GASTROINTESTINAL DISORDERS IN PREGNANCY

Appendicitis During Pregnancy

Acute appendicitis is the most common extra-uterine surgical emergency requiring immediate surgical intervention during pregnancy [1]. Six young female patients presented with appendicitis during May 1996 to May 2001 in different service hospitals. Five patients underwent emergency appendectomy successfully. Gestational age at presentation included first trimester in 4 patients, second trimester in 2 patients and none in third trimester. 84% had pathologically proven acute appendicitis. One patient presented with appendicular lump in first trimester, proved on ultra sonography examination, which was treated by Oshner Sherren regime and subsequently interval appendectomy was done in second trimester. No long term adverse maternal morbidity or mortality was reported. One patient had premature onset of labour and delivered. Natural history of acute appendicitis is not changed during pregnancy while gestational physiological changes obscure the accurate diagnosis of acute appendicitis.

Haemorrhoids during pregnancy

Haemorrhoids are varicose veins of the rectum covered by mucosa at or near the anal canal. They are normally asymptomatic, can occur at any age and affect both males and females. In this review, we address the issue of the approach of the obstetrician to haemorrhoids and their management. Haemorrhoids are common in young women and commoner during pregnancy and the puerperium. Obstetricians and gynaecologists should be familiar with haemorrhoids, a proctological disease, diagnosis and their treatment, but they have little experience regarding the impact of pregnancy on haemorrhoids. The obstetrician must be able to relieve symptoms in patients who are pregnant, or who have just delivered.

Acupuncture for Dyspepsia in Pregnancy: A Prospective, Randomised, Controlled Study

Objectives

This study was undertaken to describe under real-life conditions the effects of acupuncture on symptomatic dyspepsia during pregnancy and to compare this with a group of patients undergoing conventional treatment alone.

Methods

A total of 42 conventionally treated pregnant women were allocated by chance into two groups to be treated, or not, by acupuncture. They reported the severity of symptoms and the disability these were causing in daily aspects of life such as sleeping and eating, using a numerical rating scale. The study also observed the use of medications.

Results

Six women dropped out (one in the acupuncture group and five in the control group). Significant improvements in symptoms were found in the study group. This group also used less medication and had a greater improvement in their disabilities when compared with the control group.

Conclusions

This study suggests that acupuncture may alleviate dyspepsia during pregnancy.

Oral and maxillofacial surgery for the pregnant patient

This article describes clinical approaches for the perioperative management of the pregnant oral and maxillofacial surgical patient. The following topics are discussed: ethical principles of treatment during pregnancy, physiologic changes and their treatment considerations, fetal and maternal risks of various medications, medical problems occurring during pregnancy, and common minimally invasive approaches that the surgeon can apply to minimize the risk to the mother and unborn child. The strategies discussed provide successful treatment outcomes during this important time in the female surgical patient's life.

Pregnancy in scleroderma

Pregnancy in systemic sclerosis may be uneventful with good maternal and fetal outcomes. Scleroderma is a multisystem disease and complications do occur; however, careful antenatal evaluations, discussion of potential problems, and participation in a high-risk obstetric monitoring program are important to optimize the best outcome. Women who have diffuse scleroderma are at a greater risk for developing serious cardiopulmonary and renal problems early in the disease so they should be encouraged to delay pregnancy until the disease stabilizes. All patients who become pregnant during this high-risk time should be monitored extremely carefully, particularly for renal crisis.

Conservative management of symptomatic and/or complicated haemorrhoids in pregnancy and the puerperium

BACKGROUND

Haemorrhoids (piles) are swollen veins at or near the anus, normally asymptomatic. They do not constitute a disease, unless they become symptomatic. Pregnancy and the puerperium predispose to symptomatic haemorrhoids, being the most common ano-rectal disease at these stages. Symptoms are usually mild and transient and include intermittent bleeding from the anus and pain. Depending on the degree of pain, quality of life could be affected, varying from mild discomfort to real difficulty in dealing with the activities of everyday life. Treatment during pregnancy is mainly directed to the relief of symptoms, especially pain control. The so-called conservative management includes dietary modifications, stimulants or depressants of the bowel transit, local treatment, and phlebotonics (drugs that cause decreased capillary fragility, improving the microcirculation in venous insufficiency). For many women, symptoms will resolve spontaneously soon after birth, and so any corrective treatment is usually deferred to some time after birth. Thus, the objective of this review is to evaluate the efficacy of conservative management of piles during pregnancy and the puerperium.

OBJECTIVES

To determine the possible benefits, risks and side-effects of the conservative management of symptomatic haemorrhoids during pregnancy and the puerperium.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 June 2004).

SELECTION CRITERIA

Randomised-controlled trials comparing any of the conservative treatments for symptomatic haemorrhoids during pregnancy and the puerperium (such as dietary modifications, stimulant/depressant of the bowel transit, local treatments, drugs that improve the microcirculation in venous insufficiency) with a placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed a methodological assessment for deciding which studies to include/exclude from the review and extracted data.

MAIN RESULTS

From 10 potentially eligible studies, two were included in this review (150 women). Both compared oral rutosides against placebo. Rutosides seem to be effective in reducing the signs identified by the healthcare provider, and symptoms and signs reported by women, of haemorrhoidal disease. For the outcome no response to treatment: relative risk 0.07, 95% confidence interval 0.03 to 0.20. Regarding perinatal outcomes, one fetal death and one congenital malformation (possible not related to exposure) were reported in the control and treatment group respectively.

AUTHORS' CONCLUSIONS

Although the treatment with oral hydroxyethylrutosides looks promising for symptom relief in first and second degree haemorrhoids, its use cannot be recommended until new evidence reassures women and their clinicians about their safety. The most commonly used approaches, such as dietary modifications and local treatments, were not properly evaluated during pregnancy and the puerperium.

Scleroderma and pregnancy

Pregnancy in systemic sclerosis may be uneventful, with both good maternal and fetal outcomes. Because scleroderma is a multisystem disease and complications do occur, however, careful antenatal evaluations, discussion of potential problems, and participation in a high-risk obstetric monitoring program is very important to optimize the best outcome. Because women with diffuse scleroderma are at greater risk for developing serious cardiopulmonary and renal problems early in the disease, they should be encouraged to delay pregnancy until the disease stabilizes. All patients who become pregnant during this high-risk time should be monitored extremely carefully. Although there are some suggestions that there are increases in infertility and miscarriages before disease onset, recent studies show that these issues probably do not have major impact for women with established scleroderma who plan to become pregnant. The high risk of premature and small infants may be minimized with specialized obstetric and neonatal care, however. Renal crisis in scleroderma is the only truly unique aspect of these pregnant, which, unlike blood pressure elevation in nonscleroderma pregnancies, must be treated aggressively with ACE inhibitors. Other pregnancy problems may not be unique to scleroderma, but because it is a chronic illness, any complication carries higher risks for both mother and child. Careful planning, close monitoring, and aggressive management should allow women with scleroderma to have a high likelihood of a successful pregnancy.

Hemorrhoids, anal fissure, and carcinoma of the colon, rectum, and anus during pregnancy

The pregnant patient afflicted with a variety of colorectal conditions merits special consideration for reasons related to the safety and timeliness of operation while preserving fetal viability and fertility. The literature is scanty with respect to hemorrhoids, fissures, and colorectal and anal carcinoma. Therefore, the patient has to have a forthright discussion with her physician(s) about the pros and cons of operative and nonoperative approaches, which can result in either therapeutic abortion and timely surgery versus preserving the fetus and taking on the unknown factor of whether delay in treatment will cause an adverse outcome. This underscores the need for a frank discussion with the patient with regard to anticipated outcomes. In benign conditions, there is more latitude to adopt a conservative approach, as the patient's ability to tolerate the symptoms of her condition would dictate the need for definitive operative therapy. In the patient with malignancy, delaying surgical or radiation therapy carries an unknown risk to the patient. Here, the patient's personal views regarding abortion and future fertility dictate the timing of definitive treatment.

Rectal carcinoma during pregnancy

Rectal carcinoma presenting during pregnancy is rare with a reported incidence of 0.002%. Management of such an emotionally charged condition can be difficult, especially when the twin goals of curing the disease and preserving the pregnancy are divergent. Four cases of rectal carcinoma presenting during pregnancy are reported. In the first or second trimester of pregnancy, it is possible to resect the tumour with preservation of pregnancy, and in the third trimester, it is best to bring the pregnancy to term before removing the tumour. Unfortunately, the prognosis for such rectal cancer is poor.