Chapter 23 Gastroenterologic Disorders In Pregnancy Flashcards
Differential diagnosis of nausea vomiting
Other gastrointestinal conditions Genitiurinary Tract pathology Metabolic disease Neurological disorder Drug toxicity Preeclampsia
Nausea and vomiting of pregnancy.
Virtually all women present with symptoms before 9 weeks
Prevention of nausea and vomiting
Women who take multivitamins prior to conception are less likely to need medical attention for vomiting
First line therapy of nausea and vomiting
B6 with or without doxylamine
10-25mg 3-4 times daily
Add doxylamine 12.5mg 3-4 times daily
Add promethazine 12-25mg every 4 hrs or dyphenhydramine 50-100mg every 4-6hrs
Gastrointestinal reflux disease (GERD), heartburn is most common complaint, approx __ of pregnant women at some point, and __ experience it daily
80%, 25%
factors associated with GERD include:
prepregnancy sx, advancing gestational age, parity.
etiology of GERD
lower esophageal sphincter TONE is DECREASED during pregnancy. there is a presumed INCREASED intraabdominal pressure and delayed gastric emptying.
esophageal sphincter tone decreased
increased intraabdominal pressure
delayed gastric emptying
dx of GERD:
substernal burning, dyspepsia, regurgitation. extraesophageal sx include: hoarseness, chronic cough, laryngitis, asthma.
lifestyle and dietary changes for GERD:
avoid meals prior to bedtime; avoid alcohol, smoking, caffeine, chocolate, peppermint
meds for gerd:
histamine (H2) receptor antagonists cat B - (zantac, pepcid, tagamet)
proton pump inhibitors (PPIs) cat B (protonix, prevacid, nexium)
except ompremazole (c) (prilosec)
APPENDICITIS - one of most common causes of acute abdomen in pregnancy. rate:
1 in 1500 gestations. fetal loss rates for appendectomy are higher than for other surgical procedures during pregnancy. approx 2.6%. loss rates increase to 10% if peritonitis is present.
dx of appendicitis:
right lower quadrant pain. r/o urinary tract infection and pulmonary pathology.
evaluation of acute appendicitis, useful adjuncts include:
Computed tomography (CT) and magnetic resonance imaging (MRI) MRI has no fetal exposure to radiation. high positive and negative predictive value for MRI. iconclusive or normal sonogram should prompt CT / MRI.
management of appendicitis:
surgical intervention.
Irritable bowel syndrome (IBS) characterized by
chronic recurring abdominal pain and altered bowel habits.
dx of IBS:
history, PE, routine labs. diagnostic criteria for IBS: recurrent abdominal pain / discomfort at least 3 days / month for the past 3 months, associated with 2 or more of the following:
1. improvement with defecation
2. onset associated with change in frequency of stool
3. onset associated with a change of form (appearance) of stool.
Diff Dx: celiac dx, atypical crohn’s disease, chronic constipation
management of IBS:
normalizing bowel habits.
identify and eliminate foods that worsen sx.
Inflammatory Bowel Disease (IBD) refers to:
- Crohn’s disease
2. ulcerative colitis
viral hepatitis
most common cause of jaundice during pregnancy. . hepatitis A and hepatitis E exhibit no risk of chronic maternal disease. vertical transmission is potentially possible in all viruses except HAV
routine perinatal screening of all pregnant women by HbsAG testing is recommended. why?
identify those at risk of perinatal transmission and thus appropriately provide prophylaxis to the newborn.
is hepatitis A vaccination and immune globulin safe in pregnancy?
yes. pregnant women postexposure or who are traveling to endemic areas should be considered.
all preg women should be tested for HbsAG; infants born to women who are positive or unknown, should..
receive hepatitis B vaccine and hepatitis B immune globulin (HBIG) within 12 hours of birth.
infants born to mothers who are HbsAG neg should receive hep B vaccine before
2 months
preterm infants <2000g should have first vaccine delayed until
1 month after birth.
risk of transmission of hepatitis B associated with amniocentesis is:
low
breast feeding is not contraindicated with
HAV with appropriate hygienic precautions
chronically infected with HBV providing infant receives vaccine and HBIG
or women with hepatitis C
Gallbladder disease. Cholelithiasis is common in adult population. __ and ___ increase frequency of gallstones
obesity and parity
pregnancy appears to increase incidence of gallstones. why:
elevated levels of sex steroid hormones resulting in biliary stasis and increased cholesterol saturation of bile.
disorders associated with gallstones:
biliary colic acute cholecystitis common bile duct obstruction ascending cholangitis gallstone ileus pancreatitis
dx of gallbladder dx:
biliary colic associated with anorexia, nausea and vomiting, upper quadrant pain, fectious complications usually leukocytosis and fever.
labs for gallbladder dx:
elevated bilirubin; aspartate aminotransferase (AST), alamine aminotransferase (ALT), alkaline phosphatase. US.
management of gallbladder disease:
withdrawal of food and liquids, IV fluids, pain control, nasogastric suction and antibiotics.
Intrahepatic cholestasis of pregnancy (ICP)
1% caucasians
2% south asians
5% chilean women.
elevated bile acid levels.
diagnosis of intrahepatic cholestasis of pregnancy:
pruritis without a rash; this is usually generalized but can affect palms and soles.
lab workup for intrahepatic cholestasis of pregnancy:
serum bile acids and liver transaminases.
if dx is uncertain, a liver US should be performed to r/o gallstones or biliary obstruction.
true
management of intrahepatic cholestasis (ICP)
ursodeoxycholic acid. usually will improve biochemical abnormalities. no data powered sufficiently to assess whether correction of the bile acids will reduce fetal risks associated with ICP.
management of intrahepatic cholestasis with regards to delivery
delivery by 38 wks or delivery after 36 weeks after confirmation of fetal pulmonary maturity
Acute fatty liver of pregnancy (AFLP)
under nonpregnant conditions, individual who is heterozygous for these enzyme mutations will be asymptomatic. however, if a heterozygous woman is carrying a homozygous fetus, fetal fatty acids may accumulate in maternal circulation, accumulate in maternal liver, and ultimately lead to hepatic dysfunction. care providers of neonate should be informed of this potential mutation to allow screening.
etiology of fatty liver of pregnancy:
disorders of fatty acid b-oxydation. woman who is heterozygous for long chain 3-hydroxyacyl-coenzyme A dehydrogenase (LCHAD) carrying a fetus with homozygous deficiency for this enzyme may be unable to metabolize the increased amounts of fatty acids; increased metabolic load may result in hepatotoxicity.
increased in twins.
sx of fatty liver of pregnancy:
nonspecific: nausea, vomiting, anorexia, upper quadrant pain.
dx of fatty liver of pregnancy
coagulopathy, diseeminated intravascular coagulation, elevated bilirubin, liver function tests including bilirubin; metabolic acidosis, renal dysfunction, and elevated ammonia. CT may be helpful but inconsistent. dx is usually made on clinical eval.
management:
maternal stabilization followed by expeditious delivery of fetus. serial lab studies including:
CBC, PT, PTT, fibrinogen, blood urea nitrogen BUN, creatinine, liver function tests, blood gases, ammonia levels every 6 hrs.
usually have hypoglycemia and require IV glucose infusions.
