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임신과 관련된 위장관 질환

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  • 1. 임신과 관련된 위장관 질환
    내 과
    정 성 훈
  • 2. Clinicians treating a pregnant woman
    Differentiate symptoms that are normal during pregnancy vs. serious disorders
    Disorder and Pregnancy
    Safe evaluation tools
    Risk of disease against risk of treatment
    Safely treat without causing adverse effects on mother or fetus
  • 3. United States FDA Pharmaceutical Pregnancy Categories
  • 4. Contents
    Diagnostic tools
    GI motility disorders
    Nausea and vomiting
    Hyperemesisgravidarum
    Constipation
    Diarrhea
    GERD
    Peptic ulcer disease
    Inflammatory bowel disease
  • 5. Diagnostic Testing in Pregnancy
    Radiologic and related studies
  • 6.
    • Cell death
    • 7. Teratogenic effects
    • 8. Carcinogenesis
    • 9. Genetic effects
    • 10. Missed diagnosis
    • 11. Unnecessary elective abortion
  • 12. Fetal risk of anomalies, growth restriction, or abortion is not increased with radiation exposure of less than 5 Rad(50mGy).
  • 13. Estimated Conceptus Dose
  • 14. US / MRI better alternatives
    US/MRI
    X-Ray/CT
    Radioactive iodine contraindicated during pregnancy
    MRI should be avoided in the 1st trimester
  • 15. Gastrointestinal Endoscopy
  • 16. Risk of Endoscopy to the Fetus
  • 17. Risk of Endoscopy to the Mother
  • 18. Indicationsfor Upper Endoscopy in Pregnancy
  • 19. Contraindication to Endoscopic Procedures
  • 20. Summary of Recommendations for the Performance of Endoscopy in Breast-feeding Patients
    Grade B, observational studies; Grade C, expert opinion
  • 21. Drugs used during Endoscopy
  • 22.
  • 23. General Endoscopy: Recommendations
  • 24. Gasatrointestinal Motility Disoders
    Nausea and vomiting
    Hyperemesisgravidarum
    Constipation
    Diarrhea
    GERD
  • 25. Nausea and vomiting
    Frequent (70~90%)
    particularly in 1st trimester
    Mild to moderate; physiologically statistically normal
    m/c complaints during the 1st 5 months of pregnancy
    Symptoms begin by 4~6 weeks, peak in 8~12 weeks and resolve by 3~4 months
    “morning sickness”
    Excellent prognosis
  • 26. Risk factors
    Younger, obese, women from western cultures
    Fewer than 12 years of former education
    Women who experience nausea and vomiting while taking oral contraceptives
    Corpus luteum in the right ovary
    Heaviness of placenta
    Nonsmoker
    History of nausea in previous pregnancy
    History of nausea and vomiting in pt’s mother
  • 27. Hyperemesisgravidarum
    Severe, debilitating condition characterized by vomiting severe enough to result in weight loss(>5% of body weight), dehydration, hypokalemia, or acidosis
    Up to 2%
    Exclusion diagnosis
    Gastroenteritis
    Cholecystitis
    Pyelonephritis
    Primary hyperparathyroidism
    Liver dysfunction
  • 28. Pathogenesis
    Estrogen and hCG increase during 1st trimester
    Increased progesterone and reduced motilin levels
    Gastric dysrhythmia in EGG
    H. pylori infection
  • 29.
  • 30. Treatment
    Supportive therapy
    Ingestion of multiple small-portion meals high in carbohydrate and low in fats
    Antiemetics; backbone
    Vitamin B6; good alternative
    psychotherapy
  • 31.
  • 32.
  • 33. NVP
    Moderate to severe
    HG
    Mild
    Nonphamacologic
    Phamacologic
    persistent
    Complementary & alternative
    Dietary change
    - small, frequent meal
    - Avoid fatty, spicy, odorous foods
    Drugs
    Ginger p.o.
    Pyridoxine –doxylamine
    +
    Lifestyle modification
    - frequent naps
    - shorten work day
    Acupressure
    Add antihistamine (Diphenhydramine or meclizine
    Persistent with dehydration
    IV fluid with vitamin B12
    Persistent without dehydration
    +
    Ondansetron
    Add dopamine antagonist (metoclopramide)
    persistent
    persistent
    Methylprednisolone
  • 34. Gastroesophageal Reflux Disease
    “위 내용물의 비정상적인 식도로의 역류로 인한 증상 혹은 점막손상”
    30~50% of pregnant women (up to 80%)
    Symptoms worse during 3rd trimester and abate soon after delivery
  • 35.  Montreal Classification of GERD
    Am J Gastroenterol 2006
  • 36. Pathogenesis
    This high incidence may relate to a hypotonic LES and GI dysmotility, attributed to
    gestational hormones(progesterone)
    gastric compression by the gravid uterus
  • 37. Treatment
  • 38. H2 antagonists generally safe, including 1st trimester
    Ironically, majority of studies of PPI safety involve omeprazole
  • 39. Constipation I
    Prevalence 11~38%
    Symptoms tend to be worse in the 1st and 3rd trimester
    Progesterone affects small intestine and colon motility and may inhibit motilin release
    Motilin(stimulatory GI hormone) decrease
    Enlarging uterus physically affect the small bowel motility
  • 40. Constipation II
    Initial treatment
    Patient education
    Reassurance
    Increased physical activity
    Increased fluid intake
    Dietary supplementary of fiber (bran or wheat fiber)
  • 41.
  • 42. Diarrhea
    When a pregnant woman presents with new-onset diarrhea, a standard evaluation is indicated.
    If the diarrhea appears to be mild and nonspecific but sufficiently bothersome to warrant treatment, non-systemically absorbed medications should be tried first.
  • 43.
  • 44. Peptic Ulcer Disease
    True incidence of PUD during pregnancy is unknown, but very low
    Only 6 cases in 23000 deliveries (Lancet 1969)
    Beneficial effect on PUD
    혈장의 히스타민 분해효소 증가로 위점막의 히스타민 농도 감소하고 위산 분비 감소
    에스트로겐 증가로 위산 분비 억제
    프로제스테론 증가로 위점막의 점액 분비 증가
    면역학적 내성으로 H. pylori에 대한 면역학적 공격이나 점막손상 감소
    EGF 증가로 위십이지장 점막 성장 촉진
    임신중 술, 담배, NSAIDS, 스트레스등의 궤양 원인을 피하고 충분한 영양과 휴식 취함
  • 45. Treatment I
    Antacids are generally safe for the fetus,
    magnesium should be avoided near delivery (retard labor and possibly cause neurologic depression in the newborn)
    sodium bicarbonate should be avoided throughout pregnancy(fluid overload or metabolic alkalosis)
    Antacids must be administered frequently because of low potency, and frequent administration can cause diarrhea or constipation and electrolyte or mineral abnormalities.
    Sucralfate has minimal systemic absorption, but its aluminum content is of concern to the fetus in mothers with renal insufficiency.
    H2 receptor antagonists are useful in treating GERD and PUD when symptoms are more severe or occur later in pregnancy.
    Ranitidine and famotidineare preferable because nizatidine is possibly toxic to the fetus, and cimetidine has antiandrogenic effects.
  • 46. Treatment II
    PPI were initially reserved for refractory, severe, or complicated GERD and PUD during pregnancy.
    Lansoprazole, rabeprazole, and pantoprazole(FDA B) appear to be safer than omeprazole (FDA C), and are therefore recommended during pregnancy.
    Metoclopramide is probably not teratogenic, but frequently causes maternal side effects.
    Helicobacter pylori eradication should be deferred until after parturition and lactation because of concern about the fetal safety of administered antibiotics such as clarithromycin and metronidazole.
  • 47. Inflammatory Bowel Disease
    The majority of cases of IBD first present in women younger than age 30 years, the years of peak fertility.
    IBD may be more common in women than in men; some authors report approximately 30% greater risk
    Effects on fertility; controversy
    Pregnancy rates may be spuriously low because of sexual avoidance and voluntary childlessness.
    Female fertility itself, however, does not appear to be impaired by uncomplicated IBD.
    UC patients treated with total colectomy and IPAA;three-fold increase in the risk of infertility (pelvic adhesions and fallopian tube scarring)
    Male fertility is impaired by sulfasalazine treatment, which causes decreased sperm counts that usually return to normal within 6 months of discontinuing the drug.
  • 48. Effect of IBD on pregnancy
    Inactive IBD; minimal effects on the course and outcome of pregnancy
    Risk appear to be related to the disease activity rather than to the medication
    Active, nonfulminant UC combined abortion/stillbirth rate 18~40%, Fulminant UC necessitating surgery ~60%
    Severe CD necessitating surgery maternal fetal mortality rates ~60%
    There is every reason to strive for remission before conception and to aggressively treat flares medically in order to prevent complications
  • 49. Effect of pregnancy on IBD
    • Pregnancy does not appear to increase the severity of, or morbidity due to, preexisting IBD
    • 50. Disease activity prior to conception seems to be the most important factor determining the cause of the illness during gestation.
    ZS Heetun et al., Aliment PharmacolTher 2007;26:513
  • 51. IBD and Breast-Feeding
    Oral 5-ASA products or corticosteroids is generally safe (poorly secreted in milk)
    Topical mesalamine is probably safe during breast-feeding
    No data about AZT/6-MP, ciprofloxacin, metronidazole
    MTX and cyclosporine; contraindicated
  • 52. Treatment
    Most experts agree that during gestation affected patients should continue optimized prepregnancy therapy to avoid possible flares resulting from medication withdrawal.
    Treatment of fulminant colitis is the same as in nonpregnantindividuals, namely high-dose glucocorticoids, intravenous antibiotics, cyclosporine, and salvage biological therapies.
    IBD patients are at risk for poor pregnancy outcomes, even if they have mild or inactive disease. Major complications include premature birth, low-birth-weight and small-for-gestational-age infants, and increased cesarean section rates.
    The risk of fetal malformations in this setting is unclear.
  • 53.
  • 54.
  • 55. Summary I
    The differential diagnosis of gastrointestinal symptoms and signs is particularly extensive during pregnancy. The differential diagnosis includes obstetric, gynecologic, and gastrointestinal disorders related to pregnancy
    Pregnancy can affect the clinical presentation, frequency, or severity of gastrointestinal diseases. For example, GERD markedly increases in frequency, whereas PUD markedly decreases in frequency (or becomes inactive) during pregnancy.
    Abdominal ultrasound is the most useful imaging modality to evaluate gastrointestinal conditions during pregnancy.   
  • 56. Summary II
    EGD and flexible sigmoidoscopycan be performed when strongly indicated during pregnancy, for example, for significant acute upper and lower gastrointestinal bleeding, respectively.   
    Most gastrointestinal drugs appear to be relatively safe to the fetus and can be used with caution when strongly indicated during pregnancy, especially during the second and third trimesters after organogenesis has occurred (FDA category B and C).
    Gastrointestinal drugs to be avoided during pregnancy include misoprostol, which is an abortifacient (category X), methotrexate (category X), 6-mercaptopurine (category D), azathioprine (category D), most chemotherapeutic agents, and certain antibiotics.
  • 57. 경청해 주셔서 감사합니다