Dyspepsia in pregnancy

Dyspepsia in females of childbearing age is predominantly due to non ulcer dyspepsia, reflux oesophagitis, gallstones and, rarely, peptic ulcer. This pattern is altered by pregnancy in a number of ways. Early pregnancy is characterised by centrally determined nausea and vomiting in the absence of any gastrooesophageal pathology. Later in pregnancy dyspepsia is dominated by reflux oesophagitis. Peptic ulcer is very rare as is biliary colic and gallstone pancreatitis.The limited range of pathology and suitable drugs means that investigations are rarely necessary. Treatment is largely limited to antacids and dietary measures. Failure to respond to simple measures or a past history of peptic ulceration should prompt further investigation including, where relevant, ultrasound and endoscopy. Resistant peptic ulcer may require treatment with sucralfate, while biliary colic or gallstone pancreatitis may necessitate surgery in the second trimester.     

Drugs in pregnancy. Pharmacokinetics in pregnancy.

Pharmacokinetics describes the handling of a drug by the body - how the drug is absorbed, distributed and eliminated and how these processes determine plasma concentrations of the drug. Changes in maternal physiology during pregnancy influence pharmacokinetics, and this may have important sequelae for drug dosing, especially for drugs for which adverse effects occur at concentrations within, or just above, the therapeutic range. For many drugs absorption is decreased and elimination increased, thus tending to reduce plasma concentrations. There are, however, relatively few specific data on pharmacokinetics in pregnancy, compared to the non-gravid state, because of the obvious ethical issues surrounding studies during pregnancy. Most therapeutic guidelines are thus based on observational studies and basic principles.     

Prescribing in pregnancy. Epilepsy in pregnancy

In women with epilepsy, seizure control during pregnancy can be improved by maintaining the serum anticonvulsant drug concentration within the therapeutic range. Treatment with one anticonvulsant drug plus folic acid supplementation 5 mg per day seems appropriate in most cases. This should be achieved before conception whenever possible. No anticonvulsant drug seems free of teratogenic risk. With the commonly used anticonvulsant drugs-phenytoin, phenobarbitone, carbamazepine and sodium valproate-the risk is relatively low and represents less potential harm to the fetus than might occur with uncontrolled seizures.     

Dyspepsia and ulcers

Dyspepsia, characterized by persistent abdominal pain thought to arise in the upper gastrointestinal tract, is a common reason for visits to primary care physicians. One third of the patients with dyspepsia, when fully evaluated, will have a definable abnormality to explain the symptomatology. Esophagitis, gastritis, and peptic ulcer disease are the most common entities. Helicobacter pylori has been implicated as the etiologic agent in peptic ulcer disease. There are invasive and noninvasive methods for identification of this organism. There are excellent new treatment protocols aimed at eradicating H. pylori and curing the ulcerative disease associated with infection. This review discusses clinical management and diagnostic options for primary care physicians faced with the patient complaining of dyspepsia, discusses the role of H. pylori in both duodenal and peptic ulcers, and outlines accepted protocols for ulcer treatment.     

Prescribing in pregnancy. Bacterial infections in pregnancy

Certain infections, such as UTI, may have an increased incidence during pregnancy owing to physiological changes. Between 2 and 10% of pregnant women have covert or asymptomatic bacteriuria which is associated with an increased incidence of acute symptomatic UTI in later pregnancy if left untreated. Thus antenatal screening to detect the presence of bacteriuria is justified. Most women will remain abacteriuric throughout the remainder of pregnancy after a single course of antibiotic therapy but a small percentage will fail to respond or have recurrent UTIs. Maternal infection with certain organisms, namely those which resist phagocytosis, may result in transplacental infection of the fetus in utero. Congenital syphilis is preventable and antenatal serological screening is usually routinely performed. Listeriosis following maternal infection in pregnancy is less predictable and the epidemiology of L. monocytogenes remains unclear. Genital tract carriage of sexually transmitted organisms, such as N. gonorrhoeae or C. trachomatis, may also be detected during pregnancy and antibiotic therapy will be indicated to eradicate such organisms and prevent maternal and neonatal morbidity. Antibiotic therapy during pregnancy will not, however, eradicate carriage of GBS from the genital tract, although carriage status at term can now be reliably predicted by using enriched culture techniques and swabbing multiple sites on more than one occasion. Where carriage is confirmed, the administration of intrapartum antibiotics to the mother appears a useful approach in the prevention of early onset neonatal GBS disease. Broad spectrum intrapartum antibiotics may also be indicated when there are complications, such as prolonged labour or premature rupture of membranes, which are associated with a higher incidence of maternal postpartum endometritis and morbidity than in women following uncomplicated vaginal delivery. Serious postnatal sepsis and shock is fortunately now rare. The pharmacokinetics of antibiotics in late pregnancy and the puerperium are altered and maternal serum levels may be reduced by 10-50%. Most antibiotics cross the placenta and are excreted in breast milk. Some agents, such as the beta-lactams, are considered safe in pregnancy and breast-feeding women while other antibiotics are contraindicated owing to risk of toxicity (often rare) or teratogenicity (often theoretical). Caution is necessary with many agents which may cause side effects or toxicity although this does not necessarily contraindicate their use in pregnancy.(ABSTRACT TRUNCATED AT 400 WORDS)     

Parasuicide in pregnancy.

Parasuicide is a significant risk factor for completed suicide. Furthermore, suicide is emerging as an important cause of maternal death, especially among young mothers. There are no published reports of parasuicide in pregnancy from poor countries. Three cases are reported to highlight this issue and to demonstrate management options available to health professionals working in the field of women's health.     

Cholecystectomy in pregnancy.

During the 17 years 1955 through 1971, 20 gravid patients underwent cholecystectomy. This represented 1 case for every 1259 deliveries (0.079% of 25,189 deliveries). The primary indication for surgery was repeated attacks of gallbladder colic. Generally, surgery was performed between the 10th and the 20th week of gestation. There was one spontaneous abortion; this occurred at 10 weeks of gestation, 42 days after surgery.     

Hypertension in pregnancy.

Pregnancies complicated by hypertension require a well-formulated management plan. Women with chronic hypertension should be evaluated prior to pregnancy. At onset of pregnancy, they should be classified into low-risk and high-risk groups. The majority of pregnant women identified as low-risk hypertensives will have good perinatal outcome without the use of antihypertensive drugs. In general, antihypertensive medications should be reserved for those considered as having high-risk hypertension. In either case, all these women should have close follow-up of maternal and fetal conditions throughout pregnancy. All women with diagnosed preeclampsia should be hospitalized at the time of diagnosis for evaluation of maternal and fetal well-being. Subsequent management will then depend on gestational age and the severity of the disease process. An individualized management plan and a referral to a tertiary care center will improve maternal and perinatal outcome in those women who are remote from term and in those with the HELLP syndrome.     

Scleroderma in pregnancy.

The case records of four patients with scleroderma who booked for care between 1989 and 1994 at the Birmingham Women's Hospital (formerly the Birmingham Maternity Hospital), a tertiary care obstetric unit, were studied retrospectively. The aim of the study was to look at infertility, early and late pregnancy losses, fetal growth retardation and maternal complications in these four women afflicted with this rare condition. Two patients gave a history of infertility. There were two growth retarded fetuses and one intrauterine fetal death. Worsening Raynaud's phenomenon occurred in three patients. Another patient developed massive haematemesis due to an oesophageal tear resulting from intractable vomiting. Scleroderma may adversely affect pregnancy: obstetrical complications are common and require close monitoring.     

Drugs in pregnancy. Anticoagulants.

Pregnancy is a period of heightened coagulability and enhanced risk for thrombotic complications. Thromboembolism is the leading cause of maternal mortality. Anticoagulants are very useful during pregnancy for the acute treatment of venous thromboembolism and for the prevention of recurrent venous thromboembolism. They may also be beneficial in patients with thrombophilias, particularly among women who have experienced adverse pregnancy outcomes such as recurrent pregnancy loss. Anticoagulation is essential but problematic in the management of pregnant women with mechanical heart valve prostheses. When utilizing these medications among pregnant women the potential benefits must be balanced against the possibility of maternal haemorrhagic complications, adverse effects on the pregnancy or toxic effects on the fetus. This chapter summarizes current knowledge about the anticoagulant agents, their potential toxicities and their therapeutic role in pregnant women with various indications for anticoagulant therapy.