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

Topics to be covered...

• Acute events–Acute Appendicitis

–Acute Pancreatitis

–Acute Cholecystitis

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