Download PDF
Clin Colon Rectal Surg 2010; 23(2): 080-089
DOI: 10.1055/s-0030-1254294
© Thieme Medical Publishers

Gastrointestinal Conditions during Pregnancy

Sherri A. Longo1 , Robert C. Moore1 , Bernard J. Canzoneri1 , Alfred Robichaux1
  • 1Department of Obstetrics and Gynecology, Section of Maternal-Fetal Medicine, Ochsner Clinic Foundation, New Orleans, Louisiana
Further Information

Publication History

Publication Date:
28 May 2010 (online)

    Permissions and Reprints

ABSTRACT

Pregnancy causes anatomic and physiologic changes in the gastrointestinal tract. Pregnant women with intestinal disease such as Crohn disease or ulcerative colitis pose a management challenge in clinical diagnosis, radiologic evaluation, and treatment secondary to potential risk to the fetus. Heightened physician awareness on possible etiologies such as appendicitis, diverticulitis, and rarely colorectal cancer is required for rapid diagnosis and treatment to improve maternal/fetal outcome. A multidisciplinary approach to evaluation is a necessity because radiologic procedures and treatment medications commonly used in nonpregnant patients may have a potential harmful effect on the fetus. The authors review several gastrointestinal conditions encountered during pregnancy and address presentation, diagnosis, and treatment of each condition.

KEYWORDS

Gastrointestinal - pregnancy - constipation - inflammatory bowel disease

REFERENCES

  • 1 Bonapace Jr E S, Fisher R S. Constipation and diarrhea in pregnancy.  Gastroenterol Clin North Am. 1998;  27(1) 197-211
    CrossrefPubMedGoogle Scholar
  • 2 Greenhalf J O, Leonard H S. Laxatives in the treatment of constipation in pregnant and breast-feeding mothers.  Practitioner. 1973;  210(256) 259-263
    PubMedGoogle Scholar
  • 3 Levy N, Lemberg E, Sharf M. Bowel habit in pregnancy.  Digestion. 1971;  4(4) 216-222
    CrossrefPubMedGoogle Scholar
  • 4 Singer A J, Brandt L J. Pathophysiology of the gastrointestinal tract during pregnancy.  Am J Gastroenterol. 1991;  86(12) 1695-1712
    PubMedGoogle Scholar
  • 5 West L, Warren J, Cutts T. Diagnosis and management of irritable bowel syndrome, constipation, and diarrhea in pregnancy.  Gastroenterol Clin North Am. 1992;  21(4) 793-802
    PubMedGoogle Scholar
  • 6 Creasy R, Resnik R, Iams J D, Lockwood C J, Moore T R. Maternal fetal medicine principles and practice. 6th ed. Philadelphia; WB Saunders 2008
    Google Scholar
  • 7 Wald A. Constipation, diarrhea, and symptomatic hemorrhoids during pregnancy.  Gastroenterol Clin North Am. 2003;  32(1) 309-322, vii
    CrossrefPubMedGoogle Scholar
  • 8 Pedrosa I, Lafornara M, Pandharipande P V, Goldsmith J D, Rofsky N M. Pregnant patients suspected of having acute appendicitis: effect of MR imaging on negative laparotomy rate and appendiceal perforation rate.  Radiology. 2009;  250(3) 749-757
    CrossrefPubMedGoogle Scholar
  • 9 Basaran A, Basaran M. Diagnosis of acute appendicitis during pregnancy, a systematic review.  Obstet Gynecol Surv. 2009;  64(7) 481-488 quiz 499
    CrossrefPubMedGoogle Scholar
  • 10 Sadot E, Telem D, Arora1 M, Butala1 P, Nguyen1 S Q, Celia M, Divino C M. Laparoscopy: a safe approach to appendicitis in pregnancy.  Surg Endosc. 2010;  24(2) 383-389
    CrossrefPubMedGoogle Scholar
  • 11 Williams R, Shaw J. Ultrasound scanning in the diagnosis of acute appendicitis in pregnancy.  Emerg Med J. 2007;  24(5) 359-360
    PubMedGoogle Scholar
  • 12 Ames Castro M, Shipp T D, Castro E E, Ouzounian J, Rao P. The use of helical computed tomography in pregnancy for the diagnosis of acute appendicitis.  Am J Obstet Gynecol. 2001;  184(5) 954-957
    CrossrefPubMedGoogle Scholar
  • 13 Creasy R, Resnik R, Creasy R, Resnik R, Iams J D, Lockwood C J, Moore T R et al.. Maternal fetal medicine principles and practice. 6th ed. Philadelphia; WB Saunders 2008: 1046-1047
    Google Scholar
  • 14 Tracey M, Fletcher H S. Appendicitis in pregnancy.  Am Surg. 2000;  66 555-559
    PubMedGoogle Scholar
  • 15 Tamir I L, Bongard F S, Klein S R. Acute appendicitis in the pregnant patient.  Am J Surg. 1990;  160(6) 571-575 discussion 575-576
    CrossrefPubMedGoogle Scholar
  • 16 Rudloff U, Jobanputra S, Smith-Levitin M, Kessler E. Meckel's diverticulum complicating pregnancy. Case report and review of the literature.  Arch Gynecol Obst. 2005;  271(1) 89-93
    PubMedGoogle Scholar
  • 17 Andres P G, Friedman L S. Epidemiology and the natural course of inflammatory bowel disease.  Gastroenterol Clin North Am. 1999;  28(2) 255-281, vii
    CrossrefPubMedGoogle Scholar
  • 18 Hudson M, Flett G, Sinclair T S, Brunt P W, Templeton A, Mowat N A. Fertility and pregnancy in inflammatory bowel disease.  Int J Gynaecol Obstet. 1997;  58(2) 229-237
    CrossrefPubMedGoogle Scholar
  • 19 Nielsen O H, Andreasson B, Bondesen S, Jarnum S. Pregnancy in ulcerative colitis.  Scand J Gastroenterol. 1983;  18(6) 735-742
    CrossrefPubMedGoogle Scholar
  • 20 Nielsen O H, Andreasson B, Bondesen S, Jacobsen O, Jarnum S. Pregnancy in Crohn's disease.  Scand J Gastroenterol. 1984;  19(6) 724-732
    PubMedGoogle Scholar
  • 21 Mogadam M, Korelitz B I, Ahmed S W, Dobbins III W O, Baiocco P J. The course of inflammatory bowel disease during pregnancy and postpartum.  Am J Gastroenterol. 1981;  75(4) 265-269
    PubMedGoogle Scholar
  • 22 Morales M, Berney T, Jenny A, Morel P, Extermann P. Crohn's disease as a risk factor for the outcome of pregnancy.  Hepatogastroenterology. 2000;  47(36) 1595-1598
    PubMedGoogle Scholar
  • 23 Willoughby C P, Truelove S C. Ulcerative colitis and pregnancy.  Gut. 1980;  21(6) 469-474
    CrossrefPubMedGoogle Scholar
  • 24 Khosla R, Willoughby C P, Jewell D P. Crohn's disease and pregnancy.  Gut. 1984;  25(1) 52-56
    CrossrefPubMedGoogle Scholar
  • 25 Porter R J, Stirrat G M. The effects of inflammatory bowel disease on pregnancy: a case-controlled retrospective analysis.  Br J Obstet Gynaecol. 1986;  93(11) 1124-1131
    PubMedGoogle Scholar
  • 26 Mogadam M, Dobbins III W O, Korelitz B I, Ahmed S W. Pregnancy in inflammatory bowel disease: effect of sulfasalazine and corticosteroids on fetal outcome.  Gastroenterology. 1981;  80(1) 72-76
    PubMedGoogle Scholar
  • 27 Baiocco P J, Korelitz B I. The influence of inflammatory bowel disease and its treatment on pregnancy and fetal outcome.  J Clin Gastroenterol. 1984;  6(3) 211-216
    PubMedGoogle Scholar
  • 28 Hanan I M, Kirsner J B. Inflammatory bowel disease in the pregnant woman.  Clin Perinatol. 1985;  12(3) 669-682
    PubMedGoogle Scholar
  • 29 Larzilliere I, Beau P. [Chronic inflammatory bowel disease and pregnancy. Case control study].  Gastroenterol Clin Biol. 1998;  22(12) 1056-1060
    PubMedGoogle Scholar
  • 30 Fonager K, Sørensen H T, Olsen J, Dahlerup J F, Rasmussen S N. Pregnancy outcome for women with Crohn's disease: a follow-up study based on linkage between national registries.  Am J Gastroenterol. 1998;  93(12) 2426-2430
    CrossrefPubMedGoogle Scholar
  • 31 Korelitz B I. Inflammatory bowel disease and pregnancy.  Gastroenterol Clin North Am. 1998;  27(1) 213-224
    CrossrefPubMedGoogle Scholar
  • 32 Cappell M S, Sidhom O. Multicenter, multiyear study of safety and efficacy of flexible sigmoidoscopy during pregnancy in 24 females with follow-up of fetal outcome.  Dig Dis Sci. 1995;  40(2) 472-479
    CrossrefPubMedGoogle Scholar
  • 33 Cappell M S, Colon V J, Sidhom O A. A study at 10 medical centers of the safety and efficacy of 48 flexible sigmoidoscopies and 8 colonoscopies during pregnancy with follow-up of fetal outcome and with comparison to control groups.  Dig Dis Sci. 1996;  41(12) 2353-2361
    CrossrefPubMedGoogle Scholar
  • 34 Nørgård B, Czeizel A E, Rockenbauer M, Olsen J, Sørensen H T. Population-based case control study of the safety of sulfasalazine use during pregnancy.  Aliment Pharmacol Ther. 2001;  15(4) 483-486
    CrossrefPubMedGoogle Scholar
  • 35 Nørgård B, Puho E, Pedersen L, Czeizel A E, Sørensen H T. Risk of congenital abnormalities in children born to women with ulcerative colitis: a population-based, case-control study.  Am J Gastroenterol. 2003;  98(9) 2006-2010
    PubMedGoogle Scholar
  • 36 Nørgård B, Pedersen L, Christensen L A, Sørensen H T. Therapeutic drug use in women with Crohn's disease and birth outcomes: a Danish nationwide cohort study.  Am J Gastroenterol. 2007;  102(7) 1406-1413
    CrossrefPubMedGoogle Scholar
  • 37 Burtin P, Taddio A, Ariburnu O, Einarson T R, Koren G. Safety of metronidazole in pregnancy: a meta-analysis.  Am J Obstet Gynecol. 1995;  172(2 Pt 1) 525-529
    CrossrefPubMedGoogle Scholar
  • 38 Caro-Patón T, Carvajal A, Martin de Diego I, Martin-Arias L H, Alvarez Requejo A, Rodríguez Pinilla E. Is metronidazole teratogenic? A meta-analysis.  Br J Clin Pharmacol. 1997;  44(2) 179-182
    CrossrefPubMedGoogle Scholar
  • 39 Berkovitch M, Pastuszak A, Gazarian M, Lewis M, Koren G. Safety of the new quinolones in pregnancy.  Obstet Gynecol. 1994;  84(4) 535-538
    PubMedGoogle Scholar
  • 40 Bomford J AL, Ledger J C, O'Keeffe B J, Reiter C. Ciprofloxin use during pregnancy.  Drugs. 1993;  45(Suppl 3) 461-462
    CrossrefPubMedGoogle Scholar
  • 41 Loebstein R, Addis A, Ho E et al.. Pregnancy outcome following gestational exposure to fluoroquinolones: a multicenter prospective controlled study.  Antimicrob Agents Chemother. 1998;  42(6) 1336-1339
    PubMedGoogle Scholar
  • 42 Schluter G. Osterotoxic effect of ciprofloxacin on Beagle dogs. Paper presented at: 1st International Ciprofloxacin Workshop November 6–8, 1985 Leverkusen, Germany;
    Google Scholar
  • 43 Linseman D A, Hampton L A, Branstetter D G. Quinolone-induced arthropathy in the neonatal mouse. Morphological analysis of articular lesions produced by pipemidic acid and ciprofloxacin.  Fundam Appl Toxicol. 1995;  28(1) 59-64
    CrossrefPubMedGoogle Scholar
  • 44 Schacht P, Arcieri G, Hullmann R. Safety of oral ciprofloxacin. An update based on clinical trial results.  Am J Med. 1989;  87(5A) 98S-102S
    CrossrefPubMedGoogle Scholar
  • 45 Decosta E J, Abelman M A. Cortisone and pregnancy; an experimental and clinical study of the effects of cortisone on gestation.  Am J Obstet Gynecol. 1952;  64(4) 746-767
    PubMedGoogle Scholar
  • 46 Koren G, Pastuszak A, Ito S. Drugs in pregnancy.  N Engl J Med. 1998;  338(16) 1128-1137
    CrossrefPubMedGoogle Scholar
  • 47 Norjavaara E, de Verdier M G. Normal pregnancy outcomes in a population-based study including 2,968 pregnant women exposed to budesonide.  J Allergy Clin Immunol. 2003;  111(4) 736-742
    CrossrefPubMedGoogle Scholar
  • 48 Källén B, Rydhstroem H, Aberg A. Congenital malformations after the use of inhaled budesonide in early pregnancy.  Obstet Gynecol. 1999;  93(3) 392-395
    CrossrefPubMedGoogle Scholar
  • 49 Alstead E M, Ritchie J K, Lennard-Jones J E, Farthing M J, Clark M L. Safety of azathioprine in pregnancy in inflammatory bowel disease.  Gastroenterology. 1990;  99(2) 443-446
    CrossrefPubMedGoogle Scholar
  • 50 Francella A, Dyan A, Bodian C, Rubin P, Chapman M, Present D H. The safety of 6-mercaptopurine for childbearing patients with inflammatory bowel disease: a retrospective cohort study.  Gastroenterology. 2003;  124(1) 9-17
    CrossrefPubMedGoogle Scholar
  • 51 Cleary B J, Kallen B. Early pregnancy azathioprine use and pregnancy outcome.  Birth Defects Res Part A. 2009;  85 647-654
    CrossrefPubMedGoogle Scholar
  • 52 Angelberger S, Reinisch W, Dejaco C. Prevention of abortion by ciclosporin treatment of fulminant ulcerative colitis during pregnancy.  Gut. 2006;  55(9) 1364-1365
    PubMedGoogle Scholar
  • 53 Bertschinger P, Himmelmann A, Risti B, Follath F. Cyclosporine treatment of severe ulcerative colitis during pregnancy.  Am J Gastroenterol. 1995;  90(2) 330
    PubMedGoogle Scholar
  • 54 Reindl W, Schmid R M, Huber W. Cyclosporin A treatment of steroid-refractory ulcerative colitis during pregnancy: report of two cases.  Gut. 2007;  56(7) 1019
    PubMedGoogle Scholar
  • 55 Lichtiger S, Present D H, Kornbluth A et al.. Cyclosporine in severe ulcerative colitis refractory to steroid therapy.  N Engl J Med. 1994;  330(26) 1841-1845
    CrossrefPubMedGoogle Scholar
  • 56 Bermas B L, Hill J A. Effects of immunosuppressive drugs during pregnancy.  Arthritis Rheum. 1995;  38(12) 1722-1732
    CrossrefPubMedGoogle Scholar
  • 57 Armenti V T, Ahlswede K M, Ahlswede B A, Jarrell B E, Moritz M J, Burke J F. National Transplantation Pregnancy Registry—outcomes of 154 pregnancies in cyclosporine-treated female kidney transplant recipients.  Transplantation. 1994;  57(4) 502-506
    CrossrefPubMedGoogle Scholar
  • 58 Armenti V T, Jarrell B E, Radomski J S, McGrory C H, Gaughan W J, Moritz M J. National Transplantation Pregnancy Registry (NTPR): cyclosporine dosing and pregnancy outcome in female renal transplant recipients.  Transplant Proc. 1996;  28(4) 2111-2112
    PubMedGoogle Scholar
  • 59 Radomski J S, Ahlswede B A, Jarrell B E et al.. Outcomes of 500 pregnancies in 335 female kidney, liver, and heart transplant recipients.  Transplant Proc. 1995;  27(1) 1089-1090
    PubMedGoogle Scholar
  • 60 al-Khader A A, Absy M, al-Hasani M K, Joyce B, Sabbagh T. Successful pregnancy in renal transplant recipients treated with cyclosporine.  Transplantation. 1988;  45(5) 987-988
    CrossrefPubMedGoogle Scholar
  • 61 Bar Oz B, Hackman R, Einarson T, Koren G. Pregnancy outcome after cyclosporine therapy during pregnancy: a meta-analysis.  Transplantation. 2001;  71(8) 1051-1055
    CrossrefPubMedGoogle Scholar
  • 62 Lichtenstein G, Cohen R D, Feagan B G et al.. Safety of infliximab in Crohn's disease: data from the 5000-patient TREAT Registry. [abstract].  Gastroenterology. 2004;  126(suppl) A54
    PubMedGoogle Scholar
  • 63 Katz J A, Antoni C, Keenan G F, Smith D E, Jacobs S J, Lichtenstein G R. Outcome of pregnancy in women receiving infliximab for the treatment of Crohn's disease and rheumatoid arthritis.  Am J Gastroenterol. 2004;  99(12) 2385-2392
    CrossrefPubMedGoogle Scholar
  • 64 Anderson J B, Turner G M, Williamson R C. Fulminant ulcerative colitis in late pregnancy and the puerperium.  J R Soc Med. 1987;  80(8) 492-494
    PubMedGoogle Scholar
  • 65 McEwan H P. Ulcerative colitis in pregnancy.  Proc R Soc Med. 1972;  65(3) 279-281
    PubMedGoogle Scholar
  • 66 Bohe M G, Ekelund G R, Genell S N et al.. Surgery for fulminating colitis during pregnancy.  Dis Colon Rectum. 1983;  26(2) 119-122
    CrossrefPubMedGoogle Scholar
  • 67 Boulton R, Hamilton M, Lewis A, Walker P, Pounder R. Fulminant ulcerative colitis in pregnancy.  Am J Gastroenterol. 1994;  89(6) 931-933
    PubMedGoogle Scholar
  • 68 Scott H J, McLeod R S, Blair J, O'Connor B, Cohen Z. Ileal pouch-anal anastomosis: pregnancy, delivery and pouch function.  Int J Colorectal Dis. 1996;  11(2) 84-87
    CrossrefPubMedGoogle Scholar
  • 69 Brandt L J, Estabrook S G, Reinus J F. Results of a survey to evaluate whether vaginal delivery and episiotomy lead to perineal involvement in women with Crohn's disease.  Am J Gastroenterol. 1995;  90(11) 1918-1922
    PubMedGoogle Scholar
  • 70 Minter A, Malik R, Ledbetter L, Winokur T S, Hawn M T, Saif M W. Colon cancer in pregnancy.  Cancer Control. 2005;  12(3) 196-202
    PubMedGoogle Scholar
  • 71 Harma M, Harma M, Uzunkoy A. Colorectal cancer presenting with uncommon soft tissue invasion during pregnancy.  Acta Obstet Gynecol Scand. 2005;  84(5) 491-493
    PubMedGoogle Scholar
  • 72 Bernstein M A, Madoff R D, Caushaj P F. Colon and rectal cancer in pregnancy.  Dis Colon Rectum. 1993;  36(2) 172-178
    CrossrefPubMedGoogle Scholar
  • 73 Girard R M, Lamarche J, Baillot R. Carcinoma of the colon associated with pregnancy: report of a case.  Dis Colon Rectum. 1981;  24(6) 473-475
    CrossrefPubMedGoogle Scholar
  • 74 Cappell M S. Colon cancer during pregnancy.  Gastroenterol Clin North Am. 2003;  32(1) 341-383
    CrossrefPubMedGoogle Scholar
  • 75 Lolis E D, Likoudis P, Voiniadis P, Hassiakos D, Samanides L. Synchronous rectal and colon cancer caused by familial polyposis coli during pregnancy.  J Obstet Gynaecol Res. 2007;  33(2) 199-202
    CrossrefPubMedGoogle Scholar
  • 76 Mechery J, Ikhena S E. Cancer of the descending colon during pregnancy.  J Obstet Gynaecol. 2007;  27(3) 311-312
    CrossrefPubMedGoogle Scholar
  • 77 Slattery M L, Samowitz W S, Holden J A. Estrogen and progesterone receptors in colon tumors.  Am J Clin Pathol. 2000;  113(3) 364-368
    CrossrefPubMedGoogle Scholar
  • 78 Cappell M S. Gastrointestinal endoscopy in high-risk patients.  Dig Dis. 1996;  14(4) 228-244
    CrossrefPubMedGoogle Scholar
  • 79 Cappell M S. Colon cancer during pregnancy. The gastroenterologist's perspective.  Gastroenterol Clin North Am. 1998;  27(1) 225-256
    CrossrefPubMedGoogle Scholar
  • 80 Gonzalez A B, Stafford I, Mancuso P, Carney S. Delivery of a polyp.  Obstet Gynecol. 2008;  112(2 Pt 2) 488-490
    CrossrefPubMedGoogle Scholar
  • 81 Walsh C, Fazio V W. Cancer of the colon, rectum, and anus during pregnancy. The surgeon's perspective.  Gastroenterol Clin North Am. 1998;  27(1) 257-267
    CrossrefPubMedGoogle Scholar
  • 82 Mason III M H, Kovalcik P J. Ovarian metastases from colon carcinoma.  J Surg Oncol. 1981;  17(1) 33-38
    CrossrefPubMedGoogle Scholar
  • 83 Pitluk H, Poticha S M. Carcinoma of the colon and rectum in patients less than 40 years of age.  Surg Gynecol Obstet. 1983;  157(4) 335-337
    PubMedGoogle Scholar
  • 84 Knoepp Jr L F, Ray J E, Overby I. Ovarian metastases from colorectal carcinoma.  Dis Colon Rectum. 1973;  16(4) 305-311
    CrossrefPubMedGoogle Scholar
  • 85 Holzer E, Haigermoser A, Pickel H. [Metastatic ovarian tumor on both sides as acute puerperium complication].  Gynakol Rundsch. 1976;  16(3) 211-216
    PubMedGoogle Scholar
  • 86 Heres P, Wiltink J, Cuesta M A, Burger C W, van Groeningen C J, Meijer S. Colon carcinoma during pregnancy: a lethal coincidence.  Eur J Obstet Gynecol Reprod Biol. 1993;  48(2) 149-152
    CrossrefPubMedGoogle Scholar
  • 87 Stephens J D, Golbus M S, Miller T R, Wilber R R, Epstein C J. Multiple congenital anomalies in a fetus exposed to 5-fluorouracil during the first trimester.  Am J Obstet Gynecol. 1980;  137(6) 747-749
    PubMedGoogle Scholar
  • 88 Antonelli N M, Dotters D J, Katz V L, Kuller J A. Cancer in pregnancy: a review of the literature. Part II.  Obstet Gynecol Surv. 1996;  51(2) 135-142
    CrossrefPubMedGoogle Scholar
  • 89 Woods J B, Martin Jr J N, Ingram F H, Odom C D, Scott-Conner C E, Rhodes R S. Pregnancy complicated by carcinoma of the colon above the rectum.  Am J Perinatol. 1992;  9(2) 102-110
    Article in Thieme ConnectPubMedGoogle Scholar

Sherri A LongoM.D. 

Department of Obstetrics and Gynecology, Section of Maternal-Fetal Medicine, Ochsner Clinic Foundation

1514 Jefferson Hwy., New Orleans, LA 70121

Email: slongo@ochsner.org

      >