Presentation on theme: "The Care of the Pregnant Patient with GI Diseases"— Presentation transcript:
1The Care of the Pregnant Patient with GI Diseases Mary Pat Pauly, MD FACP AGAFKaiser PermanenteClinical Professor of Internal Medicine and Gastroenterology at UC Davis
2Outine Management of common GI diseases in pregnancy GERDPUDConstipationSpecial considerations for pregnancy patients requiring endoscopySpecial considerations for patients with IBDManagement of the pregnant patient with liver disease.
3GERD Heartburn Heartburn occurs in 30 – 50% of pregnancies Usually mild symptomsLife style modificationsDietary modifications
435 yo female calls for advice 35 yo female calls for advice. She is about 3 months pregnant and having severe heart burn.She has tried life style changes without success.Her obstetrician advised her to take antacids.Her mother has her taking tumsand her neighbor recommended sodium bicarbonate.Her mother in law takes pepcid.Her husband insists omeprazole is the drug of choice.What should she do?
5Treatment of Reflux in pregnancy AntacidsIn general OK , short term – butAVOIDMagnesium trisilicates (Gaviscon)Fetal nephrolithiasis, hyponatremia and respiratory distressExcessive calcium carbonateMilk alkali syndromeHypercalcemia, renal impairment and metabolic alkalosisAvoid -Na HCO3fetal metabolic alkalosisFluid overload
6FDA classification for the use of Medications in pregnancy FDA pregnancy categoryInterpretationAControlled studies in animals and women show no risk in 1st trimester, and possible fetal harm is remote.BEither animal studies have not shown fetal risk but no controlled studies in pregnant women, or animal studies have shown an adverse effect that was not confirmed in women in 1st trimester.CNo controlled studies in humans have been performed, and animal studies have shown AE, or studies in humans and animals are not available: give if potential benefit outweighs riskDPositive evidence of fetal risk is available, but the benefits may outweigh the risk if life threatening or serious disease.XStudies in animals or humans show fetal abnormalities: drug contraindicated
7What about H2 Blockers and proton pump inhibitors? Category BTagametRanitidineMany studies available supporting safetyPepcidLess data available…makes “choice of another agent prudent.”*PPICategory COmeprazoleAnimal toxicity: embryonic toxicity and fetal mortality in preg rats and rabbits.Multiple cohort studies suggest low risk of human toxicitySlightly Increased risk of cardiac malformationsCategory BEsomeprazole, pantoprazolelansoprazoleLimited data: low risk* AGA review of used of GI meds in pregnancy 2006
8She is doing better on ranitidine twice daily and has changed to eating her main meal at noon and small dinnerShe reminds you that her father had history of GERD and Barrett’s esophagus and died of Esophageal cancer at age 40.She asks if she should have Endoscopy to check for Barrett’s?
9Endoscopy in the Pregnant patient The need for procedure has to be driving forceMust have good indicationElective procedures should be deferredEndoscopy is usually safe during pregnancy– during second and third trimestersRisks includeRisk of sedationRisk of hypoxemiaRisk of aspiration
1035 year old G2 P1 female 32 weeks pregnant comes in with hematemesis and melena. BP 80/60 with pulse 120 and Hb 5.8Conservative therapy is initially recommended. She is resussitated with fluids and given blood. BP 90/70 P 100.NGT shows BRBnot clearing with lavageWhat do you recommend?
11Endoscopy in pregnancy Be certain good indication for EGDFor 2nd and third trimesterOb consultationOb anesthesia consultationFetal heart tone monitoringEither before and after the procedure or during the procedure if it may be prolonged.Position patient on left side laterallyTo avoid compression of vena cava by gravid uterusSedationMinimize sedative drugsTopical anesthesiaRecommendation is to “Gargle and spit”
12Endoscopy in patient with active GI Bleed - preferred modes of intervention EndoclipsIntervention of choiceBipolar cauteryMinimizes chance of stray currents going through fetusInjection of epinephrineFDA pregnancy category CCan be associated with decreased uterine blood flowA note about Monopolar cauteryAvoid having the uterus between the catheter and grounding padConsider grounding pad in upper right arm if this mode is necessary
13Hospital coures FHT were normal after the procedure She recovered from sedationWas kept on side with HOB elevated after procedureShe was started on IV Pantoprazole…and the Clotest was positive for HP !!What would you recommend now?
14Gall stone pancreatitis with Cholangitis Can be associated with sepsis, end-organ failure and death.Can lead to pre term labor and fetal lossCharcot’s triad –RUQ pain, jaundice and feverReynold’s pentad –add hypotension and confusionTreatment of choice - ERCPBut in generalBest avoided until after first trimester when organogenesis is completeWait until second or third trimester when possible
15But the pain recurred 2 days ago and progressed 28 year old pregnant female at 34 weeks gestation presents to ER at 11pm with severe RUQ pain,N,V,T and shaking chills.These sx are similar to sx that resolved spontaneously when she was 8 weeks pregnant with gall stones pancreatitisand recovered with conservative medical therapy.Plan was to have cholecystectomy after delivery.But the pain recurred 2 days ago and progressedshe noticed dark colored urine the day of presentation. Temp 102
16Which antibiotics are safe to be used in pregnancy? Initial vs:T 101, BP 100/70 P 120 O2 sat 1--% on 2 L with resp 16RUQ tendernessLabs: ALP 456AST/ALT 468/502Bilirubin 3.1Amylase and lipase nlCreatinine 1.3,Initial management included IV fluids, O2,NPO, admission to ICU and antibioticsWhich antibiotics are safe to be used in pregnancy?
17Antibiotics inidcated and contraindicated in pregnancy Safe in pregnancyCephalosporinsPenicillinsClindamycinGentamycinContraindicated in pregnancyQuinolonesTetracyclinesstreptomycinAvoid during the first trimestermetronidazole(flagyl)Avoid during second and third trimestersulfonamidesnitrofurantoin
18The patient was placed on Zosyn The next day the patient was still in pain requiring IV pain medications.VS 110/ resp 20 and O2 sat 100% on 2L O2Labs: ALT and AST still >450Bilirubin 5.9US – 8 mm stone in 11 mm distal CBD –What is the best management at this point?
19ERCP in pregnancy Keep procedure and fluoro time to minimum Pre op AntibioticsAmpicillin (B) and gentamycin (B)Positioning of ptProne is difficultOn back increases compression of aorta and/or vena cavaPreferably left lateral positionHead up a little to avoid aspirationRadiationShield the babyLead between patient and tableradiation comes from belowKeep procedure and fluoro time to minimum
20What about sedation? Use as little sedation as possible Propofol and demerol are drugs of choice.Small amounts of IV versed are OK if neededFentanyl crosses BBB more quicklyMany recommendFHT monitored during procedure or at least prior to and after procedureOB consult and preferably OB Anesthesia to assistEsp if case may be longCetacaine or hurricane spray is OK but most recommend “gargle and spit.”If breast feeding, pump and dump.
21What about cautery Sphincterotomy requires Monopolar cauteryPut grounding pad on right armNever allow uterus to be between the cautery and the grounding pad.Amniotic fluid is good conducting medium
22She was evaluated by OBFHT checked just prior to sedationOur most experienced and expert endoscopist did ERCPCannulated and aspirated bileMade a sphincterotomy and extracted stoneOB returned to check FHT 30 minutes later.Uneventful recoveryCholecystectomy scheduled for later …after delivery.
23What is my chance of transmission to my baby? 24 yo Hmong female 25 weeks pregnant with Hepatitis B asks for advice.She has had HBV since she was born and transmission at birth as her mother had HBV and now has cirrhosis.She in HBeAg positive, HBeAb negativepersistently normal ALT 17 – 19.High viral load 6 x 10 (9)What is my chance of transmission to my baby?Is there anything that can be done to decrease the chance of transmission
24Anti- viral therapy decreases rate of transmission of HBV Active and passive immunization has decreased transmission rates of HBV90% effectiveHBIG and vaccination within 12 hours of birthFollowed by additional 2 doses of vaccinationIf HBV viral load >10 (8) chances of transmission is higherUp to 38% in some studiesLamivudine100 mg daily in third trimester decreases rate of transmission
2528 year old female with Hepatitis C asks for advice. She has hepatitis Cgenotype 2viral load 392,000 IU/mlnormal ALTno signs of chronic liver diseaseINR, bilirubin, and platelet count are normalNo medical problemsContemplating pregnancyEffect of pregnancy on disease?Effect of disease on pregnancy?Chance of passing disease on to baby?
26HCV - Modes of Transmission BloodBlood transfusions – before 1992Intra venous Drug abuseDialysisTattoos, piercing, razors, toothbrushOtherIntranasal cocaineSexualMother to baby (< 5 %)Associated with higher viral loadHIV co-infection
27Pregnancy in patients with Inflammatory Bowel Disease The highest age adjusted incidence of IBD overlap the peak productive yearsNewer medications allow patients to be healthier and disease freeFor longer periods of timeAnd this …leads toIncreased opportunity of successful conception
28AGE AND SEX DISTRIBUTION OF IBD Crohn’s disease and ulcerative colitis can have their onset at any age, but the peak incidence is in late adolescence and early adulthood. In some studies there is a second peak of Crohn’s colitis in women during their 6th and 7th decades of life. In general, the frequency of ulcerative colitis and Crohn’s disease is similar in males and females with a very slight female predominance in some studies. Multiple studies demonstrate a correlation of proximal Crohn’s disease (gastric, duodenal and small bowel location) with early onset disease and of colonic inflammation with late onset Crohn’s disease.• Rogers BH, Clark LM, Kirsner JB. The epidemiologic and demographic characteristics of inflammatory bowel disease: an analysis of a computerized file of 1400 patients. Journal of Chronic Disease 1971;24:743.
2932 year old woman newly diagnosed with Crohn’s disease Moderate to severe ileo-colonic CDShe has questions about the most effective therapiesAfter complete review with physician she is placed on budesonide 9 mg dailyShe has concerns about the impact on pregnancyDiseasemedications
30Treatment of Crohn’s Disease SurgeryBowel restCyclosporineAnti TNF agentsInfliximabAdalimumabcertolizumab6MP, AZA, MTXCorticosteroidsAntibioticsmesalamine
31Before pregnancy Be sure disease under good control Preferably in remissionActive disease associated withDecreased ability to conceiveIncreased risk of spontaneous abortionIdeally healthcare maintenance up to dateCheck iron, B12, folate, vitamin D leveVitamin D deficiency is associated with infertilityIdentify high risk obstetricianCounseling regarding medications duringPregnancyBreast feeding
32Common questions Inheritance? Fertility ? Effect of pregnancy on disease activity?Effect of disease on pregnancy outcomes?Safety of medications?Management of flares?
33Inheritance Multifactorial One parent with CD5% chance for offspringOne parent with UC1.6%If both parents have IBD a child’ risk of IBD is higherPregnancy should not be discouraged for this reason
34FertilityWith either UC of CD, the risk of infertility prior to surgery is probably similar to the general populationIn UC patients there seems to be decreased fertility after IPAA (J pouch)As much as 40-80%One study from Scotland *fertility was only 1/5th of those with UC prior to IPAA.*Olsen KO et al. Gastro 2002;122:15-19
35Effect of Pregnancy on Disease Activity in IBD Chances of flareSame as non pregnant patient33%per yearPostpartum flaresUsually associated with medication discontinuation
36Pregnancy outcome in IBD In general Healthy pregnanciesHealthy babiesEven with disease in remission Higher rates of adverse outcomespreterm birthSpontaneous abortionLow birth weightComplications of labor and delivery
37Medications in IBD use during pregnancy Stopping medications during pregnancy can be harmfulIncreased risk of flareHarmful to pregnancyImpair ability of mother to care for child after deliveryMost medications are low risk and compatible with pregnancy and lactationExcept METHOTREXATE (X)TeratogenicDiscontinue 3-6 months prior to pregnancy
38Medications in IBD use during pregnancy Mesalamine (B)Safe for use in pregSulfasalazineFolate 2 gm dailyASACOL (C)Recently reclassified to class “C”Due to presence of dibutyl phthalate in the coatingAzothioprine and 6-mercaptopurine (D)controversialConsider risks and benefitsTeratogenic in animalsIncreased rate of VSD and ASD*Increased rated ofPremature birthLow birth weightProbably disease related* Swedish Medical Birth RegisterCleary Birth Defects Research 2009;85:
39Corticosteroids ( C) Prednisone Considered low risk during pregnancy Can be used for flare upRisk in motherGestational DiabetesRisk to babyOverall risk of malformations is lowIncreased risk of cleft palateUse in first trimester
40Anti –TNF agents Inlfiximab and adalimumab Certolizumab Low risk Low risk, can be used in pregnancyIgG1 antibodiesCross placentaCan be detected in infant for up to 6 m after deliveryLast dose at wAvoid live vaccines for 6 mCertolizumabLow riskCan be used in pgFab fragmentMinimal placental transfer by passive diffusionContinue through pgNo change in vaccination schedule
41The same 32 year old woman recently diagnosed with Crohn’s disease and currently being treated with Budesonide returns 16 weeks pregnant with problems.RememberModerate to severe ileo-colonic CDPresentation pain, distention, n,v, and obstipation.T 102, palpable mass in LQ.ESR 64, CRP 6.8, WBBC 17,800Admitted and placed on Antibiotics and underwent imaging study to rule out abscess.
42Antibiotics indicated and contraindicated in pregnancy Safe in pregnancyCephalosporinsPenicillinsClindamycinGentamycinContraindicated in pregnancyQuinolonesTetracyclinesstreptomycinAvoid during the first trimestermetronidazoleflagylAvoid during second and third trimestersulfonamidesnitrofurantoin
43Imaging studies in CD CT should be avoided in pregnancy US MRI No contraindicationsMRIOK if imaging study is needed butAvoid gadolinium – especially in first trimesterTeratogen
44She was treated with Zosyn and underwent MRI There was inflammatory mass in RLQIleumShe improved clinicallyAfebrile, no distention, good BMs,Steroids were added and she was started on a taperShe was switched to anti TNF agentcertiluzimab
45One more consideration… Modes of deliveryUsually at discretion of high risk ObstetricianC-section preperredActive perianal diseaeIleal-pouch anal anastomosisPreserves sphincter continence
46Pregnancy in patients with cirrhosis Pregnancy is usually NOT encouraged in patients with cirrhosisPregnancy is rare in patients with cirrhosisAdvanced liver disease does not typically occur until later in lifeUntil after most patients have completed their reproductive years.Higher incidence of anovulation and amenorrheaDue to metabolic and hormonal derangementsMaternal mortality is higher in cirrhosis
47Pregnancy in cirrhosis – effects on the fetus Data is sparseIncreased spontaneious abortin rateIncreased risk of prematurityIncreased perinatal death rate
48Effects of cirrhosis and portal hypertension Esophageal variceal bleeding – varices get worse during pregnancyReported in 18 – 32% with cirrhosisUp to 50% of those with known portal hypertensionUp to 78% in those with pre-existing varices.Most commonly in 2nd and 3rd trimesterBlood volume highestFetus compreses IVCMortality rates are highReports up to 18 – 50% mortality in cirrhosi with PHTN – and only about 2-6% in pateints with non cirrhotic portalhypertension
49Treatment of variceal bleeding Endoscopic variceal band ligationSuperior to sclerotherapy – no chemicals instilled into blood stream. -Expert opinionOctreotide (B)Safety in pg not determinedCould cause arterolar vasospasmDecreased placental perfusion and increased risk of placental abruption as well asHTN, MI, peripheral ischemiaEndoscopySafe when done with caution
50Prophylactic treatment of varices in cirrhosis Screening EGDBefore pregnancyOr at beginning of second trimester*Blood volume increasedGravid uterus compressing IVCProphylaxis –optionsnon selective beta blockersOr variceal band ligation* AASLD recommendations
51Pregnancy and cirrhosis Review of data from 1984 – 2009Kings College Hospital62 pregnancies in 29 womenMedian MELD was 7 (range 6 – 17)Median CPS was 5 ( range 5-8)Live birth rate was 58%Median gestational age 36 wWestbrook RH et al ClinGastroHep 2011;9: 694-9
52Pregnancy and cirrhosis Maternal complications occurred in 10%AscitesEncephaolpathyVariceal hemorrhageAssociated with MELD > 10MELD predicted which patients were to have liver related complicationsAUC 0.883% sensitivity and 83% specificityNo one with MELD <6 had any liver related complicationsWestbrook RH et al ClinGastroHep 2011;9: 694-9
53Constipation in pregnancy Fiber is first line therapyLactulose (B)Magnesium containing products (B)Senna (C)*Lubiprostone (C)*PEG (C)*Do not useCastor oil (X) – associated with uterine rupture*Low risk if used short term
54In summaryMany young women who are pregnant have GI problems and will seek care from gastroenterologistsIt is very important for the mother to be as healthy as possibleTreat the disease in mother so she will be able to have a healthy babyWhen treating patients you must consider the effects of the medications on the baby as well as the motherNo drugs that we routinely use are class AUse class B or C drugs when the benefit outweighs the risk
55Remember special concerns when performing endoscopy And special considerations for sedationPropofol when available and position pt appropriatelyPatients with IBD and cirrhosis have higher rates of complications when pregnantPatients with IBD need extra special care and follow upGet disease under control with as safe a medication as possiblePatients with cirrhosis have high risk of variceal bleeding and other complicationsPregnancy is strongly discouragedScreen for varices and treat prophylactically when possible.