AMERICAN COLLEGE OF GASTROENTEROLOGY
Pregnancy
in Gastrointestinal Disorders

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AMERICAN COLLEGE OF GASTROENTEROLOGY
Pregnancy
in Gastrointestinal Disorders
Dedication
This second edition of the Monograph is dedicated to the memory of Radhika Srinivasan, M.D., MACG,
past Chair of the American College of Gastroenterology Women in GI Committee and the driving force
behind this revision of the first edition of this educational monograph.

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Table of Contents
I.
Constipation, Diarrhea, Hemorrhoids and Fecal Incontinence . . . . . . . . . . . . 4

Jennifer A. Christie, M.D. & Suzanne Rose, M.D., FACG


a. Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4


b. Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5


c. Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6


d. Fecal Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
II.
Endoscopy in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Asyia Ahmad, M.D. & Barbara B. Frank, M.D., FACG


a. Upper Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10


b. Lower Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11


c. ERCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12


d. Percutaneous Endoscopic Gastrostomy (PEG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13


e. Sedation in Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
III.
Heartburn, Nausea, Vomiting During Pregnancy . . . . . . . . . . . . . . . . . . . . . 18

Joel E. Richter, M.D., MACG


a. Heartburn in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18


b. Aspiration During Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20


c. Nausea and Vomiting During Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
IV.
Hyperemesis Gravidarum and Nutritional Support . . . . . . . . . . . . . . . . . . . . 26

Lillian P. Harvey-Banchik, M.D., FACS, CNSP & Karen Trujillo, M.D.


a. Liver Abnormalities in Hyperemesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26


b. Treatment of Hyperemesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27


c. Protein/Calorie Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28


d. Carbohydrate Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28


e. Fat Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28


f.
Vitamins and Minerals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28


g. Venous Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29


h. Monitoring of Pregnant Patients on TPN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
V.
Liver Diseases in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Jamilé Wakim-Fleming, M.D. & Nizar N. Zein, M.D.


a. Physiological Changes of Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32


b. Imaging in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33


c. Safety of Drugs in Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34


d. Liver Disorders Unique to Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34


e. Intercurrent Liver Diseases in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39


f.
Pregnancy in Patients with Preexisting Liver Disease . . . . . . . . . . . . . . . . . . . . . . . . 44


g. Liver Transplant and Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46


h. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

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VI.
Surgical Problems in the Pregnant Patient . . . . . . . . . . . . . . . . . . . . . . . . . 54

Sareh Parangi, M.D. & Susan Pories, M.D.


a. General Guidelines for Surgery During Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . 55


b. Appendicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55


c. Biliary Tract Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56


d. Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57


e. Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58


f.
Intestinal Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58


g. Splenic Artery Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59


h. Hepatic Lesions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59


i.
Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59


j.
Inflammatory Bowel Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60


k. Colorectal Malignancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
VII. Pregnancy in Inflammatory Bowel Disease . . . . . . . . . . . . . . . . . . . . . . . . . 66

Sunanda Kane M.D., MSPH, FACG


a. Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66


b. Effect of IBD on Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67


c. Effect of Pregnancy on IBD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67


d. Treatment of IBD During Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68


e. Surgery and Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69


f.
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

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Constipation, Diarrhea, Hemorrhoids and Fecal Incontinence
Jennifer A. Christie, M.D. & Suzanne Rose, M.D., FACG
Mount Sinai School of Medicine
Pregnant women are susceptible have not been well studied in humans.
to a host of bowel disturbances
However, pregnant rats were found to
such as constipation, diarrhea,
have prolonged colonic transit com-
and fecal incontinence at rates
pared to nonpregnant or oviarectomy
similar to that of the general popula-
controls.1 In dogs, progesterone has been
tion. However, there is data to suggest
shown to reduce the contractile force of
that the pathophysiology of the altera-
both circular and longitudinally oriented
tion in bowel pattern may be specific
strips of smooth muscle in vitro.3 These
Jennifer A. Christie, M.D.
Adjunct Assistant Professor
to hormonal and structural changes that
effects were found to be mediated by cy-
Division of Gastroenterology
occur during pregnancy and as a result
toplasmic Ca 2+ concentration. There are
Mount Sinai School of Medicine
of delivery. In this section, we will dis-
no studies on colonic transit in pregnant
cuss how the physiologic changes that
women. However, there are a few stud-
occur during pregnancy may contribute
ies looking at the effect of sex hormones
to the development of specific bowel
on colonic transit. Women were found
disturbances. In addition, we will ad-
to have slightly slower colonic transit
dress therapy for these conditions with
than men, yet no significant difference
special consideration for maternal and
was found. The effect of the menstrual
fetal safety.
cycle on colonic transit suggests that fe-
male sex hormones modestly affect co-
Suzanne Rose, M.D., FACG
Constipation
lonic transit.
Professor, Medical Education
Professor, Medicine
Constipation defined as 1) straining at
Division of Gastroenterology
The approach to management of con-
Mount Sinai School of Medicine
defecation at more than 25% of bowel
movements 2) hard stool at more than
stipation in pregnancy is similar to that
25% of bowel movements, and 3) two or
of the general population. Commonly,
fewer movements a week is thought to
constipation is managed primarily by
occur in 1/3 of women in their third tri-
dietary and behavioral modification. Di-
mester.1 However, in another study only
etary changes include increasing water
1.5 % of pregnant constipated women
(>8 glasses/day) and fiber intake (20-35
required laxatives.2
grams/day). Bulk laxatives, psyllium
and methylcellulose, are safe and effec-
The etiology of constipation during
tive in pregnancy.1 Osmotic laxatives
pregnancy is multi-factorial (Table 1).
such as polyethylene glycol (PEG) (8-25
The hormonal changes that occur during
gms/day) and lactulose (15-30 cc/day)
pregnancy, such as increased progester-
stimulate fluid accumulation in the gut.
one and estrogen, and decreased motilin
Consequently, PEG has been found to
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Constipation, Diarrhea, Hemorrhoids and Fecal Incontinence
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increase bowel frequency, accelerate colorectal transit
Diarrhea
times and improve defecation in patients with non-or-
ganic constipation refractory to dietary fiber and stim-
There are no recent studies that report on the preva-
ulant laxatives.
lence of diarrhea in pregnancy. Nonetheless, the only
5 Although not FDA approved for use
in pregnancy, PEG is inert and minimally absorbed,
physiologic alteration that may theoretically stimulate
therefore toxicity is unlikely but does carry a preg-
diarrhea in pregnancy is the increase in prostaglandins
nancy category C rating. A PEG solution, Miralax
which induce smooth muscle contraction, resulting in
©, is
now available over-the-counter.
enhanced propulsive forces.9 In addition, as is seen
with exogenous prostaglandins, such as misoprostol,
the gut may be stimulated to secrete water and elec-
trolytes.10
The approach to management
The etiology of diarrhea during pregnancy spans the
of constipation in pregnancy
spectrum of diagnosis similar to that of the nonpreg-
is similar to that of the
nant individual. The most common causes of acute
general population.
diarrhea in pregnancy are infectious viral agents such
as rotavirus and Norwalk virus. Bacterial infections
such as Campylobacter, Shigella, Escherichia coli,
Mineral oil has been found to be associated with de-
Yersinia, and Salmonella may also result in acute diar-
creased maternal absorption of fat soluble vitamins,
rhea. Noninfectious causes include medications, food
neonatal hypoprothrombinemia, and hemorrhage, and
intolerances, lactose, fructose, sorbitol and mannitol
therefore is not recommended in pregnancy.
intolerance, inflammatory bowel disease, and irritable
1 Castor
oil and saline hyperosmotic agents should be avoided
bowel syndrome.1 (Table 1)
during pregnancy because they may induce premature
Table 1
uterine contractions and salt and water retention, re-
Etiology of Constipation and Diarrhea during Pregnancy
spectively.1 Stimulant laxatives such the anthroqui-
Constipation
Diarrhea
nones, senna and cascara, are safe in pregnancy if
used intermittently, but are not recommended for reg-
Dehydration
Infection
ular use.6 Docusate sodium reduces surface tension,
Decreased physical activity

Viral
thereby permitting intestinal fluids to penetrate into
Slowed GI transit

Bacterial
the fecal mass. However, there is no evidence-based
Increased progesterone

Parasites
data to support efficacy in constipation.7

Increased estrogen
Inflammatory bowel disease

Decreased motilin
Accelerated GI transit

? Increased relaxin

Increased prostaglandins
Tegaserod, a 5-HT receptor agonist, was approved
Low fiber diet

Medications
for chronic constipation in non-pregnant patients.
Enlarged gravid uterus
Irritable bowel syndrome
However, tegaserod was suspended from the market
Pelvic floor dysfunction
Food intolerances
in March 2007 and in July 2007 it was announced it
Metabolic

Lactose
will be available only on a restricted basis on an IND

Thyroid disease

Fructose
protocol. A newer agent approved for constipation

Diabetes mellitus

Sorbitol

Mannitol
is lubiprostone.7,8 However, this agent has not been
studied in pregnant patients and is not recommended
for general use during pregnancy. (Table 2)
The evaluation of acute diarrhea is warranted if the
diarrhea is persistent or if alarm symptoms such as
weight loss and malnutrition develop. The diagnostic
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Pregnancy in Gastrointestinal Disorders
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work-up should include collecting stool for bacterial
creasing dietary fiber and water intake as well as stool
culture, analysis for ova and parasites, fecal leuko-
softeners.12 Hydrocortisone suppositories may reduce
cytes, and stool assay for Clostridium difficile toxin.9
swelling and pruritus. Witch hazel pads are safe and
Flexible sigmoidoscopy is safe in pregnancy when
effective in relieving pruritus as well, but should be
necessary. A multicenter study by Cappell and associ-
used judiciously as long-term use can lead to thinning
ates found that in 8 pregnant women, sigmoidoscopy
of the perianal area.
was not associated with pre-term labor or fetal mal-
formations.10
Surgical hemorrhoidectomy
Typically, the treatment of acute diarrhea involves
conservative management with oral rehydration, cor-
is a safe option in pregnancy
rection of potential electrolyte abnormalities with
when medical therapy fails.
orange juice and bananas (K+ replacement), salted
crackers and broth. Of the anti-diarrheals, loperamide
is most often recommended. In a prospective case
controlled study, loperamide use in the first trimes-
If conservative therapy is unsuccessful, surgical or
ter of pregnancy was not associated with a significant
endoscopic therapy may be indicated. Internal hem-
difference in the development of major fetal malfor-
orrhoids can safely be treated with endoscopic band
mations between the treatment and control groups.11
ligation, injection sclerotherapy, and infrared coagula-
However, diphenoxylate with atropine has been found
tion.1 Surgical hemorrhoidectomy is a safe option in
to be teratogenic in animals and humans in the second
pregnancy when medical therapy fails.13
and third trimester of pregnancy, and therefore is not
recommended in pregnancy.1 Bismuth subsalicylate is
Fecal Incontinence
not recommended in pregnancy because it has been
found to be associated with decreased birth weight,
Fecal incontinence (FI) is an embarrassing and social-
neonatal hemorrhage, and increased perinatal mortal-
ly-limiting problem. Many patients do not volunteer
ity.
this symptom to their physician and it is not always
9 (Table 3)
part of the physician’s repertoire in eliciting a review
of systems. In a U.S. household survey by Drossman
Hemorrhoids
et al., the prevalence of this condition was found to be
Hemorrhoids are a common complaint during preg-
7.% in the overall population.14 A community-based
nancy. They are even more common in the postpartum
survey from Wisconsin reported a general prevalence
period. Symptomatic hemorrhoids manifested by pru-
of 2.2%.15 Interestingly, anal incontinence has been
ritus, pain, and bleeding, develop during pregnancy in
found to be prevalent before, during, and three months
1/3 of women. Increased abdominal pressure by the
after pregnancy in 1.4%, 7.0%, and 8.7% of women,
enlarging gravid uterus is thought to cause vascular
respectively.16
engorgement and venous stasis.12
Normal continence depends on several factors: stool
Additionally, straining on defecation in constipated
volume and consistency, anal sphincter and pelvic
patients and pressure from pushing during the second
floor function, neurological integrity, rectal sensation,
stage of labor may contribute to hemorrhoid develop-
storage capacity, and psychological motivation. Dur-
ment.
ing pregnancy, laxity of the pelvic floor may occur
as a result of increased pelvic floor pressure from the
Symptomatic hemorrhoids in pregnant individuals
gravid uterus. Furthermore, there appears to be two
should initially be treated conservatively with in-
additional causes of incontinence related to childbirth:
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Constipation, Diarrhea, Hemorrhoids and Fecal Incontinence
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traumatic disruption of the sphincter muscles resulting
Treatment for incontinence may include dietary modi-
in fecal incontinence immediately after delivery and
fication, fiber supplementation, and pharmacologic
pudendal neuropathy causing late manifestations of
intervention with agents such as loperamide. Bio-
incontinence. However, in a recent systemic review,
feedback and surgical techniques such as creating a
cesarean section was not associated with a decrease
neosphincter have also been shown to be effective.
incidence of FI.17 Therefore, aside from childbirth
Newer therapies such as sacral nerve stimulation and
trauma, laxity of the pelvic floor during pregnancy
implantable artificial sphincter devices show prom-
seems to be the most important risk factor for FI in
ise for patients suffering with fecal incontinence. It is
pregnant women.
important to clarify the etiology of fecal incontinence
and thus to tailor therapy accordingly.
In conclusion, disturbances in bowel function are com-
It is imperative that we have
mon in pregnancy. These disturbances are frequently
a good understanding of
responsive to conservative medical therapy. However,
the pathophysiology of the
even some medical therapies are contraindicated in
bowel disturbance and the
pregnancy due to the risk of fetal and maternal com-
plications they may incur. Therefore, it is imperative
appropriate therapy for our
that we have a good understanding of the pathophysi-
pregnant patients.
ology of the bowel disturbance and the appropriate
therapy for our pregnant patients.
Anorectal physiologic tests include anorectal ma-
nometry, electromyography (EMG), pudendal nerve
conduction studies, defecography, anal endosonogra-
phy, and functional magnetic resonance imaging. The
evaluation of fecal incontinence may include all of the
above tests. However, defecography is not helpful in
detecting sphincter or nerve defects associated with
childbirth. The evaluation of fecal incontinence may
include all of the above tests, however, should be re-
served for patients six months postpartum who suffer
with fecal incontinence. Currently, pelvic MRI is in-
vestigational and is not recommended for routine use.
Sultan et al reported in the New England Journal of
Medicine that vaginal delivery may be associated with
mechanical disruption of both the internal and external
anal sphincter. Anal endosonography revealed sphinc-
ter damage in 35% of primiparous women and % of
multiparous women six weeks after delivery. Sphinc-
ter injury was associated with a decrease in maximal
resting anal pressure. Anal endosonography and ma-
nometry evaluation in these women did not change six
months postpartum and there was a strong association
between symptoms and sphincter defects.18
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Pregnancy in Gastrointestinal Disorders
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Table 2
FDA Classification of Drugs Used for Constipation in Pregnancy
Drug

FDA Class
Comments*
Bulk Laxatives
Psyllium
None

Considered safe
Methlycellulose

None

Considered safe
Osmotic Agents
Polyethylene glycol (PEG)
C


Inert, minimally absorbed, limited data, considered safe
Lactulose

B


Limited by bloating
Stimulants
Senna

C


Safe in pregnancy
Bisacodyl
B


Limited by cramping
Emolients/Lubricants
Ducosate Sodium
C


Safe, but questionable efficacy
Mineral Oil
X


Decrease absorption of fat soluble vitamins
Castor Oil
X


Premature uterine contractions
Prokinetics
Tegaserod
B


Limited data in pregnancy, no teratogenic effects in rats; Suspended
from the market in March 2007 with restricted availability as of July
2007
Lubiprostone
(chloride channel activator)
C


No data in pregnant humans, no teratogenic effects in rabbits or rats
* See text for References
Table 3
FDA Classification of Drugs Used for Diarrhea in Pregnancy
Drugs FDA Class
Comments*
Antidiarrheals
Loperamide
B


Considered safe
Diphenoxylate with atropine

C


Not recommended in pregnancy
Bismuth subsalicylate
D


Decreased birth weight, neonatal hemorrhage, and increased perinatal
mortality
Cholestyramine
C


May cause malabsorption of fat soluble vitamins, not recommended
* See text for References
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