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 gravidarumHyperemesis 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 Disorders Reflux • 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 Gravidarum 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 Gravidarum Vomiting 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. Treatment Should 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. Antiemetics The 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 Gastroenteritis Viral , 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 Virus Parenteral 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 Virus Hepatitis 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 Virus Management • 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 • 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 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 Appendicitis The 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 Cholecystitis Second 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 pancreatitis 1 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