Dr. Afaf I. Alnoury GIT DSEASES With PREGNANCY بسم الله الرحمن الرحـيـم

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY The alimentary tract is altered physiologically and anatomically during pregnancy 90% of women will experience bother some GIT sometimes during pregnancy The diagnosis of GIT disorders is more difficult during pregnancy

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY NAUSEA & VOMITING 60 – 80 % of women will experience some nausea and vomiting (motion sickness) 3 - 4/1000 the symptoms may be severe or persist throughout pregnancy. THEORIES: The endocrine changes of pregnancy alter the emetic threshold centrally, sensitizing the pregnant women to nausea and vomiting. TREATMENT supportive

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY HYPEREMESIS GRAVIDARUM Pathologic state of nausea & vomiting. This syndrome is defined as vomiting sufficiently pernicious to produce weight loss, dehydration, acidosis (starvation) or alkalosis (loss of HCL in vomitus) and hypokalemia. In severe cases weight loss, acetonuria, ketonemia with accompanying neurological, hepatic and renal damage. More common in women with infertility, immature &/or passive dependant personality types

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY HYPEREMESIS GRAVIDARUM LABORATORY: 1.U & E’s 2.Tests for ketoacidosis and acidosis 3.Urine analysis 4.LFT, Kidney function, CBC TREATMENT: 1.Hospitalization 2.correction of dehydration 3.Electrolyte replacement 4.Nutritional support 5.Ant emetic therapy 6.Psychological and social support

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY REFLUX ESOPHAGITIS (PYROSIS) Raising the head of the bed Oral antacids Endoscopy in persistent casesACHLAIA Is a motor disorder of esophageal smooth muscle in which the lower sphincter doesn't relax properly with swallowing and there are abnormal esophageal contractions PEPTIC ULCER Is uncommon during pregnancyCONSTIPATION

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY ACID ASPIRATION SYNDROME Predisposing factors Patient has eaten sometimes prior to labour Delayed gastric emptying Lower esophageal sphincter tone sedative

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY DISEASES OF THE LIVER CATEGORIZED: 1.Hepatic disorders not related to pregnancy 2.Hepatic disorders occurring as a result of pregnancy associated disease 3.Pregnancy specific hepatic disorders LIVER IN NORMAL PREGNANCY: Size Blood flow Histologically Clinicallyspider angiomata palmar erythema Hepatic excretory functionBSP clearance decrease in 2 nd half serum cholic acid increase

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY DISEASES OF THE LIVER HEPATIC ENZYMES & PROTEIN DURING PREGNANCY: Albumin  Globulin  Fibrinogen  SGPT SGOT PRIMARY HEPATIC DISEASE : Viral Hepatitis Is the most common cause of jaundice in pregnancy 6 types 78% hepatitis B 8% hepatitis A

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY DISEASES OF THE LIVER Hepatitis A: Hepatitis A: Immune globulin prophylaxis can be given during pregnancy Hepatitis A virus doesn't traverse the placenta Maternal infection late weeks of pregnancy – neonate infection Hepatitis B: Hepatitis B: HBV (acute) 1 st trimester no transmission to the fetus 2 nd trimester 6% transmission to the fetus 3 rd trimester 67% transmission to the fetus Postpartum 100% transmission to the fetus Chronic Antenatally intrapartum postpartum

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY DISEASES OF THE LIVER Hepatitis C: Hepatitis C: Higher risk for developing chronic active hepatitis Pregnant women at higher risk of contracting hepatitis C At higher risk of fulminating hepatitis, hepatic necrosis and death

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY DISEASES OF THE LIVER Hepatic disease in pregnancy associated disorders: Hepatic disease in pregnancy associated disorders: PIH Mild PIH  associated alteration in LFT Severe PIH  associated alteration in LFT Diagnosis: History Clinical examination LFT, PT, PTT, Platelet Subcapsular hematomas or liver rupture Subcapsular hematomas or liver rupture Prompt recognition and diagnosis Aggressive support with fluids Cardiovascular support Blood transfusion Partial liver resection &/or hepatic a. ligation Mortalitymaternal 76% perinatal 75%

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY DISEASES OF THE LIVER PREGNANCY APECIFIC HEPATIC DISORDERS: PREGNANCY APECIFIC HEPATIC DISORDERS: Intrahepatic Cholestasis: Intrahepatic Cholestasis: The 2 nd most common cause of jaundice in pregnant women. Mediterranean, Scandinavian Common in 3 rd trimester Associated with HLA BW 16 antigen Pruritis followed by mild jaundice, darkened yellow urine, normal colored stool. LFT – bile acid increased (7-10 folds) SGOT, SGPT mild increase Serum bilirubin increased 5 mg% Coagulation profile is normal, but PT may be prolonged (absorption of vit. K) Fetus at risk from prematurity, death, asphyxia

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY DISEASES OF THE LIVER PREGNANCY SPECIFIC HEPATIC DISORDERS: PREGNANCY SPECIFIC HEPATIC DISORDERS: Acute fatty liver of pregnancy Acute fatty liver of pregnancy Rare Lethal disease maternal mortality 80% fetal mortality 75% C/P Develops in primigravida, third trimester 36 – 40 weeks) May be 30 weeks Rare in immediate postpartum Low grade fever Nausea, vomiting Abdominal pain Jaundice Tachycardia, hypertension, proteinuria

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY DISEASES OF THE LIVER PREGNANCY SPECIFIC HEPATIC DISORDERS: PREGNANCY SPECIFIC HEPATIC DISORDERS: Acute fatty liver of pregnancy Acute fatty liver of pregnancy Laboratory findings Leukocytosis Increased liver enzymes Increased bilirubin level mg/100ml Severe hypoglycemia Prolonged PT, PTT & decrease platelets Treatment Meticulous attention to fluids, electrolytes, cardiovascular function & coagulation Hypotension should not be overlooked Frequent microbiologic assessments Antacids (stress ulcer) Cause of death Renal DIC

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY DISEASES OF THE LIVER HEPATIC NEOPLASM: HEPATIC NEOPLASM: OCP increased incidence of hepatoma, adenoma pregnancy may be increased incidence of hepatoma and adenoma Clinically: Systemic symptoms in advanced cases Pain and tender in right hypochondrium Enlarged liver Severe pain in case of hemorrhage LFT affected Ultrasound, CT, MRI Needle Bx

Dr. Afaf I. Alnoury GIT DISAESES DURING PREGNANCY DISEASES OF THE LIVER CIRRHOSIS AND PORTAL HYPERTENSION: CIRRHOSIS AND PORTAL HYPERTENSION: Frequently women sterile, however pregnancy is possible Higher risk of hepatic dysfunction Patient with successful partocaval shunt may conceive and deliver without risk of increasing dysfunction Obstetric management: Stabilization and then delivery on obstetric basis Survival mother and fetus – no significant disability and long term hepatic dysfunction No recurrence

Dr. Afaf I. Alnoury