Gastrointestinal Complications in Pregnancy Dr Sharda Jain

Gastrointestinal
Complications
in Pregnancy
…Caring hearts, healing hands
Dr Sharda Jain
Sec General of DGF

Nausea
&
Vomiting
in
Pregnancy

Proprietary and confidential — do not distribute
Nausea & Vomiting in Pregnancy (NVP)
Common condition affecting approximately 85% of pregnant women
Symptoms typically appear between 4 and 9 weeks of pregnancy & are usually most
severe between 7 and 12 weeks of pregnancy
In the majority of pregnant women, the symptoms subside between 12 and 16 weeks
of pregnancy
In about 15% of women, symptoms continue up to 20 weeks of gestation; <10% of
women suffer
Lee NM and Saha S. Nausea and vomiting of pregnancy. Gastroenterol Clin North Am. 2011 Jun;40(2):309-34, vii.
Erick M, Cox JT, Mogensen KM. ACOG Practice Bulletin 189: Nausea and Vomiting of Pregnancy. Obstet Gynecol. 2018 May;131(5):935.

Nausea & Vomiting in Pregnancy (NVP)
Hyperemesis Gravidarum (HG)
HG can be diagnosed when there is protracted NVP with the triad
of more than 5% pre-pregnancy weight loss, dehydration, and
electrolyte imbalance.
In a survey of 808 women who terminated their pregnancies secondary to HG, 123 (15.2%) had at least
one termination due to HG, and 49 (6.1%) had multiple terminations. Prominent reasons given for the
terminations were inability to care for the family and self (66.7%), fear that they or their baby could die
(51.2%), or that the baby would be abnormal (22%).

Risk Factors
Young
Primigravida
Obese and lean
Multiple pregnancy
Women with a maternal/family history of NVP
Personal history of motion sickness
NVP: Nausea & Vomiting in Pregnancy.

Etiopathogenesis
The etiology of NVP is unknown, factors
have been proposed including:
NVP: Nausea & Vomiting in Pregnancy; hCG: Human chorionic gonadotropin
The onset of NVP is in the
first trimester and if the
initial onset
is after 10+6weeks of
gestation, other causes
need to be considered.
It typically starts between the
fourth and seventh weeks of
gestation, peaks in
approximately the ninth
week, and resolves by the
20th week in 90% of women.
Metabolic and
hormonal stimulus
–hCG &
progesterone
Immune system
dysregulation
Gastrointestinal
motility
H. pylori
infection and
psychological
predisposition

Maternal Effects of NVP
Wernicke encephalopathy
Splenic avulsion
Esophageal rupture
Pneumothorax
Systematic review
demonstrated significantly
higher depression & anxiety
scale scores in women with
NVP/HG
Wernicke’s
encephalopathy due to
vitamin B1 (thiamine)
deficiency classically
presents with blurred
vision, unsteadiness, and
confusion/memory
problems/drowsiness, and
on examination, there is
usually nystagmus,
ophthalmoplegia,
hyporeflexia or areflexia,
gait and/or finger–nose
ataxia.
Severe abdominal or
epigastric pain is unusual
in NVP and HG and may
warrant further
investigation of serum
amylase levels and an
abdominal ultrasound,
and possibly esophageal
gastroduodenoscopy,
which is considered safe
in pregnancy.
NVP: Nausea & Vomiting in Pregnancy.

Non-Pharmacologic Treatment
Treatment Recommendations
Dietary
measures
 Standard recommendation to take prenatal vitamins for 1 month before
pregnancy
 Frequent, small meals every 1–2 hours to avoid a full stomach
 Dietary modifications should include avoiding spicy food
Emotional
support
 Emotional support always be offered by a medical professional.1
 Supportive psychotherapy, behavioral therapy, and hypnotherapy may be
beneficial in women with severe NVP
Ginger  Ginger helps by stimulating gastrointestinal tract motility and inducing the flow
of saliva, bile, and gastric secretions
Thiamine supplementation (either oral or intravenous) should be given to all women admitted with
prolonged vomiting, especially before administration of dextrose or parenteral nutrition.
Erick M, Cox JT, Mogensen KM. ACOG Practice Bulletin 189: Nausea and Vomiting of Pregnancy.Obstet Gynecol. 2018 May;131(5):935
NVP: Nausea & Vomiting in Pregnancy

Pharmacology Therapy (1/3)
Agents Pregnancy category Comment
Vitamin B6 (Pyridoxine)-
doxylamine combination
Pyridoxine (category A)
and doxylamine7
 Approved by the USFDA for treatment of NVP5
 Recommended as first-line pharmacotherapy
 Found to be safe and does not cause adverse
effects in the fetus
Dopamine antagonists
 Metoclopramide
 Phenothiazine medications
(Promethazine,
Prochlorperazine)
 Droperidol
Metoclopramide
(category B),
promethazine,
prochlorperazine
(category C)7
 Side-effects of metoclopramide include dystonia,
restlessness, and somnolence7
 In 2009, the FDA added a black box warning to
metoclopramide due to the risk of tardive dyskinesia with
chronic use.
 Side-effects of droperidol include drowsiness,
dizziness, and cardiac arrythmias.
 Droperidol bears black box warning as it may cause
QT prolongation and cardiac dysrhythmias.
Drug-induced extrapyramidal symptoms and oculogyric crises can occur with the use of phenothiazines and
metoclopramide. If these occur, there should be prompt cessation of the medications.

Agents Pregnancy category Comment
Antihistamines
 Diphenhydramine
 Dimenhydrinate
Category B.  Side effects include drowsiness, dizziness and
fatigue.
Serotonin
5-hydroxy tryptamine type 3 (5-HT3)
receptor antagonists
 Ondansetron
Category B.  Common adverse effects of ondansetron
include headache, drowsiness, fatigue, and
constipation.5
 Ondansetron can prolong the QT interval,
especially in patients with underlying heart
problems.
 There is insufficient data on fetal safety with
ondansetron use.
 A possible association of ondansetron use in
the first trimester and cleft palate has been
reported.
There is evidence that ondansetron is safe and effective, but because data are limited, it should be used as
second-line therapy.
Pharmacology Therapy (2/3) …Caring hearts, healing hands

Corticosteroids
 Methylprednisolone
Category B.  Side effects include hyperglycemia and
possible increased risk of oral facial clefts
with first trimester use.
H2 blockers
 Ranitidine
Category B.  Side effects include drowsiness,
dizziness, diarrhea, or constipation.
Proton pump inhibitors
 Lansoprazole
 Esomeprazole
Category B.  Side effects include nausea, diarrhea,
fatigue.
Pharmacology Therapy (3/3) …Caring hearts, healing hands

Recommended Antiemetic Therapies and
Dosages

PUQE Index …Caring hearts, healing hands

Management Algorithm

Management Algorithm
An objective and validated index of nausea and
vomiting such as the Pregnancy-Unique
Quantification of Emesis (PUQE) score can be
used to classify the severity of NVP

Hyperemesis Gravidarum
Hyperemesis affects between 0.3% and 2.3% of all pregnancies
The condition is defined as uncontrolled vomiting requiring hospitalization, severe
dehydration, muscle wasting, electrolyte imbalance, ketonuria, and weight loss of more
than 5% of body weight
Most of these patients also have hyponatremia, hypokalemia, and a low serum urea
level

Management
Erick M, Cox JT, Mogensen KM. ACOG Practice Bulletin 189: Nausea and Vomiting of
Pregnancy.Obstet Gynecol. 2018 May;131(5):935
Inpatient management should be considered if there is at least one of the
following:
 Continued nausea and vomiting and inability to keep down oral
antiemetics
 Continued nausea and vomiting associated with ketonuria and/or weight
loss (greater than 5%of body weight), despite oral antiemetics
 Confirmed or suspected comorbidity (such as urinary tract infection and
inability to tolerate oral antibiotics)
 Intravenous (IV) fluids should be provided to replenish the lost
intravascular volume. Rehydration along with replacement of
electrolytes is very important in the treatment of hyperemesis.
 Normal saline or Hartmann solution are suitable solutions;
potassium chloride can be added as needed.
 While replacing electrolytes, the physician must consider the
risks of rapid infusion in order to prevent such conditions as
central pontine myelinolysis.
 Normal saline with additional
potassium chloride in each bag,
with administration guided by
daily monitoring of electrolytes, is
the most appropriate intravenous
hydration.
 Dextrose infusions are not
appropriate unless the serum
sodium levels are normal and
thiamine has been administered

An Indian study demonstrated that excessive vomiting in pregnancy
(defined as vomiting that lasted beyond 5 months) was significantly (OR
4.48, 95% CI 1.10–18.28) associated with underweight children (in those
aged less than 3 years) compared with vomiting lasting less than 5 months.
When women with severe HG are considered, it has been shown that
those requiring repeated admissions have an 18% incidence of small-for-
gestational-age babies and significantly lower birthweights than babies of
women with HG and single admissions.
Sanghvi U, Thankappan KR, Sarma PS, Sali N. Assessingpotential risk factors for child malnutrition in rural Kerala,India. J Trop Pediatr2001;47:350–5.
Association Between Excessive Vomiting in
Pregnancy and Underweight Children

Constipation
in
Pregnancy

Constipation is common condition, affecting
about half of women at some point during
pregnancy; it is associated with
Straining
Hard stools
Incomplete evacuation
Constipation can lead to
Impaired quality of life
Hemorrhoids
Distress for pregnant women
A number of women suffer from
constipation prior to conception and find
their symptoms worsen during pregnancy
Rungsiprakarn et alCochrane Database Syst Rev. 2015 Sep 4;(9):CD011448. 10.1002/14651858.CD011448.pub2.
2. Cullen et al. Best Pract Res Clin Gastroenterol. 2007;21(5):807-18.
3. The Cochrane Library 2014, Issue 12 ,
Trimester Prevalence of
constipation
First trimester 24%
Second trimester 16%
Third trimester 26%
Post partum 24%
What is Constipation …Caring hearts, healing hands

Possible Causes of Constipation During
Pregnancy
Other Hormones
• Progesterone-induced ↓ levels of
motilin (which normally stimulates
gastric activity)
• ↓Levels of relaxin (Which normally
inhibits GL smooth muscle)
Physical Activity
• ↓ levels Of physical activity
• Strenuous exercise may
exacerbate
Dietary factors
• ↓Water intake
• Lack of fiber
• Iron supplementation
• Vomiting
Effects Of Progesterone on Gl tract
• Inhibition off gastric smooth muscle
• ↓colonic smooth muscle contractility
• Prolonged gastric emptying
• Delayed colonic transit
Metabolic
• Hypothyroidism
• Hypercalcemia
• Hypokalemia
• Diabetes mellitus
Increased Colonic
Water Absorption
• Progesterone-induced ↑
aldosterone levels
• Prolonged colonic transit time
Mechanical Factors
• Physical impedance due to uterine
and intestinal movement
• Fetal compression
• Pelvic floor muscle dysfunction
• Colonic disease: neoplasm/stricture
• Pregnancy-induced hemorrhoids
Drugs
Drugs like Calcium, Iron Salts and
MgSo4
Causes of
constipation
in
pregnancy

Clinical Implications
ClinGastroenterol2007;21(5):807-18; Gastroenterology 1985;89(5):996-9
Straining during
defecating can damage
the pudendal nerve and
impair the supportive
function of the pelvic
floor musculature
Disturbed defecation can
result in the development
of uterovaginal prolapse
Cesarean section rate in
pregnant women with
functional constipation
(66.97%) is higher as
compared to the other
methods of delivery
(27.29%)
GI function may be
disrupted for longer in
women who had
constipation,
irrespective of mode
of delivery

Management Algorithm of Constipation
Laxatives
Pharmacologic
approach
ClinGastroenterol2007;21(5):807-18; Gastroenterology 1985;89(5):996-9]
Data on file ; Trottier M, Erebara A, Bozzo P. Treating constipation during pregnancy. Can Fam Physician. 2012;58(8):836–38.
Bradley CS, Kennedy CM, Turcea AM, et al. Constipation in pregnancy: Prevalence, symptoms, and risk factors. Obstet Gynecol. 2007;110(6):1351–7
50 % of the cases,
despite
diet and lifestyle
modification, constipation
was recurrent
Non-
pharmacologic
approach
Evidence showed that daily
fiber intake and an active
lifestyle were not correlated
with the prevalence
of constipation
Bulk Laxatives
Bran, Isabgol
Suppositories
Glycerol
suppositories
Osmotic Laxatives
Lactulose, sorbitol
Stimulant
Laxatives
Bisacodyl,
senna
Increase
dietary
fiber,
fluid
intake
&
moderate
exercise
Increase dietary fiber,
fluid intake & moderate
exercise

Safety Profile of Laxatives in PREGNANCY
 Castor oil is risky; it can lead to premature labor term
 Bisacodyl to be used with caution in pregnancy and breastfeeding
Duphalac Prescribing Information https://www.medicines.org.uk/emc/product/173/smpc#:~:text=Milk%20of%20Magnesia%20is%20indicated,not%20exceed%20the%20stated%20dose. Accessed on 5th June 2020
Dulcolax 5 mg Gastro-resistant Tablets Summary of Product Characteristics. 2017. https://www.medicines.org.uk/emc/product/361/smpc Accessed Sept 4th 2018
Senokot Tablets Summary of Product Characteristics. 2015. https://www.medicines.org.uk/emc/product/1449/smpc Accessed Sept 4th 2018
Trottier M, Erebara A, Bozzo P. Treating constipation during pregnancy. Can Fam Physician. 2012;58(8):836–
38.https://www.medicines.org.uk/emc/product/173/smpc#:~:text=Milk%20of%20Magnesia%20is%20indicated,not%20exceed%20the%20stated%20dose. Accessed on 5th June 2020

Case Study
What should be the management approach ?
Hypothetical case
• Age: 35 years
• Working lady
• BMI = 25
• Wt.: 65 kgs
Presented with
constipation
symptoms
Episodic constipation
during the first
trimester,
recommended light
exercise and an
increase of fiber &
water intake in the diet
Increasing intensity in
second trimester
which is impacting her
quality of life
Case presentation
Clinical presentation

POLL : What Should be the Management Approach in our Case?
1. Continue with Non-pharmacological approach like lifestyle and diet
modification
2. Management with safer alternative like lactulose
3. Management with stimulant laxatives like Bisacodyl

What Should be the Management Approach
in our Case?
Osmotic laxatives
 Lactulose is poorly absorbed systemically. Their
use has not been associated with adverse effects.
 Newer chewable lactulose gummies can also
help given the nausea and vomiting during early
pregnancy
Stimulant laxatives
 Stimulant laxatives are approved only for short
term use .
 Women might experience unpleasant side effects
such as abdominal cramps with the use of
stimulant laxatives.
Continue with non-
pharmacologic
approaches like lifestyle
and diet modification
Management with safer
alternative like lactulose
Episodic management
with stimulant laxatives
like Bisacodyl

Lactulose
ClinGastroenterol2007;21(5):807-18; Gastroenterology 1985;89(5):996-9]
Data on file ; Trottier M, Erebara A, Bozzo P. Treating constipation during pregnancy. Can Fam Physician. 2012;58(8):836–38.
Bradley CS, Kennedy CM, Turcea AM, et al. Constipation in pregnancy: Prevalence, symptoms, and risk factors. Obstet Gynecol. 2007;110(6):1351–7
Semi-synthetic
disaccharide, used
to adjust circadian
rhythm for colon
Properties
 Lactulose is not absorbed in the
small intestine; this is of great
significance when treating
constipation during pregnancy, as it
presents no threat to the fetus
 Lactulose also does not appear in
breast milk so that the treatment
can also be continued during
nursing
 Laxative with prebiotic effect;
suitable for diabetics as it is not
absorbed in blood
Recommendations
FOGSI TOG
recommends
lactulose in the
management of
constipation

Other Indications of Lactulose
RCOG recommendation of lactulose
In obstetric anal sphincter injury
 Immediate use in post-partum
phase In grade 3-4 perineal tears
 Post-operative for 7 to 10 days to
maintain soft stools
Royal College of Obstetricians and Gynecologists recommends Lactulose in the post-
operative management of perineal tears, to facilitate passage of soft stools

Dosage and Method of Administration
Formulations like gummies can be given 2-3/day
PI of lactulose

GASTROESOPHAGEAL
REFLUX
DISEASE

Gastroesophageal Reflux Disease
• GERD is reported by 40-85% of pregnant women, usually beginning
at the end of the first trimester, and can profoundly impair the quality
of life.
• When present, GERD persists during the entire pregnancy and
usually resolves after delivery.
• Complications such as erosive esophagitis, bleeding, or strictures
are rarely described

Management
GI diseases during pregnancy Annals of Gastroenterology 3
Management
Consultation through a Health
Worker/RMPStart of a Telemedicine For
mild symptoms, lifestyle and dietary
modifications are recommended.
Conservative measures include avoiding
eating late at night, elevating the head of
the bed by 10-15 cm and lying on the left
side.
If symptoms persist, medication may be
necessary.
First-line
treatment is
based on
antacids.
Antacids containing calcium and magnesium are considered
safe in pregnancy.
Furthermore, patients prefer to use this medication,
because it relieves the symptoms promptly and can be
taken on demand.
No teratogenic effects of these drugs have been observed
in animal studies.
Bicarbonate-containing agents, such as sodium
bicarbonate, should be avoided as they can precipitate
metabolic alkalosis and fluid overload in the mother and
fetus.
A further concern with aluminum antacids is the potential
developmental retardation described when women take
high doses of this medication.

H2 Blocker and PPI
Histamine type 2 antagonists are often the next line therapy.
Both cimetidine and ranitidine have been used with excellent safety profiles.
Although there is a safety concern with proton pump inhibitors (PPIs), in a recent meta-analysis, Gill et
al. did not find an increased risk for major congenital malformation with PPI use during pregnancy.
However, some studies in the past reported dose-related embryonic and fetal mortality in animal studies
with omeprazole.
PPIs are nowadays considered to be safe in pregnant women and are usually reserved for GERD
complications or for women who did not respond to previous treatments.
All agents that decrease gastric acidity should be used with caution, as they can lower iron absorption.
GI diseases during pregnancy Annals of Gastroenterology 3

Gastrointestinal Complications in Pregnancy Dr Sharda Jain

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