000 to 1 per 3800 pregnancies
• Gall stones are the most common predisposing factor.
• C/O: – Midepigastric pain or left upper quadrant pain radiating to the back
– Nausea, vomiting, ileus and low grade fever.• Elevated Amylases and lipases are the Keyfindings
• Treatment is essentially conservative– Cholecystectomy after the first trimester– ERCP
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