Transcript The are of the pregnant patient with GI disease

The Care of the Pregnant
Patient with GI Diseases
Mary Pat Pauly, MD FACP AGAF
Kaiser Permanente
Clinical Professor of Internal Medicine and
Gastroenterology at UC Davis
Outine
• Management of common GI diseases in
pregnancy
– GERD
– PUD
– Constipation
• Special considerations for pregnancy patients
requiring endoscopy
• Special considerations for patients with IBD
• Management of the pregnant patient with liver
disease.
GERD
Heartburn
• Heartburn occurs in
30 – 50% of
pregnancies
– Usually mild
symptoms
• Life style modifications
• Dietary modifications
• 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 tums
– and her neighbor recommended sodium
bicarbonate.
– Her mother in law takes pepcid.
– Her husband insists omeprazole is the drug
of choice.
• What should she do?
Treatment of Reflux in pregnancy
• Antacids
– In general OK , short term – but
• AVOID
– Magnesium trisilicates (Gaviscon)
• Fetal nephrolithiasis, hyponatremia and respiratory distress
– Excessive calcium carbonate
• Milk alkali syndrome
– Hypercalcemia, renal impairment and metabolic alkalosis
– Avoid -Na HCO3
• fetal metabolic alkalosis
• Fluid overload
FDA classification for the use of
Medications in pregnancy
FDA
pregnancy
category
Interpretation
A
Controlled studies in animals and women show no risk in
1st trimester, and possible fetal harm is remote.
B
Either 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.
C
No 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 risk
D
Positive evidence of fetal risk is available, but the benefits may
outweigh the risk if life threatening or serious disease.
X
Studies in animals or humans show fetal abnormalities:
drug contraindicated
What about H2 Blockers and
proton pump inhibitors?
• H2 Blockers
• Category B
– Tagamet
– Ranitidine
• Many studies available
supporting safety
– Pepcid
• Less data
available…makes “choice
of another agent
prudent.”*
• PPI
• Category C
– Omeprazole
• Animal toxicity: embryonic
toxicity and fetal mortality in
preg rats and rabbits.
• Multiple cohort studies
suggest low risk of human
toxicity
– Slightly Increased risk of
cardiac malformations
• Category B
– Esomeprazole,
pantoprazole
– lansoprazole
• Limited data: low risk
* AGA review of used of GI meds in pregnancy 2006
• She is doing better on ranitidine twice daily
and has changed to eating her main meal
at noon and small dinner
• She 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?
Endoscopy in the Pregnant
patient
• The need for procedure has to be driving force
– Must have good indication
– Elective procedures should be deferred
• Endoscopy is usually safe during pregnancy
– – during second and third trimesters
• Risks include
– Risk of sedation
– Risk of hypoxemia
– Risk of aspiration
• 35 year old G2 P1 female 32 weeks
pregnant comes in with hematemesis and
melena.
– BP 80/60 with pulse 120 and Hb 5.8
– Conservative therapy is initially
recommended. She is resussitated with fluids
and given blood. BP 90/70 P 100.
• NGT shows BRB
– not clearing with lavage
• What do you recommend?
Endoscopy in pregnancy
• Be certain good indication for EGD
• For 2nd and third trimester
– Ob consultation
– Ob anesthesia consultation
– Fetal heart tone monitoring
• Either before and after the procedure or during the procedure if it
may be prolonged.
• Position patient on left side laterally
– To avoid compression of vena cava by gravid uterus
• Sedation
– Minimize sedative drugs
• Topical anesthesia
– Recommendation is to “Gargle and spit”
Endoscopy in patient with active GI
Bleed - preferred modes of
intervention
• Endoclips
– Intervention of choice
• Bipolar cautery
– Minimizes chance of stray currents going through fetus
• Injection of epinephrine
– FDA pregnancy category C
– Can be associated with decreased uterine blood flow
• A note about Monopolar cautery
– Avoid having the uterus between the catheter and grounding pad
– Consider grounding pad in upper right arm if this mode is
necessary
Hospital coures
• FHT were normal after the procedure
• She recovered from sedation
– Was kept on side with HOB elevated after
procedure
• She was started on IV Pantoprazole
• …and the Clotest was positive for HP !!
• What would you recommend now?
Gall stone pancreatitis with Cholangitis
• Can be associated with sepsis, end-organ
failure and death.
– Can lead to pre term labor and fetal loss
• Charcot’s triad –
– RUQ pain, jaundice and fever
• Reynold’s pentad –
– add hypotension and confusion
• Treatment of choice - ERCP
– But in general
• Best avoided until after first trimester when
organogenesis is complete
• Wait until second or third trimester when possible
• 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 pancreatitis
• and recovered with conservative medical therapy.
– Plan was to have cholecystectomy after
delivery.
• But the pain recurred 2 days ago and
progressed
– she noticed dark colored urine the day of
presentation. Temp 102
• Initial vs:
– T 101, BP 100/70 P 120 O2 sat 1--% on 2 L
with resp 16
– RUQ tenderness
• Labs: ALP 456
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–
–
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AST/ALT 468/502
Bilirubin 3.1
Amylase and lipase nl
Creatinine 1.3,
• Initial management included IV fluids,
O2,NPO, admission to ICU and antibiotics
• Which antibiotics are safe to be used in
pregnancy?
Antibiotics inidcated and
contraindicated in pregnancy
• Safe in pregnancy
–
–
–
–
Cephalosporins
Penicillins
Clindamycin
Gentamycin
• Contraindicated in
pregnancy
– Quinolones
– Tetracyclines
– streptomycin
• Avoid during the first
trimester
metronidazole
(flagyl)
Avoid during second and
third trimester
sulfonamides
nitrofurantoin
• The patient was placed on Zosyn
• The next day the patient was still in pain
requiring IV pain medications.
• VS 110/40 100 resp 20 and O2 sat 100%
on 2L O2
– Labs: ALT and AST still >450
– Bilirubin 5.9
• US – 8 mm stone in 11 mm distal CBD –
• What is the best management at this
point?
ERCP in pregnancy
•
•
•
Pre op Antibiotics
– Ampicillin (B) and gentamycin (B)
Positioning of pt
• Prone is difficult
• On back increases compression of aorta and/or vena cava
• Preferably left lateral position
– Head up a little to avoid aspiration
Radiation
– Shield the baby
• Lead between patient and table
– radiation comes from below
– Keep procedure and fluoro time to minimum
What about sedation?
• Use as little sedation as possible
• Propofol and demerol are drugs of choice.
– Small amounts of IV versed are OK if needed
• Fentanyl crosses BBB more quickly
• Many recommend
– FHT monitored during procedure or at least prior to and after
procedure
– OB consult and preferably OB Anesthesia to assist
• Esp if case may be long
• Cetacaine or hurricane spray is OK but most recommend “gargle
and spit.”
• If breast feeding, pump and dump.
What about cautery
Sphincterotomy requires
– Monopolar cautery
• Put grounding pad on right arm
– Never allow uterus to be between the cautery
and the grounding pad.
• Amniotic fluid is good conducting medium
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•
•
•
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•
•
She was evaluated by OB
FHT checked just prior to sedation
Our most experienced and expert endoscopist did ERCP
Cannulated and aspirated bile
Made a sphincterotomy and extracted stone
OB returned to check FHT 30 minutes later.
Uneventful recovery
Cholecystectomy scheduled for later …after delivery.
• 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 negative
– persistently 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
Anti- viral therapy decreases
rate of transmission of HBV
• Active and passive immunization has
decreased transmission rates of HBV
– 90% effective
• HBIG and vaccination within 12 hours of birth
– Followed by additional 2 doses of vaccination
– If HBV viral load >10 (8) chances of
transmission is higher
• Up to 38% in some studies
• Lamivudine100 mg daily in third trimester
decreases rate of transmission
• 28 year old female with Hepatitis C asks
for advice.
– She has hepatitis C
•
•
•
•
genotype 2
viral load 392,000 IU/ml
normal ALT
no signs of chronic liver disease
– INR, bilirubin, and platelet count are normal
• No medical problems
– Contemplating pregnancy
• Effect of pregnancy on disease?
• Effect of disease on pregnancy?
• Chance of passing disease on to baby?
HCV - Modes of Transmission
• Blood
•
•
•
•
Blood transfusions – before 1992
Intra venous Drug abuse
Dialysis
Tattoos, piercing, razors, toothbrush
• Other
• Intranasal cocaine
• Sexual
• Mother to baby (< 5 %)
• Associated with higher viral load
• HIV co-infection
Pregnancy in patients with
Inflammatory Bowel Disease
• The highest age adjusted incidence of IBD
overlap the peak productive years
• Newer medications allow patients to be
healthier and disease free
– For longer periods of time
– And this …leads to
• Increased opportunity of successful
conception
AGE AND SEX DISTRIBUTION
OF IBD
• 32 year old woman newly diagnosed with
Crohn’s disease
– Moderate to severe ileo-colonic CD
• She has questions about the most
effective therapies
• After complete review with physician she
is placed on budesonide 9 mg daily
• She has concerns about the impact on
pregnancy
– Disease
– medications
Treatment of Crohn’s Disease
Surgery
Bowel rest
Cyclosporine
Anti TNF agents
Infliximab
Adalimumab
certolizumab
6MP, AZA, MTX
Corticosteroids
Antibiotics
mesalamine
Before pregnancy
• Be sure disease under good control
– Preferably in remission
• Active disease associated with
– Decreased ability to conceive
– Increased risk of spontaneous abortion
• Ideally healthcare maintenance up to date
• Check iron, B12, folate, vitamin D leve
– Vitamin D deficiency is associated with infertility
• Identify high risk obstetrician
• Counseling regarding medications during
• Pregnancy
• Breast feeding
Common questions
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•
•
•
•
•
Inheritance?
Fertility ?
Effect of pregnancy on disease activity?
Effect of disease on pregnancy outcomes?
Safety of medications?
Management of flares?
Inheritance
• Multifactorial
– One parent with CD
• 5% chance for offspring
– One parent with UC
• 1.6%
– If both parents have IBD a child’ risk of IBD is
higher
• Pregnancy should not be discouraged for
this reason
Fertility
• With either UC of CD, the risk of infertility
prior to surgery is probably similar to the
general population
• In 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
• Effect of Pregnancy
on Disease Activity in
IBD
• Chances of flare
– Same as non pregnant
patient
• 33%per year
• Postpartum flares
– Usually associated
with medication
discontinuation
Pregnancy outcome in IBD
• In general Healthy pregnancies
– Healthy babies
• Even with disease in remission Higher
rates of adverse outcomes
– preterm birth
– Spontaneous abortion
– Low birth weight
– Complications of labor and delivery
Medications in IBD
use during pregnancy
• Stopping medications during pregnancy
can be harmful
– Increased risk of flare
• Harmful to pregnancy
• Impair ability of mother to care for child after delivery
• Most medications are low risk and compatible with
pregnancy and lactation
• Except METHOTREXATE (X)
– Teratogenic
• Discontinue 3-6 months prior to pregnancy
Medications in IBD
use during pregnancy
• Mesalamine (B)
– Safe for use in preg
– Sulfasalazine
• Folate 2 gm daily
– ASACOL (C)
• Recently reclassified to
class “C”
– Due to presence of
dibutyl phthalate in
the coating
• Azothioprine and 6mercaptopurine (D)
– controversial
– Consider risks and
benefits
• Teratogenic in animals
• Increased rate of VSD
and ASD*
• Increased rated of
* Swedish Medical Birth Register
Cleary Birth Defects Research 2009;85: 647-54
– Premature birth
– Low birth weight
» Probably disease
related
Corticosteroids ( C)
• Prednisone
– Considered low risk during pregnancy
– Can be used for flare up
– Risk in mother
• Gestational Diabetes
– Risk to baby
• Overall risk of malformations is low
• Increased risk of cleft palate
– Use in first trimester
–
Anti –TNF agents
• Inlfiximab and
adalimumab
– Low risk, can be used
in pregnancy
– IgG1 antibodies
• Cross placenta
• Can be detected in
infant for up to 6 m after
delivery
– Last dose at 30 -32 w
– Avoid live vaccines
for 6 m
• Certolizumab
– Low risk
– Can be used in pg
– Fab fragment
• Minimal placental
transfer by passive
diffusion
– Continue through pg
– No change in
vaccination schedule
• The same 32 year old woman recently
diagnosed with Crohn’s disease and
currently being treated with Budesonide
returns 16 weeks pregnant with problems.
– Remember
• Moderate to severe ileo-colonic CD
– Presentation pain, distention, n,v, and
obstipation.
• T 102, palpable mass in LQ.
• ESR 64, CRP 6.8, WBBC 17,800
– Admitted and placed on Antibiotics and
underwent imaging study to rule out abscess.
–
Antibiotics indicated and
contraindicated in pregnancy
• Safe in pregnancy
–
–
–
–
Cephalosporins
Penicillins
Clindamycin
Gentamycin
• Contraindicated in
pregnancy
– Quinolones
– Tetracyclines
– streptomycin
• Avoid during the first
trimester
metronidazole
flagyl
Avoid during second and
third trimester
sulfonamides
nitrofurantoin
Imaging studies in CD
• CT should be avoided in pregnancy
• US
– No contraindications
• MRI
– OK if imaging study is needed but
– Avoid gadolinium – especially in first trimester
• Teratogen
• She was treated with Zosyn and
underwent MRI
• There was inflammatory mass in RLQ
– Ileum
• She improved clinically
– Afebrile, no distention, good BMs,
• Steroids were added and she was started
on a taper
– She was switched to anti TNF agent
• certiluzimab
One more consideration…
• Modes of delivery
– Usually at discretion of high risk Obstetrician
• C-section preperred
– Active perianal diseae
– Ileal-pouch anal anastomosis
• Preserves sphincter continence
Pregnancy in patients with
cirrhosis
• Pregnancy is usually NOT encouraged in
patients with cirrhosis
– Pregnancy is rare in patients with cirrhosis
• Advanced liver disease does not typically occur
until later in life
– Until after most patients have completed their
reproductive years.
– Higher incidence of anovulation and
amenorrhea
• Due to metabolic and hormonal derangements
• Maternal mortality is higher in cirrhosis
Pregnancy in cirrhosis – effects
on the fetus
•
•
•
•
Data is sparse
Increased spontaneious abortin rate
Increased risk of prematurity
Increased perinatal death rate
Effects of cirrhosis and portal
hypertension
• Esophageal variceal bleeding – varices
get worse during pregnancy
– Reported in 18 – 32% with cirrhosis
– Up to 50% of those with known portal
hypertension
– Up to 78% in those with pre-existing varices.
– Most commonly in 2nd and 3rd trimester
• Blood volume highest
• Fetus compreses IVC
• Mortality rates are high
Treatment of variceal bleeding
• Endoscopic variceal band ligation
– Superior to sclerotherapy – no chemicals instilled into blood
stream. -Expert opinion
• Octreotide (B)
– Safety in pg not determined
– Could cause arterolar vasospasm
• Decreased placental perfusion and increased risk of
placental abruption as well as
– HTN, MI, peripheral ischemia
• Endoscopy
– Safe when done with caution
Prophylactic treatment of
varices in cirrhosis
• Screening EGD
– Before pregnancy
– Or at beginning of second trimester*
– Blood volume increased
– Gravid uterus compressing IVC
• Prophylaxis –
– options
• non selective beta blockers
• Or variceal band ligation
* AASLD recommendations
Pregnancy and cirrhosis
• Review of data from 1984 – 2009
• Kings College Hospital
• 62 pregnancies in 29 women
– Median MELD was 7 (range 6 – 17)
– Median CPS was 5 ( range 5-8)
• Live birth rate was 58%
– Median gestational age 36 w
Westbrook RH et al ClinGastroHep 2011;9: 694-9
Pregnancy and cirrhosis
• Maternal complications occurred in 10%
• Ascites
• Encephaolpathy
• Variceal hemorrhage
– Associated with MELD > 10
– MELD predicted which patients were to have
liver related complications
• AUC 0.8
– 83% sensitivity and 83% specificity
– No one with MELD <6 had any liver related
complications
Westbrook RH et al ClinGastroHep 2011;9: 694-9
Constipation in pregnancy
• Fiber is first line therapy
•
•
•
•
•
Lactulose (B)
Magnesium containing products (B)
Senna (C)*
Lubiprostone (C)*
PEG (C)*
• Do not use
– Castor oil (X) – associated with uterine
rupture
*Low risk if used short term
In summary
• Many young women who are pregnant have GI problems
and will seek care from gastroenterologists
• It is very important for the mother to be as healthy as
possible
– Treat the disease in mother so she will be able to
have a healthy baby
• When treating patients you must consider the effects of
the medications on the baby as well as the mother
– No drugs that we routinely use are class A
– Use class B or C drugs when the benefit outweighs
the risk
• Remember special concerns when performing
endoscopy
– And special considerations for sedation
• Propofol when available and position pt
appropriately
• Patients with IBD and cirrhosis have higher rates of
complications when pregnant
– Patients with IBD need extra special care and follow
up
• Get disease under control with as safe a
medication as possible
• Patients with cirrhosis have high risk of variceal bleeding
and other complications
– Pregnancy is strongly discouraged
• Screen for varices and treat prophylactically when possible.