1. Gastrointestinal Bleeding in
pregnancy
Dr E.haji seid javadi

2. Upper Gastrointestinal Bleeding
The most common causes of UGIB include : ●Gastric and/or duodenal ulcers ●Esophagogastric varices ●Severe or erosive esophagitis ●Severe or erosive gastritis/duodenitis ●Portal hypertensive gastropathy ●Angiodysplasia (also known as vascular ectasia) ●Mass lesions (polyps/cancers) ●Mallory-Weiss syndrome ●No lesion identified (10 to 15 percent of patients)

3. Upper Gastrointestinal Bleeding
In some women, persistent vomiting is accompanied by worrisome upper gastrointestinal bleeding.
Occasionally, there is a bleeding peptic ulceration, however, most of these women have small linear mucosal tears near the gastroesophageal junction Mallory-Weiss tears.
Bleeding usually responds promptly to conservative measures, including:
iced saline irrigations
topical antacids
andintravenously administered H2-blockers
proton-pump inhibitors.
Transfusions may be needed
if there is persistent bleeding then endoscopy may be indicated.

4. Upper Gastrointestinal Bleeding
With persistent retching, the less common, but more serious, esophageal rupture Boerhaavesyndrome may develop from greatly increased esophageal pressure.

6. Peptic Ulcer
Erosive ulcer disease more often involves the duodenum rather than the stomach in young women.
Gastroduodenal ulcers in nonpregnant women may be caused by chronic gastritis from H pylori, or they develop from use of aspirin or other nonsteroidal antiinflammatory drugs.Neither is common in pregnancy.

7.  Peptic Ulcer
Gastroprotection during pregnancy is probably due to :
reduced gastric acid secretion
decreased motility,
considerably increased mucus secretion.
ulcer disease may be underdiagnosed because of frequent treatment for reflux esophagitis.
They noted a clear remission during pregnancy in almost 90 percent.
However, benefits were short lived. Symptoms recurred in more than half by 3 months postpartum and in almost all by 2 years.

8.   Treatment
Antacids are first-line therapy,
H2-receptor blockers or proton-pump inhibitors are safely prescribed for those who do not respond .
Sucralfate is the aluminum salt of sulfated sucrose that inhibits pepsin. It provides a protective coating at the ulcer base.
Approximately 10 percent of the aluminum salt is absorbed, and it is considered safe for pregnant women.

9. Treatment
With active ulcers, a search for H pylori is undertaken. Diagnostic aids include the urea breath test, serological testing, or endoscopic biopsy.
If any of these are positive, antimicrobial therapy is indicated.
There are several effective oral treatment regimens that do not include tetracycline and that can be used during pregnancy.
These 14-day regimens include :
amoxicillin, 1000 mg twice daily along with clarithromycin, mg twice daily; or metronidazole, 500 mg twice daily.

10. GASTROINTESTINAL TRACT
DISORDERS OF THE UPPER
GASTROINTESTINAL TRACT
Hyperemesis Gravidarum
Mild to moderate nausea and vomiting are especially common in pregnant women until approximately weeks.
In a small proportion of these, however, it is severe and unresponsive to simple dietary modification and antiemetics.

11. Hyperemesis Gravidarum
hyperemesis gravidarum is defined variably as being sufficiently severe to produce:
weight loss,
dehydration
Ketosis
alkalosis from loss of hydrochloric acid
hypokalemia
Acidosis develops from partial starvation.
In some women, transient hepatic dysfunction develops, and there is accumulation of biliary sludge.

12. Hyperemesis Gravidarum
Other causes should be considered because
hyperemesis gravidarum is adiagnosis of exclusion
appear to be an ethnic or familial predilection.
hospitalization rate for hyperemesis gravidarum was to 0.8 percent.

13. obese women are less likely to be hospitalized for this.
Hyperemesis Gravidarum
Up to 20 percent of those hospitalized in a previous pregnancy for hyperemesis will again require hospitalization.
obese women are less likely to be hospitalized for this.

14.   Hyperemesis Gravidarum
The etiopathogenesis of hyperemesis gravidarum is likely multifactorial and certainly is enigmatic.
It appears to be related to high or rapidly rising serum levels of pregnancy-related hormones.

15. Hyperemesis Gravidarum
Putative culprits include :
human chorionic gonadotropin (hCG)
estrogens
progesterone
leptin
placental growth hormone
Prolactin
Thyroxine
adrenocortical hormones.
More recently implicated are other hormones that include ghrelins, leptin, nesfatin-1, and PYY-3.

16. Hyperemesis Gravidarum
Superimposed on this hormonal cornucopia are an imposing number of biological and environmental factors.
in some but not all severe cases, interrelated psychological components play a major role.

17. Hyperemesis Gravidarum
Other factors that increase the risk for admission include:
hyperthyroidism
previous molar pregnancy
diabetes
gastrointestinal illnesses
some restrictive diets
asthma and other allergic disorders.

18. Hyperemesis Gravidarum
association of Helicobacter pylori infection has also been proposed.
for unknown reasons—perhaps estrogen-related a
female fetus increases the risk by 1.5-fold.
reported an association between hyperemesis gravidarum and preterm labor, placental abruption, and preeclampsia.

19. Complications
Vomiting may be prolonged, frequent, and severe, and a list of potentially fatal complications.

21. Management The Food and Drug Administration recently
approved Diclegis—a combination of doxylamine-
pyridoxine—for morning sickness.
When simple measures fail, intravenous Ringer lactate or normal saline solutions are given to correct:
dehydration
ketonemia
electrolyte deficits
acid-base imbalances

22. Thiamine, 100 mg, is given to prevent Wernicke Encephalopathy.
Management
There are no benefits to using 5-percent dextrose along with crystalloids .
Thiamine, 100 mg, is given to prevent Wernicke Encephalopathy.
If vomiting persists after rehydration and failed outpatient management, hospitalization is recommended.
Antiemetics such as promethazine, prochlorperazine, chlorpromazine, or metoclopramide are given parenterally.
There is little evidence that treatment with glucocorticosteroids is effective.

24. Management
pulsed hydrocortisone therapy was superior to metoclopramide to reduce vomiting and readmissions.
Serotonin antagonists are most effective for controlling chemotherapy induced nausea and vomiting .
for hyperemesis gravidarum,ondansetron was not superior to promethazine .
Serotonin antagonist use in pregnancy is limited, but these drugs appear to be safe .
With persistent vomiting after hospitalization, appropriate steps should be taken to exclude possible underlying diseases as a cause of hyperemesis.

25. Management
Other potential causes include gastroenteritis, cholecystitis,pancreatitis, hepatitis, peptic ulcer, and pyelonephritis. In addition, severe preeclampsia and fatty
liver are more likely after midpregnancy. And although clinical thyrotoxicosis has been implicated as a cause of hyperemesis, it is more likely that abnormally elevated serum thyroxine levels are a surrogate for higher-than-average serum hCG levels.

26. Management
readmission rate is 25 to 35 percent.
If associated psychiatric and social factors contribute to the illness, the woman usually improves remarkably while Hospitalized
For some women, hyperemesis can be an indication for elective termination.
In the small percentage of women who continue to have recalcitrant vomiting, consideration is given for enteral nutrition.
only a very few women will require parenteral nutrition.
complications included line sepsis in 25 percent and thrombosis and infective endocarditis

27. Lower Gastrointestinal Bleeding
Inflammatory Bowel Disease
The two presumably noninfectious forms of intestinal inflammation are ulcerative colitis and Crohn disease.

29. Ulcerative Colitis
This is a mucosal disorder with inflammation confined to the superficial luminal layers of the colon.
It typically begins at the rectum and extends proximally for a variable distance. In approximately 40 percent, disease is confined to the rectum and rectosigmoid, and 20 percent have pancolitis.
Major symptoms of ulcerative colitis include diarrhea,rectal bleeding, tenesmus, and abdominal cramps.

30. Ulcerative Colitis
The disease can be acute or intermittent and is characterized by exacerbations and remissions.
For unknown reasons, prior appendectomy protects against development of ulcerative Colitis
Toxic megacolon and catastrophic hemorrhage are
particularly dangerous complications that may necessitate colectomy.

31. Ulcerative Colitis
Extraintestinal manifestations include arthritis, uveitis, and erythema nodosum. Another serious problem is that the risk of colon cancer approaches 1 percent per year.
With either ulcerative colitis or Crohn disease, there is also concern for possible increased risks for thromboembolism.

32. Inflammatory Bowel Disease and Pregnancy
Because ulcerative colitis and Crohn disease are relatively common in young women, they are encountered with some frequency in pregnancy.
The consensus is that pregnancy does not increase the
likelihood of an inflammatory bowel disease flare.
flare during pregnancy was decreased compared with the preconceptional rate . This diminished rate persisted for years after pregnancy.

33. Inflammatory Bowel Disease and Pregnancy
Although most of those with quiescent disease in early pregnancy uncommonly have relapses, when a flare develops, it may be severe.
Conversely, active disease in early pregnancy increases the likelihood of poor pregnancy outcome.
In general, most usual treatment regimens may be continued during pregnancy.
If needed to direct management, diagnostic evaluations should be undertaken, and if indicated,surgery should be performed.

34. Inflammatory Bowel Disease and Pregnancy
outcomes in women with ulcerative colitis or Crohn disease compared with normally pregnant women.
mortality rates are not appreciably increased.

35. Ulcerative Colitis and Pregnancy
significant effects on ulcerative colitis in approximately a third of pregnancies. In women with active disease at the time of conception, approximately 45 percent worsened, 25 percent remained unchanged, and only 25 percent improved.
Calcium supplementation is provided for osteoporosis. Folic acid is given in high doses to counteract the antifolate actions of sulfasalazine.
Flares may be caused by psychogenic stress, and reassurance is important. Management for colitis for the most part is the same as for nonpregnancy.

36. Ulcerative Colitis and Pregnancy
Treatment of active colitis, as well as maintenance therapy,is with drugs that deliver 5-aminosalicyclic acid (5-ASA) or mesalamine.
Sulfasalazine is the prototype, and its 5-ASA moiety inhibits prostaglandin synthase in colonic mucosa. Others include olsalazine (Dipentum) and coated 5-ASA derivatives (Asacol, Pentasa, Lialda).
Glucocorticoids are given orally, parenterally, or by enema for more severe disease that does not respond to 5-ASA.
Recalcitrant disease is managed with immunomodulating drugs, including azathioprine, 6-mercaptopurine, or cyclosporine, which appear relatively safe in pregnancy.

37. Ulcerative Colitis and Pregnancy
Importantly, methotrexate is contraindicated in pregnancy.
High-dose intravenous cyclosporine may be beneficial for severely ill patients and used in lieu of colectomy. Parenteral nutrition is occasionally necessary for women with prolonged exacerbations.

38. Ulcerative Colitis and Pregnancy
Colorectal endoscopy is performed as indicated .
During pregnancy, colectomy and ostomy creation for fulminant colitis may be needed as a lifesaving measure, and it has been described during each trimester.

39. Ulcerative Colitis and Pregnancy
ulcerative colitis likely has minimal adverse effects on pregnancy outcome.
perinatal outcomes in 2398 pregnancies and reported them to be not substantively different from those in the general obstetrical population.
Specifically, the incidences of spontaneous abortion, preterm delivery, and stillbirth were remarkably low.

40. Thanks