Gastrointestinal Disorders
BS. Nguyễn Hồng Anh
During normal pregnancy, the gastrointestinal (GI) tract
and its appendages undergo remarkable anatomical, physiological, and unctional alterations. Tese changes, which
are discussed in detail in Chapter 4 (p. 70), can appreciably
alter clinical ndings normally relied on or diagnosis and
treatment. Moreover, as pregnancy progresses, GI ndings
become more dicult to assess. Te clinical examination is
oten obscured by a large uterus that displaces abdominal
organs and can alter the location and intensity o pain and
tenderness.
GENERAL CONSIDERATIONS
■ Diagnostic Techniques
Endoscopy
Several endoscopic methods can be used to evaluate the gastrointestinal (GI) tract during pregnancy without reliance on
radiographic techniques. With beroptic endoscopic instruments, the esophagus, stomach, duodenum, and colon can be
inspected (Savas, 2014; Song, 2018). Te proximal jejunum
also can be studied, and the ampulla o Vater cannulated to
perorm endoscopic retrograde cholangiopancreatography—ERCP
(Fogel, 2014; Hedström, 2017). Experience in pregnancy with
video capsule endoscopy or small-bowel evaluation remains limited (Bandorski, 2016). Normal pregnancy-related slowing
o GI motility and thus increased transit time as well as the
recorder capsule’s electromagnetic eld are theoretical concerns.
Upper gastrointestinal endoscopy is used or diagnosis and
management o several problems. Common bile duct exploration and drainage are used or choledocholithiasis (Chap. 58,
p. 1043). Sclerotherapy and placement o percutaneous endoscopic
gastrostomy (PEG) tubes also are perormed endoscopically.
Colonoscopy is indispensible or viewing the entire colon and
distal ileum. Except or the midtrimester, reports o colonoscopy during pregnancy are limited, but most results suggest
that it should be perormed i necessary (De Lima, 2015; Ludvigsson, 2017). Pregnancy indications include chronic abdominal pain, hematochezia, and diarrhea (Cappell, 2011). Bowel
preparation is completed using polyethylene glycol electrolyte
(GoLYELY) or sodium sulate (Suprep) solutions (American
Society or Gastrointestinal Endoscopy, 2015). With these,
most women avoid serious dehydration that may cause diminished uteroplacental perusion. In select cases, tap water enemas
TABLE 57-1. Preprocedural Considerations for Gastrointestinal Endoscopy During Pregnancy
Plan consultation with an obstetrician, gastroenterologist, and anesthesiologist
Place patient in let lateral decubitus position
Use lowest eective dose o sedation necessary
Give prophylactic antibiotics as indicated. Penicillin, cephalosporin, erythromycin, and clindamycin are sae options
Minimize procedure time
Obtain etal heart tones at the discretion o the obstetrician. In general, pre- and post-procedure heart tones are adequate
For colonoscopy, avor preparation with PEG-ES or with tap water enemas depending on GI level to be evaluated
GI = gastrointestinal; PEG-ES = polyethylene glycol electrolyte solution.
From American Society or Gastrointestinal Endoscopy, 2012, 2015.
TABLE 57-2. Some Conditions Treated with Enteral or
Parenteral Nutrition During Pregnancya
Achalasia
Anorexia nervosa
Appendiceal rupture
Bowel obstruction
Burns
Cholecystitis
Crohn disease
Diabetic gastropathy
Esophageal injury
Hyperemesis gravidarum
Jejunoileal bypass
Malignancies
Ostomy obstruction
Pancreatitis
Preeclampsia syndrome
Short bowel syndrome
Stroke
Ulcerative colitis
aComplications arranged alphabetically.
From Billiauws, 2017; Folk, 2004; Guglielmi, 2006;
Mahadevan, 2019; Porter, 2014; Russo-Stieglitz, 1999; Saha,
2009; Spiliopoulos, 2013.
nutrition as a rst eort to prevent catabolism. For extreme
cases, such as recalcitrant hyperemesis gravidarum, percutaneous endoscopic gastrostomy with a jejunal port (PEG-J tube)
has been described.
Parenteral nutrition provides nutrients when the intestinal
tract must be quiescent. Peripheral parenteral nutrition (PPN)
administers dilute nutrient admixtures and is appropriate or
short-term use. Central venous access is necessary or central
parenteral nutrition (CPN) because its hyperosmolarity requires
rapid dilution in a high-ow vascular system (Robinson, 2018;
Worthington, 2017). Tese solutions provide 24 to 40 kcal/
kg/d, principally as a hypertonic glucose solution. Various
conditions may prompt CPN during pregnancy (Table 57-2).
Te most common indications are short bowel syndrome and
dysmotility disorders, and eeding duration averages 33 days
(Billiauws, 2017).
may be an alternative or rectosigmoidoscopy to avoid some o
these risks.
Endoscopic procedures should be perormed when indicated and ideally in the second trimester (American Society or
Gastrointestinal Endoscopy, 2012; Ludvigsson, 2017). A multidisciplinary approach with obstetricians, gastroenterologists,
and anesthesiologists is prudent. Table 57-1 outlines preprocedural considerations in pregnancy.
Noninvasive Imaging Techniques
Te ideal technique or GI tract imaging during pregnancy
is abdominal sonography. However, the gravid uterus may
obscure abdominal organs making evaluation dicult. Magnetic resonance (MR) imaging allows inspection o the abdomen and retroperitoneal space yet avoids radiation exposure
rom computed tomography (C) (Khandelwal, 2013).
Examples are MR cholangiopancreatography (MRCP) and
MR enterography (MRE) (Oto, 2009; Stern, 2014). Tese and
other imaging modalities, and their sae use in pregnancy, are
discussed in Chapter 49.
Laparotomy and Laparoscopy
Surgery is liesaving or certain GI conditions—perorative
appendicitis being the most common example. Intraabdominal
surgery is the most requently perormed nonobstetrical procedure during pregnancy (Devroe, 2019). Laparoscopic procedures have replaced traditional surgical techniques or many
abdominal disorders during pregnancy (Ye, 2019). Tese are
discussed in detail with descriptions o surgical technique in
Chapter 49 (p. 867) and in Cunningham and Gilstrap’s Operative Obstetrics, 3rd edition (Kho, 2017). Guidelines or laparoscopy during pregnancy have been provided by the American
College o Obstetricians and Gynecologists (2019) and the
Society o American Gastrointestinal and Endoscopic Surgeons
(Pearl, 2017).
■ Nutritional Support
Specialized nutritional support can be delivered enterally, usually via nasogastric tube eedings, or parenterally by venous
catheter access, either peripherally or centrally.
When possible, enteral alimentation is preerable because it
has ewer serious complications (Hoer, 2018; Stokke, 2015).
In obstetrical patients, very ew conditions prohibit enteral1014
Section 12
Medical and Surgical Complications
Parenteral nutrition complications are requent and may be
severe (Hoer, 2018). Te most common is catheter sepsis, and
Folk (2004) reported a 25-percent incidence in 27 women with
hyperemesis gravidarum. Te Centers or Disease Control and
Prevention provides detailed guidelines to prevent catheterrelated sepsis (O’Grady, 2011). Other maternal complications
include upper-extremity venous thrombosis, volume overload,
and reversible liver dysunction. Perinatal complications are
rare, however, etal subdural hematoma caused by maternal
vitamin K deciency has been described (Sakai, 2003).
Appreciable morbidity is also associated with long-term
use o a peripherally inserted central catheter (PICC). Again,
inection is the most common serious long-term complication
(Hoer, 2018; Holmgren, 2008). In a series o 84 such catheters inserted in 66 pregnant women, Cape and coworkers
(2014) reported a 56-percent complication rate, and bacteremia was the most requent. For short-term nutrition lasting a
ew weeks, PICC placement and its greater benet-versus-risk
ratio seems reasonable (Worthington, 2017).
UPPER GASTROINTESTINAL
TRACT DISORDERS
■ Hyperemesis Gravidarum
Mild to moderate nausea and vomiting are especially common
in pregnant women until approximately 16 weeks’ gestation
(Chap. 10, p. 191). In a small but signicant proportion o
these, however, it is severe and unresponsive to simple dietary
modication and antiemetics. Hyperemesis gravidarum is
dened variably as severe unrelenting nausea and vomiting that
produces weight loss, dehydration, ketosis, alkalosis rom loss
o hydrochloric acid, and hypokalemia. Acidosis develops rom
partial starvation. In some women, transient hepatic dysunction develops, and biliary sludge accumulates (able 58-1, p.
1031). Other causes should rst be considered because hyperemesis gravidarum is a diagnosis o exclusion.
Study criteria are not standardized, and thus population
incidences vary (Koot, 2018). However, an ethnic or amilial
predilection has been described (London, 2017). In several
population-based studies, the hospitalization rate or hyperemesis gravidarum was 0.5 to 2.1 percent (Fiaschi, 2019;
Vikanes, 2013). Up to 25 percent o those hospitalized in a
previous pregnancy or hyperemesis will again require admission (Nurmi, 2018).
Te etiopathogenesis o hyperemesis gravidarum is unknown
and is likely multiactorial. High or rapidly rising serum levels o pregnancy-related hormones such as human chorionic
gonadotropin (hCG), estrogen, progesterone, placental growth
hormone, prolactin, thyroxine, and adrenocortical hormones
are implicated (London, 2017; Verberg, 2005). Other associated hormones include ghrelins, leptin, nesatin-1, and peptide
YY 3–36 (Albayrak, 2013; Gungor, 2013).
Superimposed on this hormonal cornucopia are many biological and environmental actors. Moreover, in some but not
all severe cases, interrelated psychological components play a
major role (Mitchell-Jones, 2017; Senturk, 2017). Factors
that increase the risk or admission include hyperthyroidism,
previous pregnancy complicated by hyperemesis, diabetes,
GI illnesses, some restrictive diets, and asthma (Fell, 2006;
Fiaschi, 2016; Mullin, 2012). An association o Helicobacter
pylori inection has been proposed, but evidence is inconclusive
(Goldberg, 2007; London, 2017). Chronic marijuana use may
cause the similar cannabinoid hyperemesis syndrome (Alaniz, 2015;
Andrews, 2015). And or unknown reasons—perhaps estrogenrelated—a emale etus raises the risk but smoking and obesity decrease it by 1.5-old (Cedergren, 2008; Fiaschi, 2016).
Some have reported a relationship between severe hyperemesis
gravidarum and anemia, venous thromboembolism (VE),
gestational hypertension, and preeclampsia (Fiaschi, 2018). An
association between hyperemesis and preterm birth is unclear
(Kleine, 2017). Koren and colleagues (2018) suggested that
prolonged vomiting may cause metabolic abnormalities that
interere with etal brain development. No long-term maternal
consequences ollow hyperemesis. Specically, two populationbased studies ound no unavorable cardiovascular risks in
Norwegian women (Fossum, 2017, 2018).
Complications
Vomiting may be prolonged, requent, and severe, and a
list o potentially atal complications is given in Table 57-3.
Various degrees o acute kidney injury rom dehydration are
encountered, and rhabdomyolysis may be contributory (Lassey,
2016). Rarely, we and others have encountered women with
renal ailure requiring dialysis (Dayangan Sayan, 2018; Hill,
2002). Mallory-Weiss tears result rom continuous retching.
Other complications include pneumothorax, pneumomediastinum, diaphragmatic rupture, and gastroesophageal rupture—
Boerhaave syndrome (American College o Obstetricians and
Gynecologists, 2018; Chen, 2012).
At least two serious vitamin deciencies have been reported
with hyperemesis in pregnancy. One is Wernicke encephalopathy
rom thiamine deciency (Di Gangi, 2012; Palacios-Marqués,
2012). A systematic review reported that ocular signs, conusion, and ataxia were common, and approximately 60 percent
had this triad (Oudman, 2019). In some women, an abnormal
electroencephalogram (EEG) may be seen, and usually MR
imaging shows ndings (Oudman, 2019; Vaknin, 2006; Zara,
TABLE 57-3. Some Serious and Life-Threatening
Complications Reported with Hyperemesis
Gravidaruma
Acute kidney injury—may require dialysis
Depression—cause versus eect?
Diaphragmatic rupture
Esophageal rupture—Boerhaave syndrome
Hyperalimentation complications
Hypokalemia—arrhythmias, cardiac arrest
Hypoprothrombinemia—vitamin K deiciency
Mallory–Weiss tears—bleeding, pneumothorax,
pneumomediastinum, pneumopericardium
Rhabdomyolysis
Wernicke encephalopathy—thiamine deiciency
aComplications arranged alphabetically.Gastrointestinal Disorders 1015
CHAPTER 57
institution, or cost savings, we prescribe these two agents individually. Te ormula is one hal o a 25-mg Unisom (doxylamine) tablet plus a 25-mg vitamin B6 (pyridoxine) tablet. Te
same graduated dosing is used but does not exceed three total
daily doses.
Ondansetron (Zoran) is slightly more eective than the
combination o doxylamine and pyridoxine (Oliveira, 2014;
Pasternak, 2013). In some studies, the ormer has been associated with birth deects (Briggs, 2017). However, ater a recent
systematic review o Cochrane and Reprotox databases, authors
concluded that ondansetron is not teratogenic (Kaplan, 2019).
Other drawbacks include potential maternal eects rom prolonged Q-interval and serotonin syndrome. For these reasons
it is preerably reserved or severe cases ater 8 weeks’ gestation
(Lavecchia, 2018).
When simple measures ail, intravenous (IV) crystalloid
solutions are given to correct dehydration, ketonemia, electrolyte decits, and acid-base imbalances. Hypokalemia is common, and cardiac arrest has been reported (Walch, 2018). No
benets are gained by inusing 5-percent dextrose along with
crystalloids (an, 2013). Tiamine,
100 mg, is usually diluted in 1 L o
the selected crystalloid to prevent Wernicke encephalopathy or women who
require IV hydration and have vomited or more than 3 weeks (Giugale,
2015). It is inused at the maintenance
rate desired or patient hydration. Tis
thiamine dose is provided daily or the
next 2 to 3 days and is ollowed by IV
multivitamins i IV hydration continues (Levichek, 2002).
I vomiting persists ater rehydration and ailed outpatient management, hospitalization is recommended
(American College o Obstetricians
and Gynecologists, 2018). IV hydration is continued and antiemetics such
as promethazine, prochlorperazine,
chlorpromazine, or metoclopramide
are given parenterally (Table 57-4).
Several antiemetics are associated with
the long-Q syndrome, discussed in
Chapter 52 (p. 936). Outpatient treatment regimens at the hospital also are
eective (McCarthy, 2014).
Some, but not all, studies indicate
that treatment with glucocorticosteroids
is not eective (Sridharan, 2020; Yost,
2003). Tey are recommended only or
reractory cases because o their putative teratogenicity (American College
o Obstetricians and Gynecologists,
2018).
With persistent vomiting ater hospitalization, appropriate steps should
be taken to exclude possible underlying diseases as a cause o hyperemesis.
FIGURE 57-1 Algorithm or outpatient and inpatient management o pregnancy nausea
and vomiting, and hyperemesis gravidarum.
2012). One woman had recurrent encephalopathy in a subsequent pregnancy (Stephens, 2019). Maternal deaths have been
described, and long-term sequelae include blindness, convulsions, and coma (Oudman, 2019; Selitsky, 2006). Vitamin K
is a second potential deciency. Maternal coagulopathy, etal
intracranial hemorrhage, and vitamin K embryopathy have
been reported (Kawamura, 2008; Lane, 2015; Nijsten, 2021).
Management
One management algorithm or nausea and vomiting o pregnancy is shown in Figure 57-1. Most women with mild to
moderate symptoms respond to outpatient therapy with any
o several rst-line antiemetic agents (Boelig, 2018, McParlin,
2016). One mainstay is Diclegis—a combination o doxylamine
(10 mg) plus pyridoxine (10 mg). Te usual dose is two tablets orally at bedtime, and it appears sae and eective (Briggs,
2017; Koren, 2014). I relie is insucient, one additional
rst-morning tablet is added to the bedtime dose. Tis can be
urther escalated to include one rst-morning, one midaternoon, and two bedtime tablets (Duchesnay Inc., 2018). At our1016
Section 12
Medical and Surgical Complications
Tat said, in one study, endoscopy did not change management
in 49 women (Debby, 2008). Other potential sources include
gastroenteritis, cholecystitis, pancreatitis, hepatitis, peptic
ulcer, and pyelonephritis. In addition, severe preeclampsia and
atty liver are more likely ater midpregnancy. Although clinical
thyrotoxicosis has been implicated as a cause o hyperemesis, it
is more likely that abnormally elevated serum thyroxine levels
are a surrogate or higher-than-average serum hCG levels (Sun,
2014). Tis is discussed urther in Chapter 5 (p. 97). In our
experiences, serum ree thyroxine levels normalize quickly with
hydration and emesis treatment.
With treatment, most women will have a positive response
and may be sent home with oral antiemetic therapy. Te readmission rate is 25 to 35 percent in most prospective studies.
Risks or anxiety and depression are increased in these women
(Mitchell-Jones, 2017; Senturk, 2017). At Parkland Hospital,
more than one third o women with hyperemesis required readmission. Patient characteristics had limited utility in predicting
the risk o readmission. For example, maternal demographics, substance use, psychiatric illness, and initial hospitalization length were not associated with readmission (White,
2018). I psychiatric and social actors contribute to the illness,
the woman usually improves remarkably while hospitalized
(Swallow, 2004). However, symptoms relapse in a ourth o these
TABLE 57-4. Medications for Gastrointestinal Disorders in Pregnancy
Medication (Brand Name) Usual Dosing Route(s)
Options for nausea and vomiting
Antihistamine
Doxylamine + pyridoxine (Diclegis)a At bedtime; up to 4 times daily PO
Phenothiazines Every 6 hr
Promethazine (Phenergan)c 12.5–25 mg IM, IV, PO, PR
Prochlorperazine (Compazine)c 5–10 (25 PR) mg IM, IV, PO, PR
Chlorpromazine (Thorazine)c 25–50 mg IM, PO
Serotonin antagonist Every 8 hr
Ondansetron (Zoran)b 8 mg IV, PO
Benzamides Every 6 hr
Metoclopramide (Reglan)b 5–15 mg IM, IV, PO
Trimethobenzamide (Tigan) 300 mg PO
Oral options for gastroesophageal reflux disease (GERD)
Proton-pump inhibitors
Pantoprazole (Protonix)b 40 mg daily or up to 8 wks
Lansoprazole (Prevacid)b 15 mg daily or up to 8 wks
Omeprazole (Prilosec, Zegerid)c 20 mg daily or 4–8 wks
Dexlansoprazole (Dexilant)c 30 mg daily or up to 4 wks
H2-receptor antagonists
Cimetidine (Tagamet)b 400 mg 4 times daily or up to 12 wks
800 mg twice daily or up to 12 wks
Nizatidine (Axid)b 150 mg twice daily
Famotidine (Pepcid)b 20 mg twice daily up to 6 wks
aFood and Drug Administration category A.
bFood and Drug Administration category B.
cFood and Drug Administration category C.
IM = intramuscularly; IV = intravenously; PO = orally; PR = rectally.
women, and some go on to develop posttraumatic stress syndrome
(Chap. 64, p. 1150) (Christodoulou-Smith, 2011; McCarthy,
2011; Nurmi, 2018). For some women, hyperemesis may be an
indication or elective termination (Pourshari, 2007).
Grooten and colleagues (2017) showed that early enteral tube
eeding has no advantages. However, in the small percentage o
women who have recalcitrant vomiting ater intensive therapy,
consideration is given or enteral nutrition (p. 1013). Stokke
and associates (2015) described successul use o nasojejunal
eeding or up to 41 days in 107 such women. Use o sonography to conrm correct tube placement has been described and
avoids radiation exposure (Swartzlander, 2013). PEG-J tubes
also have been reported (Saha, 2009; Schrag, 2007).
Only a very ew women will require parenteral nutrition
(American College o Obstetricians and Gynecologists, 2018;
Yost, 2003). In a study o 599 women, however, Peled and
coworkers (2014) reported that 20 percent required central
parenteral nutrition.
■ Gastroesophageal Reflux Disease
Symptomatic reux is seen in up to 15 percent o nonpregnant
individuals (Kahrilas, 2018). Te spectrum o sequelae includes
esophagitis, stricture, Barrett esophagus, and adenocarcinoma.Gastrointestinal Disorders 1017
CHAPTER 57
Te main symptom o reux is pyrosis (heartburn), which is
especially common in pregnancy. In one study, its prevalence
rose rom 26 percent in the rst trimester to 36 percent in
the second and 51 percent in the third trimester (Fill Malertheiner, 2017). Te retrosternal burning sensation stems rom
esophagitis caused by gastroesophageal reux o stomach acid,
which ollows relaxation o the lower esophageal sphincter. Te
diagnosis is typically made rom symptoms alone.
Symptoms usually respond to abstaining rom tobacco and
alcohol, eating small meals, elevating the head o the bed, limiting postprandial recumbency, and avoiding “trigger” oods.
Tese may include atty oods, tomato-based oods, and co-
ee. Oral antacids are rst-line therapy. I severe symptoms
persist, a proton-pump inhibitor is given and an H2-receptor
antagonist and sucralate can be added (see able 57-4). Both
classes are generally sae or use in pregnancy (Briggs, 2017).
From preliminary data, proton-pump inhibitors taken early
in pregnancy may increase the risk or preeclampsia (Hastie,
2019). Sucralate is the aluminum salt o sulated sucrose and
inhibits pepsin. Approximately 10 percent o the aluminum
salt is absorbed, and this agent is considered sae or pregnant
women (Briggs, 2017). A 1-g sucralate tablet is taken orally 1
hour beore each o the three meals and at bedtime or up to 8
weeks. Antacids are not used within a hal hour beore or ater
sucralate doses. Despite attempts with these options, i relie
is not attained, endoscopy should be considered. Misoprostol is
contraindicated because it stimulates labor (Chap. 26, p. 490).
In nonpregnant patients, surgical undoplication can be per-
ormed (Kahrilas, 2018). Although the procedure is not done
during pregnancy, Biertho and colleagues (2006) described 25
women who had undergone laparoscopic Nissen undoplication beore pregnancy. Only 20 percent had reux symptoms
during pregnancy.
■ Hiatal Hernia
Te older literature is inormative regarding hiatal hernias in
pregnancy. Upper gastrointestinal radiographs perormed in
195 women in late pregnancy showed that 20 percent o 116
multiparas and 5 percent o 79 nulliparas had a hiatal hernia
(Rigler, 1935). O 10 women studied postpartum, hernia persisted in three at 1 to 18 months.
Te relationship o hiatal hernia with reux esophagitis is
not clear. One study demonstrated no association and showed
that the lower esophageal sphincter unctioned eectively even
when displaced intrathoracically (Cohen, 1971). Nevertheless,
during pregnancy, hiatal hernias may cause vomiting, epigastric pain, and bleeding rom ulceration. Schwentner (2011)
reported severe herniation requiring surgical repair in a woman
with a 12-week gestation. Curran and coworkers (1999)
described a 30-week pregnancy complicated by gastric outlet
obstruction rom a paraesophageal hernia.
■ Diaphragmatic Hernia
Tese are caused by herniations o abdominal contents through
either the oramen o Bochdalek or Morgagni. Fortunately,
they rarely complicate pregnancy. In one review o 18 pregnant
women who developed acute obstruction within a diaphragmatic hernia, the maternal mortality rate was 45 percent
(Kurzel, 1988). Herniation has been reported in one woman
who had antireux surgery in early pregnancy (Brygger, 2013).
Several case reports also describe spontaneous diaphragmatic
rupture rom elevated intraabdominal pressure during delivery
(Chen, 2012; Shariah, 2003). Surgical treatment is considered in symptomatic gravidas and is individualized according
to gestational age and clinical setting (Ménassa, 2019; Whang,
2018).
■ Achalasia
In this rare motility disorder, the lower esophageal sphincter ails to relax properly with swallowing. Te esophageal
muscularis also displays nonperistaltic contraction activity
(Kahrilas, 2018). Te deect is caused by inammatory destruction o the myenteric (Auerbach) plexus within smooth muscle
o the lower esophagus and its sphincter. Postganglionic cholinergic neurons are unaected, and thus sphincter stimulation
is unopposed.
Symptoms are dysphagia, chest pain, and regurgitation. Barium swallow radiography demonstrates bird beak or ace o spades
narrowing at the distal esophagus. Endoscopy is perormed to
exclude gastric carcinoma, and manometry is conrmatory.
During pregnancy, normal physiological relaxation o the
lower esophageal sphincter in women with achalasia theoretically should not occur. In one series, hal o these women had
worsened symptoms, but reux is uncommon (Vogel, 2018).
In other pregnancy studies, most women did not have worsening symptoms (Khudyak, 2006). At least one maternal death
was reported at 24 weeks’ gestation and peroration o a 14-cmdiameter megaesophagus was implicated (Fassina, 1995).
Management o achalasia includes a sot diet and anticholinergic drugs. With persistent symptoms, other options include
nitrates, calcium-channel antagonists, and botulinum toxin A
injected locally (Hoot, 2015; Kahrilas, 2018). Balloon dilation
o the sphincter may be necessary, and 85 percent o nonpregnant patients respond (Vogel, 2018). One caveat is that esophageal peroration is a serious complication o dilation. I dilation or
medical therapy ail to provide relie, myotomy is considered.
In one report, a 29-week pregnant woman with achalasia was
treated or 10 weeks with peripheral parenteral nutrition, and
surgical myotomy was done postpartum (Spiliopoulos, 2013).
■ Peptic Ulcer Disease
Te lietime prevalence o acid peptic disorders in women is
10 percent (Del Valle, 2018). Erosive ulcer disease involves the
stomach and duodenum. Gastroduodenal ulcers commonly
are caused by chronic gastritis rom Helicobacter pylori, or they
develop rom nonsteroidal antiinammatory drug (NSAID)
use. Neither is common in pregnancy (McKenna, 2003;
Weyermann, 2003). Rosen and coworkers (2021) reported
2535 pregnant women with peptic ulcer disease and ound that
complications were less requent than in nonpregnant controls.
Acid secretion also is important, and this underlies the e-
cacy o antisecretory agents. Natural gastroprotection during1018
Section 12
Medical and Surgical Complications
pregnancy probably originates rom physiological changes
that include reduced gastric acid secretion, decreased motility,
and considerably increased mucus secretion (Hytten, 1991).
Despite this, ulcer disease may be underdiagnosed because
o requent treatment or reux esophagitis (Mehta, 2010).
In the past 55 years at Parkland Hospital, during which time
we have cared or more than 600,000 pregnant women, we
have encountered very ew who had proven ulcer disease. Per-
oration is rare (Goel, 2014). Beore appropriate therapy was
commonplace, Clark (1953) studied 313 pregnancies in 118
women with ulcer disease and noted a clear remission during
pregnancy in almost 90 percent. However, benets were short
lived. Symptoms recurred in more than hal by 3 months postpartum and in almost all by 2 years.
Te mainstay o management is eradication o H pylori and
prevention o NSAID-induced disease. Antacids are usually
sel-prescribed, but other rst-line therapy is a proton-pump
inhibitor or H2-receptor blocker (see able 57-4) (Del Valle,
2018; Laine, 2012). Sucralate can be added and provides a
protective coating at the ulcer base.
With active ulcers, a search or H pylori is undertaken. Diagnostic aids include the urea breath test, serological testing, ecal
testing, or endoscopic biopsy. I any o these yield positive
results, combination antimicrobial plus proton-pump inhibitor
therapy is indicated (Chey, 2017). Several eective oral treatment regimens do not include tetracycline and can be used during pregnancy. One 14-day regimen includes clarithromycin,
500 mg twice daily, which is paired either with amoxicillin,
1000 mg twice daily or with metronidazole, 500 mg three times
daily. Tese antibiotics are given with a proton-pump inhibitor
(Del Valle, 2018).
■ Upper Gastrointestinal Bleeding
In some women, persistent vomiting is accompanied by worrisome upper gastrointestinal bleeding. Occasionally, a peptic
ulcer is the source. However, most o these women have small
linear mucosal tears near the gastroesophageal junction—
Mallory-Weiss tears (p. 1014). Bleeding usually responds
promptly to conservative measures that include IV protonpump inhibitors and topical antacids (Laine, 2012). rans-
usions may be needed, and i bleeding persists, endoscopy is
usually indicated (O’Mahony, 2007). With sustained retching,
the less common, but more serious, esophageal rupture—Boerhaave syndrome—may develop rom high esophageal pressure.
SMALL BOWEL AND COLON DISORDERS
Te small bowel has diminished motility during pregnancy.
Lawson and colleagues (1985) showed that the small bowel
mean transit times o 99, 125, and 137 minutes in each successive trimester, respectively, were slower than 75 minutes when
nonpregnant. Muscular relaxation o the colon is accompanied
by increased absorption o water and sodium that predisposes to
constipation. Tis complaint is reported by almost 25 percent
o women at some time during pregnancy and the puerperium
(Everson, 1992). Symptoms are usually only mildly bothersome, and initial treatment includes increasing uid intake
(>8 glasses/d) and ber consumption (20 to 35 g/d) (Body,
2016). I these liestyle modications ail, bulk-orming agents
such as methylcellulose may be added, and in severe cases the
stimulant laxative bisacodyl. We have encountered several pregnant women who developed megacolon rom impacted stool.
Tese women almost invariably had chronically abused stimulatory laxatives.
■ Acute Diarrhea
Te estimated monthly prevalence o diarrhea among adults
is 3 to 7 percent (DuPont, 2014). Diarrhea can be classied
as acute (<2 weeks), persistent (2 to 4 weeks), and chronic
(>4 weeks). Most cases o acute diarrhea are caused by inectious agents, and a third result rom oodborne pathogens. Te
large variety o viruses, bacteria, helminths, and protozoa that
cause diarrhea in adults also afict pregnant women. Tese are
usually accompanied by vomiting, ever, and abdominal pain.
Some o these are discussed in Chapter 64 (p. 1197).
Evaluation o acute diarrhea depends on its severity and
duration. Some indications or evaluation include prouse
watery diarrhea with dehydration, grossly bloody stools, ever
>38°C, duration >48 hr without improvement, recent antimicrobial use, and diarrhea in the immunocompromised patient
(Camilleri, 2018; DuPont, 2014). Cases o moderately severe
diarrhea with ecal leukocytes or gross blood may be treated
with empirical antibiotics rather than evaluation. However,
risks and benets should be considered, and it is reasonable to
withhold treatment until stool testing is completed to exclude
inection. Some eatures o the more common acute diarrheal
syndromes and their treatment are shown in Table 57-5.
Te mainstay o treatment is IV hydration using normal
saline or Ringer lactate and potassium supplementation in
amounts to restore maternal blood volume and to ensure uteroplacental perusion. Vital signs and urine output are monitored
or signs o sepsis. For moderately severe nonebrile illness
without bloody diarrhea or recent travel, antimotility agents
such as loperamide (Imodium) may be useul. An initial 4-mg
(two capsules) dose can be ollowed with another 2-mg capsule ater subsequently passed watery stools. Dosages should
not exceed 8 mg/d, and loperamide is not used or more than
48 h. Bismuth subsalicylate (Pepto-Bismol) also may alleviate
symptoms. Te recommended dosage is 30 mL (525 mg) o its
liquid orm or two tablets (263 mg/tablet) chewed well each 30
to 60 min and not to exceed eight doses in 24 h. Te drug will
produce harmless black stools (Riddle, 2016).
Judicious use o antimicrobial agents is warranted. For moderately to severely ill women, some recommend empirical treatment with ciprooxacin, 500 mg twice daily or 3 days. Specic
pathogens are treated as needed when identied (see able 57-5).
Syndromes or which treatment is usually unnecessary include
those caused by Escherichia coli, staphylococcal species, Bacillus cereus, and norovirus. Severe illness caused by Salmonella
species is treated with ciprooxacin or trimethoprim-sulamethoxazole; by Campylobacter species with azithromycin; by
Clostridioides dicile with oral vancomycin or daxomicin; and
by Giardia species and Entamoeba histolytica with metronidazole (DuPont, 2014; McDonald, 2018; Rocha-Castro, 2016).Gastrointestinal Disorders 1019
CHAPTER 57
Clostridioides difficile Infection
Formally known as Clostridium dicile, this anaerobic grampositive bacillus is transmitted by the ecal-oral route. In a study
rom China, 3.7 percent o normal gravidas were colonized
(Ye, 2016). It is the most requent nosocomial inection in the
United States. In 2011, 453,000 cases o C dicile and 29,000
associated deaths were reported by the Centers or Disease
Control and Prevention (Lessa, 2015). Its incidence in pregnant women has doubled during the past decade (Ruiter-Ligeti,
2018). Te most important risk actor is antibiotic use, and the
highest risk is with aminopenicillins, clindamycin, cephalosporins, and uoroquinolones. Other risk actors include inammatory bowel disease, immunosuppression, advanced age,
and gastrointestinal surgery. Most cases are hospital-acquired,
however, 10 percent are community-acquired cases (Gerding,
2018). With severe colitis, the inection-related mortality rate
is 5 percent.
Laboratory diagnosis rom a stool sample uses nucleic-acid
amplication testing (NAA) or C dicile itsel or uses an
enzyme-immunoassay-based algorithm or a unique C dicile
enzyme or its toxins A and B (McDonald, 2018). Less oten,
inection may be diagnosed endoscopically (Fig. 57-2). Only
patients with new-onset diarrhea and ≥3 unormed stool o
unexplained etiology should be tested, and posttreatment testing is not recommended. Prevention is by soap-and-water hand
TABLE 57-5. Etiology, Clinical Features, and Treatment of Common Acute Diarrheal Syndromes
Agents Incubation Emesis Pain Fever Diarrhea Treatment
Toxin producers
1. Staphylococcus spp.
2. C perringens
3. E coli (enterotoxin)
4. B cereus
1–72 hr 3–4+ 1–2+ 0–1+ 3–4+, watery
1. None
2. None
3. Ciprofoxacin
4. None
Enteroadherent
1. E coli
2. Giardia spp.
3. Helminths
1–8 days 0–1+ 1–3+ 0–2+ 1–2+, watery,
mushy 1. Ciprofoxacin
2. Tinidazole
3. As detected
Cytotoxin producers
1. C difcile
2. E coli (hemorrhagic)
1–3 days 0–1+ 3–4+ 1–2+ 1–3+, watery,
then bloody 1. Vancomycin
2. None
Inflammatory
Minimal
1. Rotavirus
2. Norovirus
Variable
3. Salmonella spp.
4. Campylobacter spp.
5. Vibrio spp.
Severe
6. Shigella spp.
7. E coli
8. Entamoeba histolytica
1–3 days
12 hr–11 days
12 hr–8 days
1–3+
0–3+
0–1+
2–3+
2–4+
3–4+
3–4+
3–4+
3–4+
1–3+, watery
1–4+ watery or
bloody
1–2+, bloody
1. None
2. None
3. Ciproloxacin
4. Azithromycin
5. Doxycycline
6. Ciproloxacin
7. Ciproloxacin
8. Metronidazole
B cereus = Bacillus cereus; C diicile = Clostridioides diicile; C perringens = Clostridium perringens; E coli = Escherichia coli;
spp. = species.
Modiied rom Camilleri, 2018; DuPont, 2014; McDonald, 2018.
A B
C D
FIGURE 57-2 Causes o colitis. A. Ulcerative colitis with diuse
ulcerations and exudates. B. Crohn colitis with deep ulcers.
C. Pseudomembranous colitis with yellow, adherent membranes.
D. Ischemic colitis. (Reproduced with permission rom Song LM,
Topazian M: Gastrointestinal endoscopy. In Jameson JL, Fauci AS,
Kasper DL, et al (eds): Harrison’s Principles o Internal Medicine,
20th ed. New York, NY: McGraw Hill; 2018.)1020
Section 12
Medical and Surgical Complications
Major symptoms o ulcerative colitis include diarrhea, rectal bleeding, tenesmus, and abdominal cramps. Te disease is
characterized by exacerbations and remissions. Toxic megacolon
and catastrophic hemorrhage are particularly dangerous complications that may necessitate colectomy. Extraintestinal mani-
estations include arthritis, uveitis, and erythema nodosum. Te
risk o associated colon cancer approaches 1 percent per year.
With either ulcerative colitis or Crohn disease, risks or VE
are higher in even asymptomatic women (Friedman, 2018;
Mahadevan, 2019).
Crohn Disease
Also known as regional enteritis, Crohn ileitis, or granulomatous colitis, Crohn disease has more protean maniestations than
ulcerative colitis. It involves not only the mucosa but also the
deeper bowel layers (see Fig. 57-2). Lesions can be seen throughout the entire GI tract, rom the mouth to the anus, but it typically is segmental (Friedman, 2018). Approximately 30 percent
o patients have only small-bowel involvement, 25 percent have
isolated colonic involvement, and 40 percent have both, usually
with the terminal ileum and colon involved. Perianal stulas and
abscesses develop in a third o those with colonic involvement.
Symptoms depend on which bowel segment(s) is involved.
Tus, complaints may include lower-right-sided cramping
abdominal pain, diarrhea, weight loss, low-grade ever, and
obstructive symptoms. Te disease is chronic with exacerbations and remissions, and importantly, it cannot be cured medically or surgically. Approximately a third o patients require
surgery within the rst year ater diagnosis, and thereater, the
rate is 5 percent per year. Reactive arthritis is common, and the
GI cancer risk, although not as great as with ulcerative colitis,
is increased substantially.
TABLE 57-6. Some Shared and Differentiating Characteristics of Inflammatory Bowel Disease
Ulcerative Colitis Crohn Disease
Shared Characteristics
Hereditary More than 100 disease-associated genetic loci–a third shared; Jewish predominance; amilial in
5–10% o cases; Turner syndrome; immune dysregulation
Other Chronic and intermittent with exacerbations and remissions; extraintestinal maniestations: arthritis,
erythema nodosum, uveitis
Differentiating Characteristics
Major symptoms Diarrhea, tenesmus, rectal bleeding, cramping pain;
chronic, intermittent; anemia
Fibrostenotic–recurrent RLQ colicky pain; ever
Fistulizing–cutaneous, bladder, interenteric
Bowel involvement Mucosa and submucosa o large bowel; usually
begins at rectum (40% proctitis only); continuous
disease
Deep layers small and large bowel; commonly
transmural; discontinuous involvement;
strictures and istulas
Endoscopy Granular and riable erythematous mucosa;
bleeding; rectal involvement
Patchy; segmental colitis; rectum spared;
perianal involvement
Serum antibodies Antineutrophil cytoplasmic (pANCA) ∼70% Anti–S cerevisiae ∼50%
Complications Toxic megacolon; strictures; arthritis; cancer (3–5%) Fistulas; arthritis; toxic megacolon; small bowel
obstruction
Management Medical; proctocolectomy curative Medical; segmental and istula resection
RLQ = right lower quadrant; S cerevisiae = Saccharomyces cerevisiae.
From Friedman, 2018; Lichtenstein, 2009.
washing, and inected individuals are isolated. reatment consists o stopping the oending antibiotics and giving 10 days
o oral vancomycin, 125 mg our times daily, or daxomicin
(Dicid), 200 mg twice daily (McDonald, 2018). Te risk o
recurrence ater an initial episode is 20 percent. Fecal microbial
transplantation may become standard or recurrent clostridial
colitis (Saeedi, 2017).
■ Inflammatory Bowel Disease
wo presumably noninectious orms o intestinal inammation are ulcerative colitis and Crohn disease. Dierentiation
between these is important because treatment diers. Tat said,
they both share common eatures, and sometimes are indistinguishable i Crohn disease involves the colon. Te eatures
shown in Table 57-6 permit a reasonably condent diagnostic
dierentiation in most cases. Te etiopathogenesis is enigmatic
in both, but a genetic predisposition is suspected, especially or
Crohn disease. Inammation is thought to result rom dysregulated mucosal immune unction in response to commensal microbiota, with or without an autoimmune component
(Friedman, 2018).
Ulcerative Colitis
Tis is a mucosal disorder with inammation conned to the
supercial luminal layers o the colon. It typically begins at the
rectum and extends proximally or a variable distance. In approximately 40 percent o cases, disease is conned to the rectum or
the rectosigmoid, but 20 percent have pancolitis. For unknown
reasons, prior appendectomy protects against ulcerative colitis
(Friedman, 2018). Endoscopic ndings include mucosal granularity and riability that is interspersed with mucosal ulcerations
and a mucopurulent exudate (see Fig. 57-2).Gastrointestinal Disorders 1021
CHAPTER 57
Inflammatory Bowel Disease and Fertility
Subertility in women is linked to active disease, but normal
ertility is likely with quiescent colitis (Mahadevan, 2019). Sub-
ertility may also be partially attributed to sulasalazine, which
causes reversible sperm abnormalities (Feagins, 2009).
For women requiring surgical resection, a laparoscopic
approach has a higher subsequent ertility rate (Beyer-Berjot, 2013). With colectomy, however, although ertility is
improved, up to hal o women will be persistently inertile (Bartels, 2012; Lee, 2019a). Sexual unction and ertility
are only modestly aected by ileal pouch–anal anastomosis
(Hor, 2016).
Inflammatory Bowel Disease and Pregnancy
Because ulcerative colitis and Crohn disease are relatively common in young women, these disorders are encountered with
some requency in pregnancy. In many studies, the outcomes
are grouped together or both entities. For example, in a study
rom Australia, Shand and colleagues (2016) reported a prevalence o 1 inammatory bowel disease (IBD) case in 320 births.
In this regard, some generalizations can be made. First, consensus supports that pregnancy does not increase the likelihood o
an IBD are (Mahadevan, 2019). Indeed, in a 10-year surveillance o women in the European Collaborative on Inammatory Bowel Disease, the likelihood o a are during pregnancy
was lower than the preconceptional rate (Riis, 2006). Although
most women with quiescent disease in early pregnancy do not
have relapses, when a are develops, it may be severe. Also,
and as discussed subsequently, active disease in early pregnancy
increases the likelihood o disease relapse during pregnancy (de
Lima-Karagiannis, 2016).
In general, most usual treatment regimens may be continued during pregnancy. Diagnostic evaluations should be undertaken i needed to direct management, and surgery should be
perormed i indicated (Mahadevan, 2019). Fecal calprotectin,
an inammatory biomarker in stool samples, is a valid tool in
pregnancy to identiy IBD ares (Julsgaard, 2017; Lichtenstein,
2018; Rubin, 2019).
At rst glance, it appears that adverse pregnancy outcomes
are increased with IBD (Boyd, 2015; Getahun, 2014). Initially, this was attributed to the act that most studies included
women with either orm o disease. Specically, Crohn disease
was noted to be linked to excessive morbidity. But, according
to Reddy (2008) and others, these adverse outcomes were in
women with severe disease and multiple recurrences. Indeed,
in the prospective European case-control ECCO-EpiCom
study o 332 pregnant women with IBD, outcomes were
similar in women with ulcerative colitis or Crohn disease
compared with unaected pregnant women (Bortoli, 2011).
Still, women with active disease during pregnancy have an
increased requency o preterm births (Kammerlander, 2017;
Shand, 2016). Importantly, perinatal mortality rates are not
appreciably increased.
Ulcerative Colitis and Pregnancy. In one review o 755 pregnancies, colitis that was quiescent at conception worsened
in approximately a third o pregnancies (Fonager, 1998). In
women with active disease at the time o conception, approximately 45 percent worsened, 25 percent remained unchanged,
and only 25 percent improved. Tese observations are similar
to those described in a review by Miller (1986) as well as in
later reports (de Lima-Karagiannis, 2016; Oron, 2012).
Osteoporosis is a signicant complication in up to a third
o aected women. Tus, vitamin D—800 IU daily—and
calcium—1200 mg daily—are given. Folic acid, 2 to 4 mg
orally daily, is recommended preconceptionally and during the
rst trimester or neural-tube deect prevention (Mahadevan,
2019). Tis high dose counteracts the antiolate actions o sul-
asalazine. Flares may be caused by psychogenic stress, and reassurance is important. Last, the venous thromboembolism risk
is doubled, but thromboprophylaxis is not routinely provided
(Hansen, 2017).
Management or colitis or the most part mirrors that
outside o pregnancy. reatment o active colitis and maintenance therapy incorporate drugs that deliver 5-aminosalicyclic acid (5-ASA), also known as mesalamine. Sulasalazine
(Azulfdine) is the prototype, and its 5-ASA moiety inhibits
prostaglandin synthase in colonic mucosa. Others include
olsalazine (Dipentum), balsalazide (Colazal), and delayedrelease 5-ASA derivatives (Apriso, Asacol, Pentasa, Lialda).
Glucocorticoids are benecial and are given orally, parenterally, or by enema or moderate or severe disease that does not
respond to 5-ASA. Corticosteroids provide a high remission
rate or active disease, but they are not given or maintenance
therapy (Friedman, 2018). Recalcitrant disease is managed
with immunomodulating drugs, including azathioprine,
6-mercaptopurine, cyclosporine, or tacrolimus, which all appear
relatively sae in pregnancy (Briggs, 2017; Mozaari, 2015).
Importantly, methotrexate is teratogenic and contraindicated
in pregnancy (Chap. 8, p. 152).
In the past, biologics were reserved or recalcitrant, moderate to severe disease. Because o their considerable ecacy,
however, these medications are now requently given initially
or this severity o disease to prevent uture complications.
Tese agents are antibodies against tumor necrosis actor alpha
(NF-α). Tose recommended or IBD treatment are shown in
Table 57-7 (Mahadevan, 2019). Women who begin pregnancy
while taking biologics should continue these through pregnancy
until several weeks beore delivery to help avoid maternal inections rom immunosuppression. Tese agents are administered
TABLE 57-7. Biologics Used to Treat Inflammatory
Bowel Disease in Pregnancy
Drug (Brand Name) Recommendations
Adalimumab (Humira) Last dose 2–3 wks beore EDC
Certolizumab pegol
(Cimzia)
Continue throughout pregnancy
Inliximab (Remicade) Last dose 6–10 wks beore EDC
Natalizumab (Tysabri) Last dose 4–6 wks beore EDC
Ustekinumab (Stelara) Last dose 6–10 wks beore EDC
Vedolizumab (Entyvio) Last dose 6–10 wks beore EDC
EDC = estimated date o coninement.1022
Section 12
Medical and Surgical Complications
IV or subcutaneously. Several studies support their saety in
pregnancy, although there are concerns that their discontinuance may prompt a relapse (Chaparro, 2018; Friedman, 2018;
Luu, 2018). Another worry is that they may cause immunosuppression in the newborn, and early neonatal vaccination with
live-attenuated agents are delayed or at least 6 months (EsteveSolé, 2017; Julsgaard, 2016).
Colorectal endoscopy is perormed as indicated. Surgical
management is tailored to disease severity (Killeen, 2017).
During pregnancy, colectomy and ostomy creation or ulminant colitis may be needed as a liesaving measure, and it has
been described during each trimester. Dozois (2006) reviewed
42 such cases and ound that, in general, outcomes have been
good with partial or complete colectomy. Parenteral nutrition is
occasionally needed or women with prolonged exacerbations.
For women with an ileal pouch and an anal anastomosis,
requency o bowel movements, ecal incontinence, and pouchitis may temporarily worsen with pregnancy. Te last is an
inammatory condition o the ileoanal pouch probably due to
bacterial prolieration and stasis. Pouchitis usually responds to
ciprooxacin or metronidazole. In one rare case, adhesions to
the growing uterus led to ileal pouch peroration (Aouthmany,
2004).
In general, women with uncomplicated colitis can be delivered vaginally (Foulon, 2017). Tat said, the cesarean delivery
rate in these women is increased (Burke, 2017). It is controversial whether women who have had a prior proctocolectomy and
ileal pouch–anal anastomosis can be saely delivered vaginally.
Hahnloser (2004) reviewed delivery routes in women with 235
pregnancies beore and 232 pregnancies ater ileoanal pouch
surgery. Functional outcomes were similar, and it was concluded that cesarean delivery should be reserved or obstetrical
indications. o the contrary, ollowing their systematic review,
Foulon and coworkers (2017) recommended cesarean delivery
with the caveat that uncomplicated vaginal delivery was sae.
As discussed, quiescent ulcerative colitis likely has minimal adverse eects on pregnancy outcome. Modigliani (2000)
reviewed perinatal outcomes in 2398 pregnancies and reported
them to be not substantively dierent rom those in the general
obstetrical population. Specically, the incidences o spontaneous abortion, preterm delivery, and stillbirth were remarkably
low. Tese authors and others also describe a cesarean delivery
rate that was substantially higher than that or normal controls
(Burke, 2017; Mahadevan, 2015). Te previously described
ECCO-EpiCom study reported similar outcomes in 187
gravidas with ulcerative colitis compared with normal control
women (Bortoli, 2011).
Crohn Disease and Pregnancy. In general, Crohn disease
activity during pregnancy is related to its status around the
time o conception. In a cohort study o 279 pregnancies conceived by 186 women whose disease was inactive at conception, a ourth relapsed during pregnancy (Fonager, 1998). In
93 with active disease at conception, however, two thirds either
remained active or worsened. Other reviews describe similar
ndings (Miller, 1986; Oron, 2012).
Calcium, vitamin D, and olic acid supplementation mirror
that or ulcerative colitis. For maintenance during asymptomatic
periods, no regimen is universally eective. Sulasalazine is
eective or some, but the newer 5-ASA ormulations are better
tolerated. Glucocorticoids induce a 60- to 70-percent remission
rate (Friedman, 2018). Prednisone therapy may control moderate
to severe ares but is less eective or small-bowel involvement.
Immunomodulators such as azathioprine, 6-mercaptopurine,
cyclosporine, and tacrolimus are used or active disease and or
maintenance. Tese appear relatively sae during pregnancy
(Chaparro, 2018; Luu, 2018). As discussed in Chapter 8
(p. 152), methotrexate is contraindicated in pregnancy. As with
ulcerative colitis, treatment with NF-α inhibitors is oten
used initially or active Crohn disease and maintenance (see
able 57-7) (Friedman, 2018; Mahadevan, 2019).
Endoscopy or conservative surgery is indicated or complications (Killeen, 2017). Patients with small-bowel involvement
are more likely to require surgery or complications that include
stulas, strictures, obstruction, abscesses, and intractable disease. In an earlier study, an abdominal surgical procedure was
required during 5 percent o pregnancies (Woolson, 1990).
Parenteral nutrition has been used successully during severe
recurrences. Tose with an ileal loop colostomy may have signicant problems. Unless there is a perianal stula or active
perianal disease, women with Crohn disease usually can
undergo vaginal delivery without complications (Foulon, 2017;
Mahadevan, 2019).
As discussed, Crohn disease compared with ulcerative colitis is associated with higher adverse pregnancy outcome rates.
Outcomes are probably related to disease activities. In a casecontrol Danish study, Norgård (2007) reported a twoold risk
o preterm births. Dominitz (2002) reported a two- to three-
old increased risk or preterm delivery, low birthweight, etalgrowth restriction, and cesarean delivery in 149 women with
Crohn disease. Recall, however, that the ECCO-EpiCom study
ound pregnancy outcomes to be similar to those in unaected
women.
■ Ostomy and Pregnancy
A colostomy or an ileostomy can be problematic during pregnancy because o its location (Hux, 2010). In a report o 82
pregnancies in 66 women with an ostomy, stomal dysunction
was common, but it responded to conservative management in
most cases (Gopal, 1985). Surgical intervention was necessary,
however, in three o six women who developed bowel obstruction and in another our with ileostomy prolapse—almost 10
percent overall. In this older study, only a third o 82 women
underwent cesarean delivery, but akahashi (2007) described
six o seven cesarean deliveries in women with Crohn disease
and a stoma. Although adhesions usually are involved with an
obstructed ileostomy, the enlarging uterus may act to cause
obstruction (Porter, 2014). Last, Farouk and coworkers (2000)
reported that pregnancy did not worsen long-term ostomy
unction.
■ Intestinal Obstruction
Te incidence o bowel obstruction is not increased during
pregnancy, although it generally is more dicult to diagnose.
Meyerson (1995) reported a 20-year incidence o 1 case inGastrointestinal Disorders 1023
CHAPTER 57
17,000 deliveries at two Detroit hospitals. O acute abdomen
cases in pregnancy, adhesive disease leading to small-bowel
obstruction was second only to appendicitis—15 versus 30
percent, respectively (Unal, 2011). Approximately hal o cases
are due to adhesions rom previous pelvic surgery that includes
cesarean delivery (Andol, 2010; Lyell, 2011). Another 25 percent o bowel obstruction is caused by volvulus, which may
involve sigmoid colon, cecum, or small bowel. Tese have been
reported in late pregnancy or early puerperium (Al Maksoud,
2015; Bade, 2014). Bokslag (2014) and Wax (2013) and their
colleagues described small-bowel obstruction in pregnancy ollowing the currently popular Roux-en-Y gastric bypass, which
is perormed or weight loss. Intussusception is occasionally
encountered (Bosman, 2014; Moliere, 2019). Bowel obstruction subsequent to colorectal surgery or cancer was increased
threeold in women who had open versus laparoscopic surgery
(Haggar, 2013). Last, Serra and coworkers (2014) described a
massive ventral hernia with intestinal obstruction.
Most cases o intestinal obstruction during pregnancy result
rom pressure o the growing uterus on intestinal adhesions.
Tis is more likely around midpregnancy when the uterus
becomes an abdominal organ; in the third trimester when the
etal head descends; or immediately postpartum when uterine
size acutely shrinks (Davis, 1983). Perdue (1992) reported
that 98 percent o aected pregnant women had either continuous or colicky abdominal pain, and 80 percent had nausea
and vomiting. Abdominal tenderness was ound in 70 percent,
and abnormal bowel sounds noted in only 55 percent. Plain
abdominal radiographs ollowing soluble contrast showed evidence o obstruction in 90 percent o aected women. Plain
radiographs, however, are less accurate or diagnosing smallbowel obstruction, and we and others have ound that C
and MR imaging can be diagnostic (Essile, 2007; Moliere,
2019). Colonoscopy can be both diagnostic and therapeutic or
colonic volvulus (Dray, 2012; Khan, 2012).
During pregnancy, mortality rates with obstruction can be
excessive because o dicult and thus delayed diagnosis, reluctance to operate during pregnancy, and the need or emergency
surgery (Firstenberg, 1998; Shui, 2011). In an older report o
66 pregnancies, Perdue and associates (1992) described 6-percent maternal and 26-percent etal mortality rates. wo o the
our women who died were in late pregnancy, and they had
bowel peroration rom sigmoid or cecal volvulus caused by
adhesions.
■ Colonic PseudoObstruction
Also known as Ogilvie syndrome, pseudo-obstruction is caused
by adynamic colonic ileus. It is characterized by massive
abdominal distention with cecal and right-hemicolonic dilation
(Fig. 57-3). Approximately 10 percent o all cases are associated with pregnancy, and its reported requency is 1 case in
1500 births (Reeves, 2015). Te syndrome usually develops
postpartum—90 percent ater cesarean delivery—but it has
been reported antepartum. In a review, peroration was common, especially i the cecal diameter exceeded 12 cm (Jayaram,
2017). More recently, treatment with an IV inusion o neostigmine, 2 mg, given during cardiac monitoring usually results
in prompt decompression (Song, 2018). In some cases, colonoscopic decompression is perormed, and in others, laparotomy
is needed or peroration (Rawlings, 2010).
■ Appendicitis
Te lietime incidence or appendicitis ranges rom 7 to 10 percent (Flum, 2015). Tus, evaluation or possible appendicitis is
relatively common during pregnancy. Teilen and colleagues
(2017) studied 171 such women during a 5-year period, but
only 14 women ultimately were ound to have pathologically
conrmed appendicitis. Ater clinical and imaging evaluation,
the requency o suspected appendicitis drops and that o con-
rmed appendicitis in more than 8 million women ranged
rom 1 case in 1000 to 5500 births (Abbasi, 2014; Hée, 1999;
Mazze, 1991).
It is repeatedly—and appropriately—emphasized that pregnancy makes the diagnosis o appendicitis more dicult. Nausea
A B
FIGURE 57-3 Ogilvie syndrome. Massive dilation o colon due to pseudo-obstruction in a woman ollowing cesarean delivery. A. Abdominal radiograph. B. Axial image rom computed tomography.1024
Section 12
Medical and Surgical Complications
and vomiting accompany normal pregnancy, but also, as the
uterus enlarges, the appendix commonly moves upward and outward rom the right lower quadrant (Baer, 1932; Erkek, 2015;
Pates, 2009). Another oten-stated reason or late diagnosis is
that some degree o leukocytosis accompanies normal pregnancy. Tat said, Teilen and coworkers (2017) observed that a
white cell count >18,000/μL made the diagnosis tenold more
likely. Neutrophilic shit is another (Gentles, 2020). Pregnant
women—especially in late gestation—requently do not have
clinical ndings “typical” or appendicitis. Tus, it commonly
is conused with cholecystitis, labor, pyelonephritis, renal colic,
placental abruption, or uterine leiomyoma degeneration.
Most reports indicate increasing morbidity and mortality
rates with advancing gestational age. And, as the appendix is
progressively deected upward by the growing uterus, omental
containment o inection becomes increasingly unlikely. It is
indisputable that appendiceal peroration is more common during later pregnancy (Abbasi, 2014). In the studies by Andersson
(2001) and Ueberrueck (2004), the incidence o peroration was
approximately 8, 12, and 20 percent in successive trimesters.
Diagnosis
Persistent abdominal pain and tenderness are the most reproducible ndings. Right lower quadrant pain is the most
requent, although pain migrates upward with appendiceal displacement (Mourad, 2000). For initial evaluation, sonographic
abdominal imaging is reasonable in suspected appendicitis,
even i to exclude an obstetrical cause o pain (Butala, 2010).
Tat said, graded compression sonography is dicult because o
cecal displacement and uterine imposition (Pedrosa, 2009).
Appendiceal computed tomography is more sensitive and accurate than sonography to conrm suspected appendicitis (Katz,
2012; Raman, 2008). Specic views can be designed to diminish etal radiation exposure (Chap. 49, p. 873).
When available, MR imaging is the preerred modality or
evaluation o suspected appendicitis in pregnancy (Fig. 57-4).
MR imaging has high diagnostic yield and accuracy, and it also
provides alternative diagnoses (Fonseca, 2014; Teilen, 2015).
One metaanalysis o 30 studies cited positive- and negativepredictive values o 96 and 99.5 percent, respectively, or MR
imaging (Duke, 2016). Others report similar ndings (Burke,
2015; Kave, 2019). However, Aguilera and colleagues (2018)
ound a sensitivity o only 18 percent in pregnant women.
Management
When appendicitis is suspected, most recommend prompt
surgical exploration. Although diagnostic errors may lead to
removal o a normal appendix, surgical evaluation is preerable
to postponed intervention and generalized peritonitis (Abbasi,
2014). In earlier reports, the diagnosis was veried in only 60
to 70 percent o pregnant women. As indicated above, however, with C and MR imaging, these gures have improved
(Duke, 2016; Teilen, 2015). Still and importantly, the accuracy o diagnosis is inversely proportional to gestational age.
Currently, laparoscopic resection is almost always used to treat
suspected appendicitis during the rst two trimesters. In a report
rom a Swedish database o nearly 2000 laparoscopic appendectomies, perinatal outcomes were similar to those o more than
1500 open laparotomies done beore 20 weeks’ gestation (Reedy,
1997). Conversely, in their review, Wilasrusmee and coworkers (2012) reported a higher rate o etal loss with laparoscopy.
Authors o three more recent systematic reviews indicate that
the level o evidence is not strong enough to demonstrate a pre-
erred approach to appendectomy (Frountzas, 2019; Lee, 2019b;
Walker, 2014). It has evolved that in many centers, laparoscopic
appendectomy is also perormed in most cases during the third
trimester (Donkervoort, 2011). Tis is encouraged by others,
including the Society o American Gastrointestinal and Endoscopic Surgeons (Pearl, 2017; Sekar, 2019; Soper, 2011).
Beore exploration, IV antimicrobial therapy is begun, usually with a second-generation cephalosporin or third- generation
penicillin. Unless there is gangrene, peroration, or a periappendiceal phlegmon, antimicrobial therapy can usually be discontinued ater surgery. Without generalized peritonitis, the
prognosis is excellent. Seldom is cesarean delivery indicated at
the time o appendectomy. Uterine contractions are common,
and although some clinicians recommend tocolytic agents, we
do not. de Veciana (1994) reported that tocolytic use substantially increased the risk or pulmonary-permeability edema
caused by sepsis (Chap. 50, p. 883).
Antimicrobial versus Surgical Treatment
Because o European studies, some advocate that many cases
o appendicitis can be treated successully with IV antimicrobials alone (Flum, 2015; alan, 2019). In one study, 6 percent
o pregnant women with appendicitis were treated medically,
and these gravidas had “considerably” elevated risks or septic
shock, peritonitis, and VE compared with surgically managed
cases (Abbasi, 2014). In another study o 20 women, ailure
rate was 25 percent (Joo, 2017). At this time, we discourage
this practice until appropriate studies have been done with
pregnant women. Certainly, i elected, such treatment should
exclude women with obstructive appendicitis, and the threshold to convert to surgical treatment must be low.
FIGURE 57-4 Magnetic resonance T2 lair image o acute appendicitis in a midtrimester pregnancy. The bright signal is inlammation and the block dot is a ecalith that can be seen in the
midappendix (arrow). The etal trunk (T) and leg (L) and amnionic
luid (A) are seen within the gravid uterus superior to the appendix.
(Reproduced with permission by Dr. Christina Herrera.)Gastrointestinal Disorders 1025
CHAPTER 57
Pregnancy Outcomes
Appendicitis increases the likelihood o preterm labor, especially
i peritonitis has developed. Spontaneous labor ater 23 weeks
ensues with greater requency ollowing surgery or appendicitis
compared with surgery or other indications (Ibiebele, 2019;
Won, 2017). In one study, the etal loss rate was 22 percent
i surgery was perormed ater 23 weeks’ gestation. Tree large
population-based studies attest to the adverse outcomes rom
appendicitis in pregnancy. From the Caliornia State Inpatient
Database, the etal loss rate was 20 percent (Won, 2017). A
nationwide study rom aiwan ound that risks or low birthweight and preterm delivery rose 1.5- to 2-old when outcomes
in 908 women with acute appendicitis were compared with
those o controls (Wei, 2012). Last, an Australian populationbased study reported an almost twoold increased incidence o
preterm birth ollowing appendectomy (Ibiebele, 2019).
Nhận xét
Đăng nhận xét