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Gastrointestinal Disorders During Pregnancy


Key Points

  • The differential diagnosis of GI symptoms and signs such as abdominal pain is particularly extensive during pregnancy. Aside from GI and other intraabdominal disorders incidental to pregnancy, the differential includes obstetric, gynecologic, and GI disorders related to pregnancy.

  • Pregnancy can affect the clinical presentation, frequency, or severity of GI diseases. For example, GERD markedly increases in frequency, and peptic ulcer disease decreases in frequency or may become inactive during pregnancy.

  • Abdominal ultrasound is the safest and most commonly used abdominal imaging modality to evaluate GI conditions during pregnancy. Other common abdominal imaging modalities, particularly computed tomography, raise serious concerns about fetal safety.

  • EGD and flexible sigmoidoscopy can be performed when strongly indicated during pregnancy, such as for significant acute upper and lower GI bleeding, respectively.

  • Most GI drugs appear to be relatively safe for the fetus (FDA categories B and C) and can be used with caution when clearly indicated during pregnancy, especially during the second and third trimesters after organogenesis has occurred. Drugs to be avoided during pregnancy include methotrexate (category X), some chemotherapeutic agents, and a few antibiotics.

Differential Diagnosis and Evaluation of Gastrointestinal Symptoms During Pregnancy

Abdominal Pain

  • ▪

    The differential diagnosis of abdominal pain during pregnancy is extensive in that it includes obstetric conditions in addition to the usual gastrointestinal (GI) and other intraabdominal conditions in the general population.

  • ▪

    The abdominal pain is typically localized to the abdominal quadrant in which the afflicted organ is located, as illustrated for pain in the right lower quadrant in Box 48.1 .

    BOX 48.1
    Differential Diagnosis of Right Lower Quadrant Abdominal Pain

    Gastrointestinal Disorders

    • Appendicitis

    • Crohn disease

    • Ruptured Meckel diverticulum

    • Intestinal intussusception

    • Cecal perforation

    • Colon cancer

    • Ischemic colitis

    • Irritable bowel syndrome

    Renal Diseases

    • Nephrolithiasis

    • Cystitis

    • Pyelonephritis

    Obstetric and Gynecologic Diseases

    • Ruptured ectopic pregnancy

    • Ovarian tumors

    • Ovarian cyst rupture

    • Ovarian torsion

    • Endometriosis

    • Uterine leiomyomas

    Other

    • Trochanteric bursitis

  • ▪

    When the diagnosis is uncertain, close and vigilant monitoring by a surgical team with frequent abdominal examination and regular laboratory tests can often clarify the diagnosis. The character, severity, localization, or instigating factors of abdominal pain often change with time. For example, acute appendicitis typically changes from a dull, poorly localized, moderate pain to an intense and focal pain as the inflammation extends from the appendiceal wall to the surrounding peritoneum. The differential diagnosis of severe abdominal pain is described in Table 48.1 .

    TABLE 48.1
    Common Causes of Acute, Severe Abdominal Pain During Pregnancy: Pain Characteristics and Diagnostic Tests
    Condition Location Character Radiation Diagnostic Tests
    Ruptured ectopic pregnancy Lower abdomen or pelvis Localized, severe None Serum β-hCG, abdominal ultrasound
    Pelvic inflammatory disease Lower abdomen or pelvis Gradual in onset, localized Flanks and thighs Abdominal ultrasound
    Appendicitis First periumbilical, later RLQ (RUQ in late pregnancy) Gradual in onset, becomes focal Back or flank Abdominal ultrasound in appropriate clinical setting
    Acute cholecystitis RUQ Focal Right scapula, shoulder, or back Abdominal ultrasound, serum liver function tests
    Pancreatitis Epigastric Localized, boring Middle of back Serum lipase and amylase, abdominal ultrasound
    Perforated peptic ulcer Epigastric or RUQ Burning, boring Right back Abdominal ultrasound, laparotomy
    Urolithiasis Abdomen or flanks Varies from intermittent and aching to severe and unremitting Groin Urinalysis, abdominal ultrasound, and occasionally fluoroscopy with contrast urography
    hCG, human chorionic gonadotropin; RLQ, right lower quadrant; RUQ, right upper quadrant.

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