Dr Amit Basnotra, Dr Richa Sharma
Pregnancy is part of normal physiology but various haemodynamic changes happen in the body of a pregnant woman which may affect or precipitate the pre existing conditions so any such high risk cases need a multidisciplinary approach so that the things are not missed and can be managed on time.Gastrointestinal diseases are one such entity which need to be addressed with involvement of Gastroentrologist.
What can be the presentation Which can mimic ?
Symptoms can be variable such as nausea, vomiting, and dyspepsia occur in 50-90% of all patients. Most of these symptoms are a manifestation of normal altered physiology in which changes occur both functionally and anatomically.
These changes may cause new symptoms, worsen preexisting disease, or mask potentially deadly disease and if have lack of experience in dealing with these symptoms it can have devastating effects especially missing potentially life-threatening complication such as preeclampsia.Need to know safety of drugs and relevant applicable investigations as at end we need – A healthy mother and a healthy baby !!What could be the reason of such changes ?
Elevated levels of progesterone may lead to alterations in gastrointestinal motility which could contribute to nausea, vomiting, and/or GERD. Pregnancy-induced diarrhea may be due to elevated levels prostaglandins and many more.Besides there can be delay in the Gastric emptying which is one of the factor of adding to cetain signs symptoms
The enlarging uterus displaces the stomach and may anatomically alter the pressure gradient between the abdomen and thorax. Increased pressure within the stomach allows for reflux of the gastric contents into the esophagus , further aggravate the upper gastrointestinal symptoms associated with pregnancy
Various Gastrointestinal Changes and Diseases which one can come across in pregnancy-
Nausea and Vomiting(Hyperemesis Gravidorum)
Nausea and vomiting are common in the first trimester of pregnancy and may be the first sign of pregnancy. It usually peaks at approximately weeks 10 to 15 of gestation and resolves at approximately week 20. Nausea of pregnancy is more common among women who are primagravid, younger, less educated, and overweight. In general, first trimester vomiting is not deleterious to mother or fetus. When vomiting is prolonged, intractable, and interferes with nutrition and fluid intake, it is termed hyperemesis gravidarum (HG). Vomiting may be severe enough to cause weight loss, electrolyte abnormalities, and acid-base disturbances requiring hospitalization. While nausea and vomiting occur in 50-90% of all pregnancies, hyperemesis gravidarum is uncommon and has an incidence varying from 0.5 to 10 per 1000 pregnancies.
It can also be secondary to other disease processes including appendicitis, pancreatitis, cholecystitis, and peptic ulcer disease. These disorders must not be overlooked because delay in diagnosis could be disastrous
Gastroesophageal RefluxDisease (GERD)-
Heartburn and regurgitation in pregnancy are almost ubiquitous symptoms, occurring in 50-90% of all pregnancies, but typically mild, becoming severe in only a small percentage of women. The peak incidence of heartburn is in the third trimester and resolves with delivery. The risk of symptomatic gastroesophageal reflux is related to increasing gestational age, presence of heartburn prepartum, and parity.
Preventive Measures
Lifestyle modifications certainly have a role to play in treating gastroesophageal reflux. Dietary measures such as limiting oral intake within 3 hours of bedtime, increasing frequency and reducing volume of meals, reducing dietary fat, and eliminating caffeine, chocolate, and mints are measures that have some effect in controlling the symptoms of gastroesophageal reflux. Alcohol and smoking should be eliminated. Elevation of the head of the bed and avoiding prolonged recumbency are additional lifestyle measures of some benefit. If lifestyle modifications do not control symptoms, the next step would be medical management
Inflammatory Bowel Disease
The term inflammatory bowel disease (IBD) comprise of ulcerative colitis and Crohn’s disease and generally pregnant women proceed to have normal, full-term pregnancies. Some patients do face a higher risk of an adverse pregnancy outcome
Intestinal Obstruction
Intestinal obstruction is relatively rare in pregnancy but is the second most common nonobstetric abdominal emergency. The incidence is 1 in 3000 pregnancies. It is extremely rare in early pregnancy but begins to increase between the fourth and fifth month of gestation when the uterus changes from a pelvic organ to an abdominal organ.
Irritable Bowel Syndrome, Constipation and Diarrhea
The most common gastrointestinal disorder is clearly irritable bowel syndrome. This disorder accounts for nearly 50% of referrals to a gastroenterologist, and female patients exceed male patients .
Acute Cholecystitis
Pregnancy increases the risk of gallstones. Gallbladder emptying and motility are decreased during pregnancy, providing the necessary environment of biliary stasis for gallstone formation.
Appendicitis
Appendectomy is the most common nonobstetric surgical emergency in pregnancy, occurring in approximately 1 in 1000 pregnancies. Symptoms are similar to those in the nonpregnant patient; however, the location of the abdominal tenderness may be different depending on the size of the uterus. The enlarging uterus may shift the appendix from the right lower quadrant to the right upper quadrant, causing confusion in the diagnosis. In addition to the change in location, other factors during pregnancy delay the diagnosis.
Conclusion
Pregnancy has a lot of metabolic and haemodynamic changes which can affect almost all organs of the body.There can be some signs symptoms which may mimic certain diseases- thumb rule is don’t ignore even if it looks minor ailment and seek help of Gastroentrologist in consultation with Your Gynecologist without wasting time.
The authors are Senior Gastroentrologist, and senior IVF Consultant)
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