Digestive tract disorders in pregnant women

 Monika Andrijauskaitė

Introduction

Digestive tract (DT) disorders are one of the most common complaints in women during pregnancy. This can be associated with increased progesterone concentration in the blood (e.g., nausea, vomiting, gastroesophageal reflux disease (GERD)) and/or increased levels of prostaglandins (e.g., diarrhea) (1). Some DT disorders are specific to pregnancy. Most of them do not require treatment, but there are cases when pregnant women experience chronic DT-related diseases, where special care and treatment become necessary. In order to find the best solution for the care and treatment of pregnant women with developed DT disorders, it is important to understand the frequency and causes of these disorders (2, 3). This article discusses the most common symptoms and diseases related to DT that develop during pregnancy.

Nausea and Vomiting

It are common DT disorders that occur at the beginning of pregnancy, usually not requiring special treatment and subsiding on their own. Nausea is reported by 50–90%, and vomiting by 25–55% of pregnant women (4, 5). Young age, obesity, first pregnancy, and smoking are identified as risk factors for nausea during pregnancy. During the first trimester of pregnancy, usually around 6–8 weeks of pregnancy, up to 91% of women experience nausea.

Morning Sickness and Its Causes

A mild form of this digestive tract disorder is called morning sickness. Although the pathophysiology of nausea in pregnant women is not completely clear, hormonal fluctuations, digestive tract motility disorders, and psychosocial factors are associated with it. If nausea and/or vomiting persist into the 2nd or 3rd trimester of pregnancy, consider other possible causes such as urinary tract infection, gastroenteritis, peptic ulcer, pancreatitis, gallbladder or bile duct damage, hepatitis, appendicitis, adrenal insufficiency, or increased intracranial pressure. In later pregnancy, hydramnios or preeclampsia may trigger these symptoms.

Dietary and Lifestyle Modifications

The choice of treatment tactics depends on the severity of the symptoms. Relieve mild nausea by changing dietary habits (eating more frequently in smaller portions, reducing fat intake, increasing carbohydrate intake) and avoiding factors that promote nausea (e.g., consumption of coffee, iron supplements, heat, humidity, poorly ventilated rooms). If these methods do not control nausea, consume ginger products (ginger candies, ginger tea) (6).

Nutritional Supplements and Medications

Pyridoxine (vitamin B6) can alleviate nausea and is safe for pregnant women. Take 10–25 mg of vitamin B6 every 6–8 hours, not exceeding a dose of 200 mg/day (7). If this treatment does not help, use a combination of pyridoxine and doxylamine to suppress nausea and vomiting. Take 20 mg of pyridoxine and 20 mg of doxylamine (one tablet) before bedtime, and increase the dose by half if necessary (8). Note that doxylamine is not currently registered in the Register of Medicinal Products of the Republic of Lithuania.

Severe Nausea and Vomiting

For severe nausea and vomiting, administer 10 mg of metoclopramide every 6–8 hours (9). Large cohort studies have shown that metoclopramide use in the first trimester of pregnancy does not cause severe congenital fetal defects, miscarriage, or increase the likelihood of preterm birth (10, 11).

GERD

GERD affects 40–85% of pregnant women (12). In many studies, it has been observed that GERD symptoms increase and intensify in later pregnancy, but after childbirth, they become milder or disappear altogether (13). The growing uterus during pregnancy causes an increase in intra-abdominal pressure and displacement of the lower esophageal sphincter (LES), which can lead to LES relaxation, considered by many authors as the main cause of GERD (14, 15). The most common GERD symptoms are heartburn and acid reflux. Burning chest pain, dysphagia, sensation of a lump in the throat, drooling occur less frequently but are also characteristic of GERD (16, 17). GERD is usually diagnosed based on clinical symptoms. The primary treatment for GERD during pregnancy consists of lifestyle and dietary changes (e.g., elevating the head of the bed while sleeping, avoiding foods that promote reflux, etc.). Medication treatment is indicated when the previously mentioned methods are not effective. It starts with antacids. However, they contain sodium bicarbonate and magnesium trisilicate, so these drugs should be avoided during pregnancy (18). Sucralfate is later administered at 1 g 3 times a day (19). If the desired effect is not achieved, H2 histamine receptor blockers are used (e.g., ranitidine at 75–150 mg twice a day) (20). Proton pump inhibitors are also prescribed during pregnancy, with preference given to omeprazole, lansoprazole, or pantoprazole (21, 22).

Abdominal bloating and constipation

Pregnant women often complain of bloating and constipation. These symptoms bother 16-39% of women from the beginning of pregnancy to 6-12 weeks after childbirth. Bloating and constipation in pregnant women are associated with hormonal changes that disrupt intestinal motility. The increased concentration of progesterone slows down the activity of intestinal smooth muscles. This effect is also influenced by the decrease in the hormone motilin in the blood. The enlarged uterus can press on the organs in the pelvis, slowing down bowel transit. To alleviate constipation symptoms during pregnancy, prioritize increasing fiber and fluid intake in the diet or consuming concentrated dietary fibers, as these substances are not absorbed in the intestine. In severe cases, lactulose or bisacodyl may be prescribed. Avoid using castor oil, as it stimulates uterine contractions and should not be used during pregnancy.

Diarrhea

Having three or more bowel movements with loose stools per day defines diarrhea. During pregnancy, about 34% of women experience this condition. Common causes include infections from salmonella, shigella, campylobacter, Escherichia coli, parasites, or viruses. Other causes may be food poisoning, drug-induced diarrhea, or irritable bowel syndrome. If diarrhea persists for more than 48 hours, involves abundant watery stools, rectal bleeding, and noticeable weight loss, identifying the cause is crucial. Recommended tests include viral antigen, stool culture, microscopy, and a complete blood count.

Management and Treatment

The main treatment focus is restoring lost fluids and electrolyte balance by administering rehydration solutions. Start medication therapy with bismuth subsalicylate. Loperamide, which inhibits diarrhea, is also safe during pregnancy. Pregnant women should avoid antispasmodics and anticholinergic drugs.

Gallbladder Stones

During pregnancy, progesterone slows down gallbladder motility, and increased estrogen levels in the blood lead to higher cholesterol synthesis and gallstone formation. Up to 31% of pregnant women develop sludge in the gallbladder, while 2% are diagnosed with gallbladder stones. Cholecystectomy ranks as one of the most common non-pregnancy-related surgeries during pregnancy, second only to appendectomy. When cholecystitis symptoms appear, conservative treatment includes acetaminophen, intravenous opioids, intravenous rehydration, dietary adjustments, and antibiotic therapy if necessary. Diagnosing gallbladder stones in pregnant women is more challenging because the increased uterus can change the nature and location of pain, and due to the relaxation of the abdominal wall, the signs of peritonitis are often less intense. Pain is usually localized in the right upper abdominal quadrant or epigastrium. Nausea, vomiting, intolerance to fatty foods, bloating, fever, or jaundice may occur. When symptoms of gallbladder stones appear during pregnancy, doctors recommend pain relief, intravenous fluid infusion, diet adjustments, and antibiotic therapy based on the cause of the symptoms. Intravenous opioids can alleviate severe pain during pregnancy, and acetaminophen can manage mild pain. Avoid prescribing nonsteroidal anti-inflammatory drugs, especially after 32 weeks of gestation. Consider surgical treatment if conservative methods are ineffective or pain episodes recur. The best time for a cholecystectomy is in the second trimester of pregnancy or at the beginning of the third trimester.

Summary

Common Issues: Vomiting, nausea, GERD, and other gastrointestinal disorders frequently occur during pregnancy. This article explores the primary causes and treatment recommendations for these conditions.

• Nausea and Vomiting: Hormonal fluctuations, changes in gastrointestinal motility, and psychosocial factors contribute to nausea and vomiting during pregnancy. Management includes dietary habit changes, avoiding nausea triggers, consuming foods with ginger, taking vitamin B6 supplements, and using metoclopramide when necessary.

• GERD: GERD typically manifests as heartburn and acid reflux. Treatment during pregnancy involves lifestyle and dietary changes, antacids, sucralfate, H2 histamine receptor blockers, and proton pump inhibitors.

• Constipation: To treat constipation during pregnancy, increase dietary fiber and fluid intake. If these measures fail, lactulose or bisacodyl may be prescribed.

• Diarrhea: To manage watery and frequent bowel movements (three or more times a day), use rehydration solutions. Bismuth subsalicylate and loperamide can help suppress diarrhea during pregnancy.

• Gallstones: Pregnancy-related hormonal changes increase the risk of gallstone formation. When cholecystitis symptoms appear, conservative treatment includes acetaminophen, intravenous opioids, intravenous rehydration, dietary adjustments, and antibiotic therapy if necessary.

Publication "Internistas".

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