Introduction
Approximately 80% of pregnant women will experience gastrointestinal distress during their pregnancy (Kametas & Nelson-Piercy, 2007). Many of the gastrointestinal symptoms reported during prenatal care are associated with normal physiological changes of pregnancy such as nausea, vomiting, constipation, and heartburn. The assessment and management of these conditions are described in Chapter 11. Pregnancy may also be associated with a more serious form of nausea and vomiting known as hyperemesis gravidarum, which is addressed in Chapter 24. This chapter reviews the signs and symptoms, and evaluation of women presenting with abnormal gastrointestinal conditions during pregnancy including gastroenteritis, intraheptic cholestasis of pregnancy (ICP), cholecystitis, and appendicitis.
Gastroenteritis
Gastroenteritis, commonly referred to as stomach flu or food poisoning, is an acute, self-limiting disorder characterized by diarrhea. It causes irritation and inflammation of the gastrointestinal tract. Gastroenteritis can be caused by infectious agents including viruses (e.g., noroviruses), bacteria (e.g., Escherichia coli), and protozoa (e.g., Giardia lamblia). Parasitic infections and food-borne toxins may also cause gastroenteritis. Most cases of acute gastroenteritis are self-limiting and benign. However, more harmful causes of gastroenteritis are Listeria, Salmonella, E. coli, Shigella, and Clostridium difficile.
Evaluation and management
Diagnosis of gastroenteritis is generally based on history and clinical symptoms. Gastroenteritis commonly presents as acute diarrhea, nausea, and vomiting, with or without fever. Women with gastroenteritis may experience cramping abdominal pain, bloating, mucus or blood in the stool, and decreased urination.
- Gestational age of the pregnancy
- Fetal movement patterns
- Presence of any uterine contractions
- Current symptoms
- Recent travel
- Exposure to animals
- Recent meals
- Anyone else in the home with same symptoms
- Contact with potentially contaminated food or water
- General status and level of distress
- Vital signs
- Mucous membranes, skin turgor, orthostatic changes
- Abdominal palpation for tenderness and signs of acute abdomen
- Fetal heart tones
- Signs of uterine irritability
- Urine ketones, leukocytes, and nitrites
Differential diagnoses for gastroenteritis depend on the severity of the signs and symptoms as well as the gestational age of the pregnancy. The differential diagnosis should include ectopic pregnancy, hyperemesis gravidarum, appendicitis, and urinary tract infection. Extensive diagnostic testing is not usually indicated in healthy pregnant women with diarrhea and gastrointestinal distress. Urine dipstick or urinalysis for ketones to detect signs of dehydration and bacteruria can be performed. Microbiological stool samples are considered if the woman has signs of more severe illness such as bloody stool, prolonged fever, and neurological involvement such as paresthesia, severe dehydration, or suspicion of exposure to food toxins (Operario & Houpt, 2011).
Oral rehydration therapy is the recommended mode of administration, but this depends on the hydration status and clinical presentation of the pregnant woman. If the woman can tolerate oral fluids, rehydration with an over-the-counter (OTC) oral rehydration solution is recommended to maintain baseline need for hydration as well as to replace fluids that have been lost in diarrhea. The woman should be instructed to drink a rehydration solution slowly, consuming small amounts hourly as opposed to trying to quickly replace fluids. Intravenous fluid replacement may be indicated if the symptoms are severe and dehydration is present. A gradual return to a normal diet, starting with bland foods, should be encouraged as symptoms subside.
Antibiotics may be required based on the results of the stool culture and sensitivity. Azithromycin is recommended to use empirically for travelers’ diarrhea and is safe to use in pregnancy. It is important to note that loperamide is not recommended in pregnancy for the treatment of acute diarrhea because it may cause complications in diarrheal illnesses associated with bacterial infections such as ileus or toxic megacolon. In addition, loperamide is contraindicated for bloody diarrhea and immunocompromised patients. Listeriosis is treated with penicillins or with sulfamethoxazole/trimethoprim (Bactrim) if the patient has an allergy to penicillin. OTC probiotics may be recommended since they can help prevent diarrhea and restore positive flora that are often destroyed during antibiotic use (Dugoua et al., 2009).
Scope of practice issues
Most pregnant women with gastroenteritis recover without intervention or complications. Obstetrical consultation is warranted for women presenting with severe and persistent nausea and vomiting with diarrhea, signs of preterm labor, or fetal distress.
Intraheptic cholestasis of pregnancy
Prenatal cholestasis, also known as ICP, affects approximately 1 in 700 pregnant women (Cuckson & Germain, 2011). It is characterized by symptoms of severe pruritis and impaired liver function. ICP has no clear etiology, and it is thought to be a multifactorial disorder caused by hormonal, genetic, immune, and environmental factors. The condition has a strong familial component and is more common in relatives and offspring of women who experience ICP during pregnancy (Kingham, 2006). The normal physiological changes of pregnancy may predispose some women to ICP. The elevated levels of progesterone during pregnancy slow gallbladder emptying during pregnancy, resulting in bile stasis. The stasis may be so severe in some women that the excess bile acids may enter the circulation. The elevated levels of estrogen during pregnancy also influence gallbladder function, redisposing women to ICP (Geenes & Williamson, 2009).
Typically, ICP presents in the third trimester but can begin at any time during the pregnancy. Severe itching, especially of the hands and feet, and reports of very dark urine are common with ICP. Bowel movements may be light colored. Jaundice may develop but is usually seen after several weeks of ICP or in severe cases. The pruritis of ICP generally worsens at night. It may be of such intensity that it becomes intolerable and interferes with the woman’s ability to function. In these cases, labor induction is considered as early as 35–37 weeks of gestation (Pathak, Sheibani, & Lee, 2010). Questions about pruritus should be a routine component of the prenatal assessment during the last trimester of pregnancy and, when women report symptoms, the condition should be evaluated promptly. ICP is associated with high rates of preterm birth (30–60%) and fetal distress (33%), and is also associated with an increased risk of intrauterine fetal death (2–5%) (Geenes & Williamson, 2009; Milkiewicz et al., 2002). Thus, prompt diagnosis and referral are imperative.
The diagnosis of ICP is based on physical examination, clinical presentation, and laboratory findings. ICP is usually a diagnosis of exclusion. Other differential diagnoses include dermatitis, hepatitis, pancreatitis, or preeclampsia. Laboratory testing should include a liver panel that includes asparate aminotransferase (AST), alanie aminotransferase (ALT), gamma-glutamyl transpeptidase (GGT), alkaline phosphatase (ALP), and total bilirubin. Coagulation studies such a prothrombin time (PT), partial thromboplastin time(PTT), and international normalized ratio (INR) should also be performed. Serum bile acid levels are an essential component of the evaluation of a woman with suspected ICP.
Once a diagnosis of ICP has been made, close fetal surveillance by nonstress testing and biophysical profile is indicated to monitor fetal health. Total serum bile acid levels are followed every 2–3 weeks to guide therapy and the timing of birth. Ursodeoxycholic acid (UDCA), more commonly known as Urso, improves clinical symptoms and liver parameters in ICP. Symptomatic relief can be offered through the use of antihistamines such as diphenhydramine (Benadryl). Oatmeal-based lotions and baths may temporarily soothe the skin and relieve itching.
Scope of practice issues
Laboratory screening should be performed immediately for pregnant women with suspected ICP. Consultation and referral to obstetrical services is essential if laboratory testing reveals ICP due to a significant risk of preterm birth, fetal distress, and fetal death. All women with ICP should have a plan for the continued assessment of fetal well-being and ongoing monitoring of maternal status and liver function.
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