Stomach Problems and IBD in Pregnancy

December 14, 2007

Heartburn Is Common In Pregnancy For Many Reasons:

1)      Progesterone, a hormone in abundance in pregnancy, slows down the movement of the gastrointestinal tract, causing decreased stomach emptying--that feeling of the food just sitting there...because it is.  With decreased motility of the esophagus, it's tone is decreased, the pressure within being less of a barrier to stomach acid refluxing upward.  That stuff burns!

2)      The distortion of the anatomy due to pregnancy has many different organs fighting it out for space, and the stomach is no exception in this turf battle.  There is displacement of the stomach which alters emptying of contents and acid.Also, the upward displacement and pressure against the stomach by the increasing size of the uterus can cause nausea long after any "morning sickness."  There are even reports of the stomach herniating into the chest, but thankfully this is uncommon.

3)The opening in the diaphragm through which the esophagus passes (from the chest into the abdomen) widens in  pregnancy.  It is a physiologic hiatal hernia, and if a stomach portion slides up through it, this can also cause interference with stomach acid going back down.  Once again, esophageal reflux.  This is why this particular aspect of heartburn is worse when lying flat instead of a slightly elevated head-up angle, because in a flat position the top of the stomach can slide up through this hernia (also called a "sliding" hernia).  Propping yourself up will allow gravity to do its thing and the stomach can fall back down into place.

4)Prenatal vitamins, with the increased amount of iron, can be irritating to the stomach.  Sometimes it's necessary to put the vitamins on hold for a couple of weeks.  (Prenatal vitamins are a great idea--especially to get your folic acid--but they're not a deal-breaker.  We got by millions of years before prenatal vitamins.)

The most conservative treatment for stomach upset is an antacid other than sodium bicarbonate (the sodium in sodium bicarbonate can cause considerable swelling).  Milk of Magnesia, Maalox, etc., are all good choices. The trick you have to remember is to use these about 20 minutes BEFORE you eat, otherwise you're just pouring it over the food and it won't act as well as an antacid at the site of acid production, the stomach lining.

More aggressive approaches use agents which decrease the secretion of acid, like cimetidine (Tagamet).These agents are for the most part safe (except for Cytotec, which can induce abortion or preterm labor).  There has been some suspicion that cimetidine may be anti-androgenic, that is, anti-testosterone, which could theoretically cause smaller testicles and/or feminization of a developing male baby, but this has only been shown in experimental animals and was fueled by a drop in sex drive among adult men who use it.  Certainly sporadic use of agents like Tagamet wouldn't make me worry in my own practice, but you should ask your own doctor.

A major concern in any complaints of "stomach" problems in pregnancy is that liver and gall bladder conditions may present (and be blown off) as simple heartburn.  Liver disease as a result of pregnancy must be at least considered to make sure the symptoms aren't in the right upper quadrant of the abdomen.  The same goes for the gall bladder.  But if the discomfort is a burning sensation in the mid abdomen right under the middle of the rib cage, is worse on an empty stomach and when lying down, then simple pyrosis (heartburn) is probably the culprit with remedies as described above.  Keep in mind, though, that any heartburn not easily remedied could be an ulcer or other gastrointestinal problem worthy of further evaluation.Hormonal and anatomical changes in pregnancy that cause heartburn, but ulcers, gall bladder problems, and liver problems related to pregnancy could be assumed to be simple heartburn if not evaluated prudently.

Pregnancy in Women with Bowel Conditions

I'm not talking about constipation and common diarrhea here. Constipation is famous in pregnancy due to the decreased mobility of the bowels under the influence of progesterone.  Common diarrhea is usually a brief self-resolving illness unrelated to pregnancy.

What I discuss here is maternal inflammatory bowel disease (IBD), the most famous of which are Crohn's Disease and Ulcerative Colitis. These are sometimes debilitating immunological diseases that cause bowel damage which can cause pain, nutritional abnormalities, and can even lead to surgery or death.  Today, treatment (including steroids and the antibiotics sulfasalazine and metronidazole) have made such dire complications rare.  And thankfully, getting pregnant during times of
quiet for these diseases usually means things will go smoothly for the pregnancy.  But there can be flare-ups of both Crohn's Disease and Ulcerative Colitis, most frequently in the first and third trimesters and then post-partum.  So before attempting pregnancy, a IBD patient should consult with both her OBGYN and her gastroenterologist.

Newly diagnosed IBD during a pregnancy is unlikely and therefore suspicious, so other causes need to be ruled out, like a weird presentation of appendicitis.  And appendicitis will always be a weird presentation during pregnancy, because the location of the appendix is pushed up and away from the famous right lower spot of the abdomen.  Also, ovarian complications like benign cysts or torsion (twisting upon itself) can present with abdominal pain, nausea, and diarrhea, just like IBD.  But it would be quite the coincidence to have a patient's very first episode of IBD occur during her pregnancy, so an obstetrician must always consider these other things with an initial presentation of symptoms like this during pregnancy.
IBD is a chronic situation, so most pregnant women with complications of IBD come to their obstetricians with a diagnosis way in advance. The second trimester, as is true with most problemmatic situations in pregnancy, is the quietest third of the pregnancy. Statistics are not very helpful with IBD in pregnancy, because 1/3 will get better, 1/3 will remain unchanged, and 1/3 will get worse.  A patient with IBD will discover that no one can tell her what to expect, because such even statistics provide no perspective at all on the likelihood of what she herself might experience.

As bad a disease process as IBD can be, it shouldn't forbid pregnancy in women who want children.  And the treatments for IBD have little risk to the baby, meaning that flare-ups can be treated.  The sometimes heart-breaking aspects of IBD are because a person has IBD, not because they have it during pregnancy.  But IBD as applied to pregnancy brings up special considerations, nevertheless.  Nutritional needs are sometimes different for IBD patients, especially those who may have had portions of bowel removed previously.  Also for this reason growth of the fetus should be monitored closely with ultrasound, as dietary derangements can affect fetal growth.

Unless the disease has resulted in distortion of the anatomy--fisutlas of the rectum or obliteration of the rectum surgically, a vaginal delivery can be anticipated.  But if the anatomy there is abnormal with a chance of worsening by vaginal delivery, C-section is sometimes a better idea.  Each case should be individualized.

A percentage of IBD patients also have depression, and most experts feel that the depression is not just because they're bummed out they have this disease, but that it is truly a related phenomenon--a "co-disease" state.  Add in the psychodynamics of worry over a high-risk pregnancy and fluctuating hormones, plus the slightly hyperthyroid affects of hCg (the pregnancy hormone), and a woman's mental health must also be respected.

Any pregnancy complicated by a medical condition has its own set of special considerations, and these are the special considerations for Irritable Bowel Disease.

Does whether you have morning sickness or not indicate whether you're going to have a boy or girl?
In a word, no.  Nor does stomach upset result from the baby having a lot of hair.  Nor does reaching your hands over your head promote knots in the umbilical cord.  Nor can you tell the gender by the fetal heart rate.  Just some other thoughts as long as I'm dispelling myths.

What's the deal on gas in pregnancy?  I'm halfway through my pregnancy and the gas has really increased.
There are many things that happen to increase the gas during pregnancy. First of all, progesterone slows down the intestinal tract, which allows it to build up.  Secondly, the increasing size of the uterus crowds out the bowel, causing some extra kinking, trapping the gas in discrete pockets.  Additionally, with the shortness of breath you can get as your uterus grows and decreases the amount of movement your diaphragm needs to do its job, you're likely to literally gulp more air than usual.

On top of all of this, normally gassy foods you may have been used to before pregnancy--and handled well--may have their effects exaggerated by the decreased bowel tone.

Now I'm not saying that people should run for their lives when you approach, but there are some things you can do.  One is to quit smoking if you smoke (more gulping of air).  Another is to avoid the famous gassy foods--fatty, greasy, and high carbohydrate foods.  You can also take something like Phazyme or Mylecon (over the counter) which has a simethicone.  Simethicone isn't absorbed, so it's safe in pregnancy; it works by breaking up the big bubbles into little bubbles (your problem is the big bubbles).

Pregnancy Gas

Good luck, and remember, there are worse things to have than gas.  (Also, don't light any matches.)

I'm seven weeks pregnant, and when I have gas, I have cramping.  When I pass the gas, the cramping goes away.  Is this normal?
It's hard to answer this question with a straight face and a tight sphincter, but it actually is a really good question.  The uterus (womb) and all of the bowel is covered with a lining called peritoneum.

This lining is peculiar in it's pain response: That is, you can burn it, you can cut it, you can do almost anything else and it won't hurt--unless you distend it.  Gas building up will distend the bowel, and with it the peritoneum covering it.  These are the same pain nerves you have in the lining covering your uterus, so it's easy for your brain, receiving pain nerve impulses from the same area, to misinterpret it as uterine cramping.

Complicating matters is the fact that in the first trimester you are also experiencing "growing" pains, as the pregnancy starts to distend the uterus, and we already know what distension does to peritoneum.

So yes, it's normal.  And I promise I won't tell anyone.

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