Gastrointestinal Disease and Pregnancy - An Overview

Introduction

Pregnancy is associated with many psychological and physiological changes in the body. The common intestinal issues during pregnancy are nausea, vomiting, diarrhea, bloating, and constipation. Some of these conditions are common during pregnancy and are resolved by following specific dietary changes, medications like Antiemetics (prevent vomit), and improving physical activity.

What Causes Gastrointestinal Diseases During Pregnancy?

• Obesity.

• Hormonal changes.

• Gastrointestinal motility disorders.

• Poor diet.

• Certain medications like anti-inflammatory medicines and their prolonged use result in gastric issues during pregnancy.

• Thyroid disorders.

• Internal changes due to expansion of the uterus.

• Lack of physical activity.

• Stress.

• History of laxative abuse.

• Consuming Antacids that contain calcium or aluminum.

• Bacterial or viral infections.

• Food allergy.

What Are the Gastrointestinal Diseases That Occur During Pregnancy?

1. Nausea and vomiting.

2. Hyperemesis gravidarum.

3. Gastroesophageal reflux disease.

4. Gallstones.

5. Diarrhea.

6. Constipation.

7. Irritable bowel syndrome.

1. Nausea and Vomiting: Nausea is a very common condition that occurs in about 90 % of pregnant women in the first trimester (first three months of pregnancy). Sometimes it can occur throughout pregnancy. Nausea is a stomach discomfort that happens before vomiting. While vomiting is an involuntary stomach emptying. The milder form of nausea and vomiting is called morning sickness.

Causes:

• The exact cause of nausea and vomiting is unclear. However, hormonal imbalances, psychosocial factors, and gastrointestinal motility disorders play a role in inducing these symptoms.

• The body during pregnancy struggles to adapt to new changes and finds it challenging to get used to the sudden rise in hormones like the human chorionic gonadotropin (hCG) or estrogen. This leads to nausea and vomiting.

• The gallbladder enlarges during pregnancy. As a result, the gallbladder empties its digestive enzymes slowly into the small intestine, and the lower esophageal sphincter (muscle in the lower end of the esophagus) resting pressure is decreased.

• A few other causes, like urinary tract infections, gastroenteritis (inflammation of the intestine), peptic ulcers (ulcers in the intestine or the stomach), pancreatitis (inflammation of the pancreas), and hepatitis (swelling of the liver), also cause nausea and vomiting.

Recommendations:

• Consuming dry foods like cereals, crackers, or toast before getting out of bed can reduce morning sickness.

• Eat bananas, rice, tea, and bland foods if you are extremely hungry and also feel nauseous.

• Acupressure wristbands can offer some comfort.

• Ginger is an excellent substance that reduces nausea.

• Consuming meals or snacks in small quantities every two to three hours can help overcome nausea. However, avoid eating large amounts of food at a time.

• Chewing the food slowly also helps in easing nausea.

• Consume liquids in minimal amounts by sipping rather than consuming large quantities of fluids.

• Avoid eating spicy, deep-fried, and greasy foods.

• A few factors like strong smell, the odor of certain foods, or consuming food cold aggravates nausea, avoiding those triggering factors.

• Certain antiemetic medications like Doxylamine, Metoclopramide, and Diphenhydramine are safe during pregnancies and do not harm the fetus. These medications can be prescribed to control nausea and vomiting.

2. Hyperemesis Gravidarum: Hyperemesis gravidarum is continuous and uncontrollable vomiting in three out of ten pregnant women. This is a severe form of vomiting during pregnancy that leads to fluid and electrolyte imbalance.

Causes: Though the exact reasons for this condition are unknown, certain genetic factors, hormonal issues, and psychological factors are believed to cause hyperemesis gravidarum during pregnancy.

Risk Factors: People who are obese during the first pregnancy and multiple gestations (carrying more than one fetus) are at high risk of experiencing hyperemesis gravidarum.

Symptoms:

• Dehydration.

• Vomiting is challenging to control.

• Ptyalism (excessive salivation that is difficult to swallow).

• More than five percent of body weight is lost.

• Abdominal pain.

• Hypokalemia (low potassium levels in the blood).

• Ketosis (when the body is deprived of carbohydrates and ketones are produced, which form the prime energy source).

• Metabolic alkalosis (acid-base balance in the blood is disturbed due to digestion issues).

• Abnormal liver enzymes.

• Mild hyperthyroidism (elevation in the levels of thyroid hormones).

Recommendations:

• Fluid infusion therapy replaces the vitamins and minerals and maintains hydration.

• Antiemetic medications like Promethazine and Pyridoxine (a form of Vitamin B6) are recommended.

• Thiamine (Vitamin B1) supplements are also recommended to replace lost multivitamins. It turns food into energy.

3. Gastroesophageal Reflux Disease (GERD): Gastroesophageal reflux disease manifests as heartburn. It is experienced by around 45% to 80% of pregnant women. About 52% of pregnant women encounter gastroesophageal reflux disease in the first trimester, around 24% to 40% in their second trimester, and nine percent of pregnant women encounter it in their third trimester.

Causes: It is caused by gastrointestinal motility disorder, lower pressure in the lower esophageal sphincter, and elevated gastric pressure.

Symptoms:

• Heartburn.

• Regurgitation.

Recommendations:

• Lifestyle modifications like consuming a small quantity of food frequently.

• Avoid consuming food within three hours of bedtime.

• Avoid bending too much or frequently.

• Place the head in an elevated position.

• Antacids like Sucrlafate are recommended and are safe during pregnancy.

• Histamine (H2) blockers like Ranitidine are recommended during pregnancy. It relieves the symptoms like heartburn by reducing acid secretion in the stomach.

4. Gallstones: Gallstones are solid calcified substances formed in the gallbladder (a pear-shaped organ on the right side of the belly region). Pregnant women are at high risk of developing gallstones that eventually lead to pancreatitis.

Causes: The causes of gallstones are unclear. However, certain factors like decreased bile emptying or increased bile stasis (reduced bile flow due to bile duct constriction or a block in the bile duct). In addition, biliary sludge (solid particle precipitation in the bile duct) can worsen, or a few women develop new gallstones.

Symptoms:

• Fever.

• Jaundice (the skin and eyes are yellow).

• Pain in the right upper belly region.

• Vomiting.

Recommendations:

• Medications: Medications like antibiotics, narcotics (painkillers to treat moderate to severe pain), and dietary modifications will be recommended.

• Cholecystectomy: It is the surgical removal of the gallbladder. This procedure will be recommended only if the symptoms are persistent and when there is weight loss. The second trimester is the safe phase to undergo surgery.

• Electroscopic Retrograde Cholecystectomy (ERCP): It is a technique that uses a long, flimsy, flexible tube with a light and a camera to view the internal organs, and images are obtained using X-ray.

5. Diarrhea: Diarrhea is uncommon in pregnancy. Diarrhea is defined as when bowel movements exceed three times a day.

Causes: It can be caused by protozoan, viral, or bacterial infections from Salmonella or Escherichia coli (E.coli). In addition, food poisoning, irritable bowel syndrome, and certain medications cause diarrhea.

Diagnosis: Diagnostic tests are considered if the stools are watery and diarrhea lasts more than 48 hours.

• Laboratory Investigations: Investigations like stool tests, where a feces sample is tested for any abnormal growth of infectious organisms.

• Flexible Sigmoidoscopy: A flexible tube-like structure is inserted into the rectum to view the internal part of the colon (the last part of the large intestine). Also, it is safe during pregnancy.

Recommendations:

• Fluid therapy.

• Medications like Loperamide can be used during pregnancy to stop diarrhea.

• Non-systemic medications like Bismuth salicylates (anti-diarrhea medications) will be the first treatment choice.

6. Constipation: Constipation is fewer bowel movements around three times a week. It is common in pregnancy. The stools are hard, dry, difficult to pass, or hard to pass, and they have a feeling that the stool has not passed.

Causes:

• Low motility in the small intestine.

• Increased water absorption.

• Due to iron supplementation.

• Decreased colon motility.

• Overuse of laxatives.

• Due to certain medications like antihistamines, painkillers, iron supplements, medicines that prevent vomiting, and blood pressure medicines.

• Already existing constipation.

Investigations:

• Digital Rectal Examination: The doctor performs this examination using a lubricant to insert the gloved hands into the rectum to check for abnormalities.

• Blood Tests: A blood test is performed to check for normal ranges of blood parameters. It is also done to check blood sugar levels, thyroid hormones, potassium, and calcium levels in the blood.

Recommendations:

• Lifestyle changes like increasing physical activity.

• Dietary changes like including fiber-rich foods.

• Use of bulking agents like Psyllium husk to relieve constipation.

7. Irritable Bowel Syndrome: Irritable bowel syndrome affects the large intestine and causes the intestinal muscles to contract more than the normal limit.

Causes: Weakened immune system.

Symptoms:

• Bloating.

• Excess gas.

• Abdominal cramps or stomach pain.

• Changes in bowel habits like hard stools, loose stools, or urgent to pass stools frequently.

• Blood in stools.

• Rectal bleeding.

• Alternate episodes of constipation and diarrhea.

Recommendations:

• Antibiotics like Amoxicillin and Clavulanic acid are recommended and are safe during pregnancy.

When Should One Visit the Doctor?

If any of the following symptoms occur, a quick visit to the hospital is recommended.

• Vomiting blood.

• Blood in stools.

• Excess weight loss.

• Feeling weak and tired constantly.

• Severe discomfort.

• Repeated episodes of choking.

• Difficulty in swallowing.

Conclusion

Gastrointestinal diseases during pregnancy are common and occur in about 80% of pregnant women. They are common in the first trimester of pregnancy. After that, they encounter symptoms like heartburn, uncontrolled vomiting, nausea, abdominal pain, bloating, etc. Medications like antiemetics, antibiotics, and vitamin supplements that are safe during pregnancy are prescribed to reduce the severity of the symptoms. If surgery is needed in cases of gallstones or biliary obstructions, it is safe to undergo surgery in the second trimester.

However, surgery will be preferred only if the symptoms are severe or persistent. If any of the symptoms mentioned above aggravate or there is blood vomiting or blood in the stool, a quick visit to the doctor's office will relieve the symptoms, reduce complications, and improve the patient's condition.