St. Luke’s College of Medicine-William H. Quasha Memorial
Batch 2012
Lecture trans + Recording
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OB Block 4
Hyperemesis Gravidarum
Severe vomiting
Gastrointestinal Disorders in Pregnancy
Gastrointestinal Disorders in Pregnancy
 Hyperemesis gravidarum
 Peptic ulcer
 Constipation
 Intestinal obstruction
 Appendicitis
 Obesity
 Intrahepatic cholestasis
 Preeclampsia- eclampsia
 Viral hepatitis
 Cirrhosis
 Acetaminophen overdosage
 Cholelithiasis/cystitis
 Pancreatitis
– weight loss, dehydration, acidosis from starvation, alkalosis (loss of HCl) and hypokalemia
 Due to high level of HCG or estrogens
 Remind your patient that this is something temporary
 Somehow has familial clustering – blame the
HCG; HCG peaks at the 8-10 th week = peak of hyperemesis gravidarum
 This will wean off slowly
 Vomiting may persist in the 14-16 th wk
 Teach the patient to look for the food that are acceptable; sometimes pregnant women don’t like sautéed food, (haha) and odor of husband
 Food – ice chips, chichirya, soup, ice cream, champoy – finding the food that will alleviate her
Christine Fernando- Palma MD
November 5, 2009
Peptic Ulcer
 Young women: usually involves duodenum rather than stomach
 Caused by Helicobacter pylori o Aspirin, NSAIDS use
 Peptic Ulcer and Pregnancy o Peptic ulcer 90% remission o Normal pregnancy change
 Dec gastric secretion
 Dec motility
 Inc mucus secretion o So ulcer is not frequently seen in pregnancy, so it’s said that the hyperacidity that is felt by the patient is due to his hyperemesis gravidarum o Antacids: 1 st line treatment o H2 receptor blocker o Proton pump inhibitors: not recommended
Constipation and Pregnancy
 Decreased small bowel motility – she still feels
 that there’s food in the stomach
Colon has increased muscular relaxation – increased absorption of water and sodium
( feces becomes harder and dehydrated)
 Prevented by high fiber diet and bulk forming laxatives
Intestinal Obstruction
 60-70% due to adhesions from previous abdominal surgery; 2 nd is volvulus ( intestine from her desire to vomit
 She will feel nauseated, the first three months, the ideal weight gain is 2 pounds – so she doesn’t have to force herself to eat ( because some pregnant women feel guilty that they are not eating)

so they push themselves to eat and vomit some more; but during the time that they are vomiting, they just have to rest their bowels, NPO
 Advice: small frequent meals
 However, if there’s severe dehydration  IV crystalloid for hydration and correct electrolyte deficits
 Antiemetics: Promethazine, Prochlorperazine,
Chlorpromazine, Metoclopramide IV;
Metoclopramide locally available- apparently, no known ill effect
Heartburn
 Retrosternal burning sensation – felt during the
13-35 th wk – because of the increase in the size of the uterus, the acid in the stomach will reflux back
 Gastroesophageal reflux
 Raise head of bed
 Tx: oral antacids; milk – to buffer the acidity
 H2 receptor antagonists: Cimetidine (Tagemet) and Ranitidine (Zantac); previously thought to be not safe for the pregnancy, but now it may be used (probably also because they usually have
GERD sa 3 rd trim na, tapos na ang organogenesis) twists on itself)
 Pressure of growing uterus on intestinal adhesion  intestinal obstruction
 Dx: plain abdomen : fluid air-levels and dilated bowel loops
 -High maternal and fetal mortality o Delay or error in diagnosis o Reluctance to operate o Inadequate preparation
Appendicitis
 Difficult diagnosis: sx similar to pregnancy
 Appendix moves upward and outward toward flank – pain/tenderness higher; significance of knowing where to palpate
 Leukocytosis seen in normal pregnancy - up to
15,000 WBC
 Appendiceal rupture more frequent because of delay in diagnosis
 Infection less likely contained by omentum – this would be a poor prognosis for the patient
 Increased risk of abortion and preterm labor
 Fetal loss 15%
 Treatment: surgery o Open surgery - traditionally o Laparoscopic: pneumoperitoneum with carbon dioxide similar perinatal outcome as laparotomy
 Antibiotics
 Silent appendicitis – stimulates pain
 stimulates labor; gravid uterus contains infection
– but after 
 Postpartum – spillage of pus in the peritoneal cavity
Ruari and Abi OB: Gastrointestinal Disorders in Pregnancy page 1 of 4

St. Luke’s College of Medicine-William H. Quasha Memorial
Batch 2012
Liver Disease and Pregnancy
 Coincidental with pregnancy o Viral hepatitis o Drug-induced hepatic failure
 Induced by pregnancy and resolves postpartum o Intrahepatic cholestasis o Acute fatty liver of pregnancy o Severe preeclampsia o Hyperemesis gravidarum
 Pregnancy superimposed on cirrhosis, chronic hepatitis, esophageal varices, liver transplant
Liver Function Test
Normal Changes during Pregnancy
 Increased o Alkaline phosphatase o Hormone binding protein o Transferrin o Lipids o Cholesterol o Fibrinogen o Factors VII, VII, X
 Unchanged o Aminotransferase o Lactic acid dehydrogenase o Bilirubin o Clotting times
 Decreased o Albumin
Intrahepatic Cholestasis of Pregnancy
 Recurrent jaundice, cholestatic hepatosis or icterus gravidarum or both
 Manifestation will be jaundice and pruritus
 Bile acids cleared incompletely by liver and accumulate in plasma
 Intrahepatic cholestasis with centrilobular bile staining without inflammatory cells *
characteristic; not infectious
 Hyperbilirubinemia
 Liver biopsy o Mild cholestasis o Intracellular bile pigments o Canalicular bile plugging without necrosis
 Generalized pruritus in last trimester from elevated serum bile salts
 10% jaundice, dark urine, light stools
 Impaired absorption of fat soluble vitamin - remember: it is the bile from the liver excreted into the colon that will absorb the vitamins, but since this is retained in the liver  impairment
 Impaired coagulation
 Lab: increased bilirubin, bile acids and alkaline phosphatase (enzyme in bile duct and canalicular membrane of hepatocytes)
 Tx: antihistamines ( Benadryl; to relieve the itching , cholestyramin)
 Adverse pregnancy outcome o Meconium staining o Preterm delivery
Liver in Preeclampsia- Eclampsia
 Periportal hemorrhage, fibrin deposition, hepatocyte disruption with necrosis
 S/sx: RUQ pain – warning for the OB for
possible liver pathology
 Increased SGOT/SGPT, thrombocytopenia
Lecture trans + Recording
 HELLP syndrome: hemolysis, elevated liver enzyme, low platelet – severe prognosis for the
patient
 If liver involvement ( see elevation in transaminases +RUQ pain) : prompt delivery
 After delivery

Liver enzyme, LDH and platelet count normalize in 2-3 days
 Intrahepatic or subcapsular hemorrhage o Diaphragmatic surface of right lobe o Liver rupture: packing, correction of coagulopathy, hysterotomy
Acute Fatty Liver of Pregnancy - extremely rare
 Spectrum from subclinical hepatic dysfunction
(increased SGOT/SGPT) to hepatic failure and coma
 Usually third trimester
 Bleeding, jaundice, nausea/vomiting, coma
 20-40% with preeclampsia
 Biopsy: microvesicular fatty transformation of hepatocytes
 Dx: high index of suspicion o Special stains for fat
 Tx: terminate pregnancy =(
Acute Viral Hepatitis *favorite of MLE and local boards,,ahem,, therefore..^^
 Most common serious liver disease in pregnancy
 Viruses not hepatotoxic- immune response causes hepatocellular necrosis
 5 types: Hepatitis A, B, C, D, E
 S/Sx: nausea, vomiting, headache and malaise; jaundice with improvement of symptoms – pain and tenderness over liver
 Labs: increase in serum aminotransferase
(SGPT/SGOT), bilirubin, antigen - antibody level
Chronic hepatitis B
- Asymptomatic carrier
- Chronic active hepatitis
- Ground glass hepatocyte
Sequela: Fulminant hepatic necrosis
- Fatal
- Usually hepatitis B
- Hepatic encephalopathy
- description of pic --- liver is smaller than normal, due to extensive areas of liver necrosis.
The liver is also soft with a wrinkled capsular surface
Hepatitis A
 Fecal –oral route
 Ingestion of contaminated food or water
 Incubation of 2-7 weeks
 IgM Anti HAV may persist for several months
 IgG Anti HAV: immunity
 Vaccine: 90% effective
Hepatitis A and Pregnancy
 No teratogenic effect in fetus
 Vertical intrapartal transmission – meaning at the time of delivery, the baby may acquire the
Hepatitis from the vaginal fluid of the mother
 Increased preterm delivery
 Exposed pregnant woman: should be given prophylaxis with 1 ml immune globulin
Ruari and Abi OB: Gastrointestinal Disorders in Pregnancy page 2 of 4

St. Luke’s College of Medicine-William H. Quasha Memorial
Batch 2012
Hepatitis B
 Serious sequelae in infected adults (5-10%) and infants (70-90%) o Chronic hepatitis o Cirrhosis o Hepatocellular carcinoma
 Transmission by infected blood/ blood products, saliva, vagina secretions and semen
 HBsAg: 1st virologic marker
 Anti HBsAg: 90%develops – which will protect the individual for life ; 10% (-)
 on pic: ballooning cytoplasm in degenerating hepatocytes
 HBeAg: infectivity & intact viral particles o (+) early acute hepatitis o Persistent: chronic infection o HBsAg and HBeAg (+): likely to transmit disease o HBsAg and HBeAg (-), Anti HBe (+): not
 HBcAg transmit
Hepatitis B and Pregnancy
 Course of hepatitis not altered
 Treatment is supportive ( hydration, pain reliever, anti-pyretic)
 Increased preterm delivery
 Transplacental viral transfer with acute hepatitis:
80-90% in 3 rd trimester * the only one that can cross the placental blood barrier
 Chronic hepatitis B: not transplacental
 Chronic hepatitis: perinatal transmission thru ingestion during delivery, breastfeeding
 85% infant: chronic carriers
 Correlates with HBeAg – again measures the infectivity of the mother
 HBsAg (+) mothers: o Infants given hepatitis B immune globulin after birth followed by hepatitis
B vaccine*
 In the first 24-48h, it has been the policy of the government to give the baby Hepa B vaccine – studies show that this decreased hepatocellular carcinoma
 Hepatitis B serological screening during prenatal care
 If (-) and high risk: may vaccinate mother o Seroprotection lower (45% vs 60-70% when nonpregnant)
Hepatitis C - the dreaded hepatitis
 Transmission as in hepatitis B
 Anti- C antibody detected 15 weeks after acute infection
 86% of antibody (+) Hep C: infectious
 20-30%  cirrhosis in 20-30 years
 No adverse perinatal outcome
 Vertical transmission: 3-6%
 Portal inflammatory infiltrates frequently with lymphoid aggregates or lymphoid follicles
 Steatosis is also present in HCV infections in contrast to HBV infection
Chronic Hepatitis (may be B, C or autoimmune)
 Hepatic necrosis, active inflammation and fibrosis – cirrhosis and liver failure
 Chronic inflammatory infiltrate in the portal areas extending beyond into the adjacent lobule
 Many hepatocytes are undergoing degeneration and necrosis
Lecture trans + Recording
 Either hepatitis B or C or autoimmune (ANA)
 Asx; elevated serum transaminase
 Interferon for antiviral, antiproliferative and immunoregulatory effects o After 6 mos: decrease viremia o Relapse rate 20%
Chronic Hepatitis and Pregnancy
 Severe disease – anovulation
 Asx chronic hepatitis: no pregnancy effect
 Higher incidence of cholestatic jaundice
 Autoimmune chronic hepatitis treated with corticosteroids +/- Azathioprine: increased fertility and survival
Cirrhosis
 Irreversible chronic injury to lover parenchyma with extensive fibrosis and regenerative nodules
 Lannec cirrhosis from chronic exposure to alcohol: most common
 Young women/ pregnancy: from chronic B or C viral hepatitis
 Hardly seen in the clinic, rarely become pregnant
 On pic: Irregular depressed areas due to bands of fibrous scar tissue that separate nodules of regenerating liver parenchyma
Cirrhosis and Pregnancy
 S/sx: jaundice, edema, coagulopathy, metabolic abnormalities, portal HPN
 Cirrhosis associated with infertility
 - High perinatal loss, maternal prognosis poor
 Bleeding of esophageal varices: greater if no portal decompression shunting
Acute Acetaminophen Overdosage
 Suicidal attempts with acetaminophen ( Tylenol) : nausea/vomiting, diaphoresis, malaise
 In 1-2 days – liver failure – resolves in 5 days
 Transplacental transfer
 Antidote: N-acetylcysteine ( increases glutathione) if: o Plasma acetaminophen after 4 hrs: 120 ug/ml o Acetaminophen overdose > 7.5 grams
Cholelithiasis and Cholecystitis
 Gallstones (GS) usually contain cholesterol
 Non pregnant: risk for surgery of silent GS –
10% at 5 years; 18% at 15 yrs
Cholelithiasis and Pregnancy
 Increased BG volume & residual volume – incomplete emptying - -cholesterol crystals – increased biliary sludge: precursor to gallstone
(GS)
 GS in pregnancy: 2.5- 10%
 Nonsurgical approaches to GS: no experience during pregnancy
 Asx GS: no treatment
 If acute symptoms: surgery
Cholecystitis
 Obstruction of cystic duct with bacterial infection in 50-85%
 S/sx; RUQ pain, anorexia, nausea, vomiting, low grade fever, leukocytosis
Ruari and Abi OB: Gastrointestinal Disorders in Pregnancy page 3 of 4

St. Luke’s College of Medicine-William H. Quasha Memorial
Batch 2012
Cholecystitis
 Cholecystectomy: acute cholecystitis, biliary colic, jaundice and acute pancreatitis
 Laparoscopic cholecystectomy: treatment of choice of most patients; increased morbidity
 Open or laparoscopic cholecystectomy: equally acceptable in pregnancy
Pancreatitis
 Triggered by activation of pancreatic trypsinogen autodigestion (cellular membrane disruption, proteolysis), edema, hemorrhage and necrosis
 Nonpregnant: associated with GS ( to the cystic duct

duct of Vater

obstruction of the hormone secretion) and ROH abuse
 Pregnant: cholelithiasis - most frequent cause
 On pic – atrophy of most of the exocrine pancreatic glands and occasional preserved islets
Lecture trans + Recording
Pancreatitis during Pregnancy
 S/sx: epigastric pain, nausea & vomiting, tenderness, increased amylase (3x normal), increased lipase
 Tx: analgesia, hydration and food abstinence
 Self limited within 3-7 days
Obesity
 Quetelet’s Index: Body Mass Index
 Wt (kg)/ Ht (m)2 = Kg/m2
 20% increase in body weight o Or BMI > 85 th percentile o 27.3 for women 20-29 years old
Morbid Obesity and Pregnancy
 Increased hypertension, diabetes, postterm pregnancy, cesarean section rate, large for gestational age babies, neural tube defects
 Weight management
Praise GOD! Ahaha! Tapos na! *clap clap clap*
Dahil natapos mo na..you have a prize! Enjoy friend!
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Ahahah…ang saya-saya!  GOD bls everyone! -- abi
Ruari and Abi OB: Gastrointestinal Disorders in Pregnancy page 4 of 4