Obstetric Topic 14. Pregnancy and gastrointestinal disorders

I. Nausea, Vomiting and GERD

Morning Sickness

• Occurs in 50-80% of pregnancies, mainly 1st trimester.
• Cause: ↑ hCG + estrogen; usually mild and self-limiting.
• Treatment: reassurance, small frequent meals, avoid triggers, fluids.
• Medication if needed: vitamin B6 ± doxylamine; metoclopramide if persistent.

Hyperemesis Gravidarum

• Definition: severe persistent vomiting → dehydration, ketosis, weight loss >5%, electrolyte disturbance.
• Risk factors: multiple pregnancy, molar pregnancy, high hCG, first pregnancy.
• Signs: tachycardia, low BP, dry tongue, decreased skin turgor, weight loss.
• Labs: hypokalemia, hyponatremia, hypochloremic alkalosis; mild transaminase elevation may occur.
• Treatment: hospitalize if severe → IV fluids, electrolytes, thiamine before glucose, antiemetics.
• Refractory cases: enteral feeding or parenteral nutrition rarely.

GERD

• Mechanism: progesterone ↓ lower esophageal sphincter tone + enlarged uterus ↑ gastric pressure → reflux.
• Symptoms: heartburn/substernal discomfort, worse after meals or lying down.
• General treatment: small meals, avoid late meals, elevate bedhead, avoid lying after meals.
• Medical treatment: antacid or sucralfate → H2 blocker → PPI if needed.

Mendelson Syndrome

• Acid aspiration during labor/anesthesia → chemical pneumonitis, pneumonia, ARDS.
• Prevention: fasting before elective cesarean, aspiration prophylaxis when anesthesia risk, prefer regional anesthesia when possible.
• Treatment: airway support, oxygen/ventilation, antibiotics only if infection.

II. Bowel and Surgical Disorders

Constipation

• Mechanism: progesterone ↓ intestinal motility + uterine compression + iron supplements → constipation.
• Treatment: fiber, fluids, activity, bulk laxatives or stool softeners.
• Avoid frequent stimulant laxative use unless necessary.

Inflammatory Bowel Disease

• Best outcome: conceive during remission.
• Active disease → miscarriage, preterm birth, IUGR risk.
• Safe/common drugs: sulfasalazine, mesalazine, corticosteroids, azathioprine if needed.
• Avoid: methotrexate.
• Supplements: folic acid, iron, vitamin B12, nutrition support.
• Delivery: vaginal unless obstetric indication or active perianal Crohn disease.

Appendicitis

• Most common non-obstetric surgical emergency in pregnancy.
• Appendix displaced upward → pain may be atypical/right upper abdomen.
• Symptoms: abdominal pain, tenderness, nausea/vomiting, low-grade fever, leukocytosis.
• Diagnosis: ultrasound first; MRI if unclear.
• Treatment: prompt appendectomy, usually laparoscopic if feasible.
• Delay → perforation → maternal sepsis, preterm labor, fetal loss.

III. Hepatobiliary Disorders

Gallbladder Disease

• Mechanism: progesterone ↓ gallbladder contractility + ↑ cholesterol saturation → sludge/stones.
• Symptoms: RUQ pain, nausea/vomiting; fever suggests cholecystitis.
• Diagnosis: ultrasound.
• Treatment: conservative if mild; laparoscopic cholecystectomy if recurrent/severe, often safest in 2nd trimester.

Intrahepatic Cholestasis of Pregnancy

• Usually 2nd-3rd trimester; resolves after delivery and often recurs in later pregnancies.
• Symptoms: intense pruritus, worse at night; mild jaundice may occur.
• Diagnosis: ↑ serum bile acids ± direct hyperbilirubinemia/transaminase elevation.
• Fetal risk: preterm birth, fetal distress, stillbirth risk rises with high bile acids.
• Treatment: ursodeoxycholic acid for symptoms/bile flow, antihistamine for itch, fetal surveillance and planned delivery according to bile acids/local protocol.

Acute Fatty Liver of Pregnancy

• Rare, life-threatening, usually 3rd trimester or early postpartum.
• Features: nausea/vomiting, abdominal pain, jaundice, hypoglycemia, ↑ liver enzymes.
• Complications: liver failure, encephalopathy, coagulopathy, DIC, renal failure.
• Treatment: urgent delivery + ICU supportive care, glucose, fluids, correction of coagulopathy.

HELLP / Severe Preeclampsia Differential

• RUQ/epigastric pain + hypertension/proteinuria + thrombocytopenia/hemolysis → think HELLP.
• Important differential from cholestasis and acute fatty liver because management is urgent maternal stabilization and delivery.