1. DIAGNOSTIC EXPLORATIONS IN PREGNANT WOMEN WITH GASTROESOPHAGEAL REFLUX

2. Functional digestive disorders have had a long history, which is scientifically grounded on research based on increasingly thorough and precise investigations that make up one of the main fields of gastroenterological practice. Infrared Isotope Analyser – IRIS Kretz Voluson 3D ultrasound Digitrapper Mk III pH- meter

3. The morpho-functional changes occurring in a woman’s body during a pregnancy are the consequence of the body adjusting to the new requirements triggered by the fetus’ presence and needs, which creates a special physiological state involving the neuro-endocrine, digestive and metabolic systems.

4. The intensity of the gastroesophageal reflux (GER) varies depending on the age of the fetus, increasing progressively as delivery approaches, and it is influenced by both mechanical (pregnant uterus) and hormonal (progesterone) factors.

5. Here are the exploration means indicated for pregnant women suffering from symptomatic GER:  esophageal pH monitoring,  double pH-metry–impedance recording,  esophageal (standard and high resolution) manometry,  upper digestive endoscopy,  aspirate investigation,  abdominal ultrasound scan,  esophageal endoscopic ultrasound scan,  gastric emptying scan.

6. Standard esophageal pH-metry may be replaced by means of pH-metric capsule attached to the esophagus wall, which record esophageal activity for 48 to 96 hours, in the absence of a nasal probe(1). The device is reliable, yet it is less sensitive to short and light reflux episodes. pH-metry sensitivity under normal endoscopic conditions is 40 – 70%. The recorded pH is transmitted by radiofrequency signal to a device worn by the patient. The method measures only acid reflux, not the reflux volume, and it has low sensitivity in detecting barely acid postprandrial reflux due to alimentary gastric plugging.

7. Esophageal pH monitoring is the most important diagnostic method, which records esophageal pH for 24 hours, by means of an electrod located 5 cm above the lower esophageal sphincter(LES), and it allows assessing acid/alkaline reflux and the mucosa exposure time to GER. A study was conducted on 32 pregnant women who experienced reflux symptoms (heartburn, acid regurgitations) and who were selected in the 2 nd Obstetrics and Gynecology Clinic in Iasi City, and the results were compared with those of the control group, which included 30 fertile women who were not pregnant and had no such symptoms.

8. DeMeester score variation (depending on the age of the fetus) GER intensity varies depending on the age of the fetus, increasing progressively as delivery approaches. GER intensity is even higher in women pregnant with twins, due to the disproportionate uterus volume increase as compared to the gestational age. pH-metric values become normal after delivery, which means that GER has a transitory effect. The most reliable pH-metric parameter is De Meester score.

9. 2. Bilimetry detects biliary reflux by the Bilitec ® method, which employs probes sensitive to bilirubin concentration thanks to their optic characteristics (spectrofotometric recording) when the absorption peak is approximately 450 nm.

10. 3. The double pH-metry–impedance recording reveals the physical nature of gaseous, liquid or mixed reflux, depending on the electric conductivity variations occurring between 2 electrodes. Liquid reflux decreases impedance, whereas gaseous reflux increases it. The method detects acid (pH 7) liquid reflux in the presence of absence of therapy. In pregnancy, the studies are limited just for ph-metry.

11. 4. Esophageal manometry (EM) records sphincter tonus and motility alterations by means of a multi- channel pressure system, which records both the basal and deglutition pressure of the LES: - normal = 15 – 25 mmHg, - less than 10 = GER. High resolution manometry allows measuring continuous esophageal motor activity at all esophageal levels and it detects more often the motor deficiencies that standard manometry fails to detect, in particular short intermittent peristalsis. The LES pressure measurement and anti-reflux barrier significance were described and supported in a research presented at the 4 th International Symposium of Gastrointestinal Motility in Canada.

12. 5. Upper digestive endoscopy (UDE) points out the GER effects on esophageal mucosa. More precisely, it allows esophagitis staging due to its 95% sensitivity and specificity. UDE is an invasive method used on certain pregnant women, especially during the 2 nd term of their pregnancy, which is a clinically calmer period for pregnant women.

13. 6. Abdominal ultrasound scanning is the most adequate imaging method, as it is non-invasive and able to reveal pregnant uterus increase, which is perfect for an accurate uterus volume determination in particular/pathological circumstances, like for instance twin pregnancy, fetal macrosomia in diabetes, polyhydramnios, pregnancy and fibroma.

14. 7. Esophageal endoscopic ultrasound scanning is the only means of recording and measuring the esophageal wall movements, which proves useful when the manometric deficiencies are significant.

15. 8. Helicobacter pylori (H. pylori) infection may be detected in pregnant women by C13/C14- urea breath test (UBT) and by serological tests for H. pylori antibodies (IgG); the Cisotope test is non-invasive, stable and nonradioactive. Food and Drug Administration (FDA) includes UBT in the C category of tests to be used on pregnant women.

16. UBT results :DOB, delta at 0 and 30 min A study was performed on 30 pregnant women in Gastroenterology Department Iasi and the prevalence of H. pylori infection detected by UBT, was 40%, less than the one reported for the East-European countries.

17. Pregnancy with its particularities determine GER by increasing level of progesterone which is produced by the placenta in high quantities, especially in the 3 rd trimester, with a direct influence in decreasing LES basal pressure.GER is also provoked by growing the pregnant uterus with 4 cm monthly, which will increase the intraabdominal and intragastric pressure. Conclusion: Thinking fetus