Chapter 23 Gastroenterologic Disorders In Pregnancy

Question 0

Differential diagnosis of nausea vomiting

Answer 0

Other gastrointestinal conditions
Genitiurinary Tract pathology
Metabolic disease
Neurological disorder 
Drug toxicity
Preeclampsia

Question 1

Nausea and vomiting of pregnancy.

Answer 1

Virtually all women present with symptoms before 9 weeks

Question 2

Prevention of nausea and vomiting

Answer 2

Women who take multivitamins prior to conception are less likely to need medical attention for vomiting

Question 4

First line therapy of nausea and vomiting

Answer 4

B6 with or without doxylamine
10-25mg 3-4 times daily
Add doxylamine 12.5mg 3-4 times daily
Add promethazine 12-25mg every 4 hrs or dyphenhydramine 50-100mg every 4-6hrs

Question 5

Gastrointestinal reflux disease (GERD), heartburn is most common complaint, approx __ of pregnant women at some point, and __ experience it daily

Answer 5

80%, 25%

Question 6

factors associated with GERD include:

Answer 6

prepregnancy sx, advancing gestational age, parity.

Question 7

etiology of GERD

Answer 7

lower esophageal sphincter TONE is DECREASED during pregnancy. there is a presumed INCREASED intraabdominal pressure and delayed gastric emptying.

esophageal sphincter tone decreased
increased intraabdominal pressure
delayed gastric emptying

Question 8

dx of GERD:

Answer 8

substernal burning, dyspepsia, regurgitation. extraesophageal sx include: hoarseness, chronic cough, laryngitis, asthma.

Question 9

lifestyle and dietary changes for GERD:

Answer 9

avoid meals prior to bedtime; avoid alcohol, smoking, caffeine, chocolate, peppermint

Question 10

meds for gerd:

Answer 10

histamine (H2) receptor antagonists cat B - (zantac, pepcid, tagamet)
proton pump inhibitors (PPIs) cat B (protonix, prevacid, nexium)
except ompremazole (c) (prilosec)

Question 11

APPENDICITIS - one of most common causes of acute abdomen in pregnancy. rate:

Answer 11

1 in 1500 gestations. fetal loss rates for appendectomy are higher than for other surgical procedures during pregnancy. approx 2.6%. loss rates increase to 10% if peritonitis is present.

Question 12

dx of appendicitis:

Answer 12

right lower quadrant pain. r/o urinary tract infection and pulmonary pathology.

Question 13

evaluation of acute appendicitis, useful adjuncts include:

Answer 13

Computed tomography (CT) and magnetic resonance imaging (MRI) MRI has no fetal exposure to radiation. high positive and negative predictive value for MRI. iconclusive or normal sonogram should prompt CT / MRI.

Question 14

management of appendicitis:

Answer 14

surgical intervention.

Question 15

Irritable bowel syndrome (IBS) characterized by

Answer 15

chronic recurring abdominal pain and altered bowel habits.

Question 16

dx of IBS:

Answer 16

history, PE, routine labs. diagnostic criteria for IBS: recurrent abdominal pain / discomfort at least 3 days / month for the past 3 months, associated with 2 or more of the following:
1. improvement with defecation
2. onset associated with change in frequency of stool
3. onset associated with a change of form (appearance) of stool.
Diff Dx: celiac dx, atypical crohn’s disease, chronic constipation

Question 17

management of IBS:

Answer 17

normalizing bowel habits.

identify and eliminate foods that worsen sx.

Question 18

Inflammatory Bowel Disease (IBD) refers to:

Answer 18

1. Crohn’s disease

2. ulcerative colitis

Question 19

viral hepatitis

Answer 19

most common cause of jaundice during pregnancy. . hepatitis A and hepatitis E exhibit no risk of chronic maternal disease. vertical transmission is potentially possible in all viruses except HAV

Question 20

routine perinatal screening of all pregnant women by HbsAG testing is recommended. why?

Answer 20

identify those at risk of perinatal transmission and thus appropriately provide prophylaxis to the newborn.

Question 21

is hepatitis A vaccination and immune globulin safe in pregnancy?

Answer 21

yes. pregnant women postexposure or who are traveling to endemic areas should be considered.

Question 22

all preg women should be tested for HbsAG; infants born to women who are positive or unknown, should..

Answer 22

receive hepatitis B vaccine and hepatitis B immune globulin (HBIG) within 12 hours of birth.

Question 23

infants born to mothers who are HbsAG neg should receive hep B vaccine before

Answer 23

2 months

Question 24

preterm infants <2000g should have first vaccine delayed until

Answer 24

1 month after birth.

Question 25

risk of transmission of hepatitis B associated with amniocentesis is:

Answer 25

low

Question 26

breast feeding is not contraindicated with

Answer 26

HAV with appropriate hygienic precautions chronically infected with HBV providing infant receives vaccine and HBIG or women with hepatitis C

Question 27

Gallbladder disease. Cholelithiasis is common in adult population. __ and ___ increase frequency of gallstones

Answer 27

obesity and parity

Question 28

pregnancy appears to increase incidence of gallstones. why:

Answer 28

elevated levels of sex steroid hormones resulting in biliary stasis and increased cholesterol saturation of bile.

Question 29

disorders associated with gallstones:

Answer 29

``` biliary colic acute cholecystitis common bile duct obstruction ascending cholangitis gallstone ileus pancreatitis ```

Question 30

dx of gallbladder dx:

Answer 30

biliary colic associated with anorexia, nausea and vomiting, upper quadrant pain, fectious complications usually leukocytosis and fever.

Question 31

labs for gallbladder dx:

Answer 31

elevated bilirubin; aspartate aminotransferase (AST), alamine aminotransferase (ALT), alkaline phosphatase. US.

Question 32

management of gallbladder disease:

Answer 32

withdrawal of food and liquids, IV fluids, pain control, nasogastric suction and antibiotics.

Question 33

Intrahepatic cholestasis of pregnancy (ICP)

Answer 33

1% caucasians 2% south asians 5% chilean women. elevated bile acid levels.

Question 34

diagnosis of intrahepatic cholestasis of pregnancy:

Answer 34

pruritis without a rash; this is usually generalized but can affect palms and soles.

Question 35

lab workup for intrahepatic cholestasis of pregnancy:

Answer 35

serum bile acids and liver transaminases.

Question 36

if dx is uncertain, a liver US should be performed to r/o gallstones or biliary obstruction.

Answer 36

true

Question 37

management of intrahepatic cholestasis (ICP)

Answer 37

ursodeoxycholic acid. usually will improve biochemical abnormalities. no data powered sufficiently to assess whether correction of the bile acids will reduce fetal risks associated with ICP.

Question 38

management of intrahepatic cholestasis with regards to delivery

Answer 38

delivery by 38 wks or delivery after 36 weeks after confirmation of fetal pulmonary maturity

Question 39

Acute fatty liver of pregnancy (AFLP)

Answer 39

under nonpregnant conditions, individual who is heterozygous for these enzyme mutations will be asymptomatic. however, if a heterozygous woman is carrying a homozygous fetus, fetal fatty acids may accumulate in maternal circulation, accumulate in maternal liver, and ultimately lead to hepatic dysfunction. care providers of neonate should be informed of this potential mutation to allow screening.

Question 40

etiology of fatty liver of pregnancy:

Answer 40

disorders of fatty acid b-oxydation. woman who is heterozygous for long chain 3-hydroxyacyl-coenzyme A dehydrogenase (LCHAD) carrying a fetus with homozygous deficiency for this enzyme may be unable to metabolize the increased amounts of fatty acids; increased metabolic load may result in hepatotoxicity. increased in twins.

Question 41

sx of fatty liver of pregnancy:

Answer 41

nonspecific: nausea, vomiting, anorexia, upper quadrant pain.

Question 42

dx of fatty liver of pregnancy

Answer 42

coagulopathy, diseeminated intravascular coagulation, elevated bilirubin, liver function tests including bilirubin; metabolic acidosis, renal dysfunction, and elevated ammonia. CT may be helpful but inconsistent. dx is usually made on clinical eval.

Question 43

management:

Answer 43

maternal stabilization followed by expeditious delivery of fetus. serial lab studies including: CBC, PT, PTT, fibrinogen, blood urea nitrogen BUN, creatinine, liver function tests, blood gases, ammonia levels every 6 hrs. usually have hypoglycemia and require IV glucose infusions.