Women are more prone than men to some digestive system diseases such as irritable bowel syndrome (irritable bowel syndrome) even when they are not pregnant. It is known that the digestive system functions of women also show some differences from men during menstrual periods. Pregnancy is a very special period in which women’s physiology and hormones show great differences compared to normal. Like many other systems of the body, digestive system functions also undergo significant changes during pregnancy compared to the non-pregnant period.
Physiological Changes During Pregnancy
There are three hormones whose blood levels vary greatly during pregnancy. These are hCG (human chorionic gonadotropin), estrogen and progesterone. hCG is particularly high in the first trimester of pregnancy and, according to some researchers, is responsible for the so-called hyperemesis gravidarum (excessive vomiting) of pregnancy. Progesterone mainly relaxes smooth muscles (involuntary muscles) in our body and in the digestive system. Estrogen has a similar effect, but less pronounced in the digestive tract.
While the emptying time of the stomach is prolonged due to these hormonal changes, the valve mechanism called sphincter, which is located at the lower end of the esophagus and whose main task is to prevent gastric fluids (stomach acid) and food from escaping back into our esophagus (reflux), begins to relax. For this reason, reflux complaints such as burning behind the breastbone and the taste of food in the mouth are common in pregnant women. In addition to the decrease in smooth muscle contraction, constipation complaints are more common in pregnant women as the reabsorption of water and salt into the body increases in the large intestine of pregnant women. Increase in gallbladder volume and decrease in gallbladder contraction due to estrogen hormone and changes in the chemical structure of bile increase the incidence of gallstones in pregnant women.
Pregnancy and Digestive System Diseases
Fecal incontinence (incontinence)
Fecal incontinence (fecal incontinence) is one of the diseases that affect the person extremely negatively. Fecal incontinence depends on the consistency of the stool and the amount of liquid, the time of progression of the stool in the intestine, the strength of the area called the rectum, which acts as a storage in the last part of the large intestine, the muscles and nerves of the pelvic region, and the proper functioning of the structure called sphincter, which consists of voluntary and involuntary muscles in the anus.
Fecal incontinence during pregnancy is often caused by damage to the anus sphincter during labor or damage to the nerves and muscles in the pelvic region. Giving birth vaginally increases the risk of fecal incontinence and the risk occurs in one woman for every 10 births. The risk of fecal incontinence is higher in women who have more than one vaginal delivery than in women who have a single delivery. Depending on the underlying cause, fecal incontinence can be treated with medications, sphincter exercises called biofeedback, electrical stimulation and surgical methods if necessary.
Constipation
Due to pregnancy hormones, constipation is observed in approximately 1/3 of pregnant women, especially in the last trimester of pregnancy. In addition, the gestation period can often lead to exacerbation of pre-existing painless constipation (intestinal laziness). In addition to hormones slowing down the time of stool passage in the intestine, the pregnant woman consuming less water and fiber, decreased physical activity, iron vitamins used to prevent anemia, the enlarged uterus pressing on the intestines and the presence of painful hemorrhoids are factors in the emergence of constipation.
Increasing the fluid and fiber consumption of the pregnant woman, increasing physical activity and, if necessary, drugs that increase the volume of stool containing cellulose are the most physiological treatment approaches. Diarrhea-inducing drugs called stimulant laxatives can be used in severe cases resistant to treatment. For this purpose, drugs containing senna, PEG and lactulose are available in our country. Castor oil should not be used in the treatment of constipation during pregnancy as it can induce premature labor and magnesium salt (English salt) increases fluid intake into the body. The most effective physiological way to increase fiber in the diet is to add 3-6 teaspoons of bran daily to meals. Although it may initially cause abdominal bloating and gas, this effect is temporary. The positive effects of dietary bran are seen after 3-4 weeks. Care should be taken as bran may reduce iron absorption.
Hemorrhoids
Hemorrhoids are a problem affecting up to 50% of the general population, with the first symptoms often appearing during pregnancy. Pain, bleeding and itching in the anal area are symptoms of hemorrhoids. It may be useful to increase fiber in the diet and the amount of water drunk, and to use stool softeners. Hemorrhoids outside the anal canal are not treated unless there is a blood clot inside. Pomades containing local anesthetics can be used safely. If the patient experiences pain, stool softeners and warm sitz baths are usually sufficient. In cases where the pain is unbearable, clot removal with local anesthesia can be safely performed. In the treatment of complicated internal hemorrhoids, endoscopic ligation or injection therapies can be safely applied.
Pregnancy and Diarrhea
Most of the summer diarrhea seen during pregnancy is mild and resolves spontaneously within 24-48 hours. It is usually sufficient to give the patient a low-fat diarrhea diet and plenty of fluids. In pregnant women with excessive bowel movements, the active ingredient loperamide can be safely administered, provided that the diarrhea is not bloody and there are no inflammatory cells in the stool. Antibiotics that can be used in infected diarrhea (dysentery, tourist diarrhea, etc.) are limited.
Antibiotics used for this purpose and for which no risk was found in animal studies are: metronidazole (after the first trimester of pregnancy), all cephalosporins (except moxalactam), erythromycin (except estolate). Antibiotics that have been shown to be low risk include: all fluoroquinolones, trimethoprim sulfamethoxazole (not to be used in the last trimester of pregnancy), vancomycin. Metronizadol should never be used in the first trimester of pregnancy as it is harmful to the fetus. Tetracycline group antibiotics have also been shown to be harmful in pregnancy.
Gastroesophageal Reflux Disease
The term reflux means “escaping back”. When Gastroesophageal Reflux Disease is mentioned, the disease picture that occurs when stomach acid and various enzymes and foodstuffs found in the stomach during digestive activity escape back towards the esophagus instead of going to the small intestine comes to mind. Although the exact cause is unknown, it has been found that prolonged and frequent relaxation of the valve called sphincter, which is formed by involuntary smooth muscles at the lower end of the esophagus, causes the disease picture to occur. The main symptoms are burning behind the breastbone (heart inflammation) and the sour taste of eaten food or stomach acid in the mouth. Although it is also common in the general population, it is found more frequently, around 50%. The symptoms of reflux disease often occur with the onset of pregnancy and disappear after delivery.
In half of the pregnant women, reflux complaints occur in the first trimester of pregnancy, while in ¼ of the cases the complaints occur in the second trimester and in 10% of the pregnant women in the last months. The reasons why reflux is so common in pregnancy have attracted the attention of clinicians and this issue has been investigated in detail. It has been found that in pregnant women without reflux, the esophageal lower end sphincter pressure increases in parallel with the intra-abdominal pressure that increases with the growth of the fetus in the womb and reflux does not occur. On the other hand, in pregnant women with reflux complaints, it has been shown that while intra-abdominal pressure increases, pressure increase in the lower end sphincter of the esophagus does not occur and reflux occurs accordingly. The main reason for this decrease in sphincter pressure is the hormones progesterone and estrogen, whose blood levels increase significantly during pregnancy and increase relaxation in smooth muscles.
For the diagnosis of reflux disease in pregnancy, it is sufficient to detect chest inflammation in the patient. Barium gastroscopy is not used in the diagnosis of reflux disease because it is an ineffective method and exposes the fetus to harmful x-rays. An endoscopic diagnostic method called gastroscopy can be used in the diagnosis of patients who are resistant to treatment or have atypical complaints. This method is extremely safe, does not cause premature labor and does not harm the mother and fetus, especially when performed after the first trimester of pregnancy and when the respiratory and circulatory system of the mother and fetus are monitored during the procedure. Intravenous drugs used to calm the mother during gastroscopy have been shown to be harmless to the fetus.
In the treatment of pregnant women with mild reflux, it is often sufficient to make some changes in lifestyle. These measures include not eating full meals and before bedtime, not consuming fatty and caffeine-rich foods and drinks, stopping smoking and alcohol consumption, and raising the head end of the bed by 15 cm. Many of the drugs used in the treatment of reflux cases without pregnancy are not suitable for safe use in pregnancy. When choosing medication for the treatment of moderate to severe reflux cases, special attention should be paid to the first ten weeks of pregnancy, when the organs of the fetus are forming. Drugs containing aluminum, calcium or magnesium, called antacids, can be used safely in pregnancy, but not in high doses and not for long periods of time. Antacids containing bicarbonate should not be used for this purpose as they may cause fluid overload and changes in blood chemistry. Drugs with sucralfate active ingredient are safely used in pregnancy as they are absorbed into the body at negligible levels.
The group of drugs called histamine 2 receptor suppressors (H2RA), which reduce gastric acid secretion, are drugs that are safely used in the treatment of pregnancy reflux. It has been shown that the active substance ranitidine from this group does not increase the risk of fetal anomalies even when used in the first trimester of pregnancy and can effectively control reflux complaints. Since there are no controlled human studies with other drugs of this group, ranitidine is the preparation of choice in this group. The active substance nizatidine should not be used during pregnancy as it increases the risk of fetal anomalies in pregnant animals. Ranitidine can also prevent chemical-induced pneumonia called Mendelson Syndrome, which occurs when stomach acid escapes into the trachea of mothers giving birth under general anesthesia. PPIs (proton pump inhibitors) given intravenously or orally for the same purpose can also be used safely.
Drugs called proton pump inhibitors (PPIs) are more effective than H2RA group drugs in the treatment of reflux disease. This group includes omeprazole, lansaprazole, rabeprazole, esomeprazole and pantaprazole. In some pregnant animal studies with the active ingredient omeprazole, the risk of fetal anomalies has been shown to increase. Therefore, in principle, it is a safe approach not to prefer omeprazole group drugs in pregnant women with mild complaints and uncomplicated reflux.
In the treatment of severe reflux disease in pregnant women who do not respond to standard treatment, the drug of choice is lansaprazole group PPI drugs, provided that they are not used in the first trimester of pregnancy. There is no evidence that lansaprazole increases the risk of anomaly in the fetus when these conditions are observed and used in the treatment of severe-complicated reflux patients. Caution should be exercised in the choice of medication in breastfeeding mothers who continue to have reflux complaints in the postpartum puerperium period. Antacid-derived drugs, H2RA group drugs except nizatidine, drugs with sucralfate active ingredient and alginate-derived drugs can be used easily as they do not pass into breast milk. PPI group drugs should not be used in breastfeeding mothers as they can harm the baby through breast milk.
Pregnancy and Ulcer Disease
When evaluating patients with gastric or duodenal ulcers during pregnancy, some points should be considered. Often, the severity of ulcer disease, ulcer-related complaints and complications decrease during pregnancy. The barium gastrectomy method used in the diagnosis of non-pregnant patients is not used in pregnancy because it may harm the fetus. Endoscopic diagnostic method called gastroscopy is a safe approach in the diagnosis of pregnant women with ulcer complaints, especially when performed from the second trimester (second three months of pregnancy). Since midazolam, which is used to calm the mother during the procedure, can suppress the respiratory functions of the mother and fetus and cause low blood pressure, monitoring the heart and respiratory functions of the mother and fetus with the help of a monitor increases safety. Gastroscopy is a reliable and highly diagnostic method that is easily applied in the diagnosis of ulcer disease in pregnancy and has been shown to have no adverse effect on the course of pregnancy, as long as the above-mentioned points are observed.
Antacids are medicines that can be used safely, as in the treatment of reflux disease in pregnancy. Although their curative effects are lower than those of other drugs, they can quickly relieve the symptoms of the disease (heartburn, burning). Antacids containing aluminum and magnesium can be used for this purpose in the second and third trimester (trimester of pregnancy). Antacids containing magnesium may have a negative effect on labor contractions and should not be used especially close to delivery. Sucralfate is an aluminum oxide-based drug that binds specifically to ulcerated tissue and heals the ulcer by interrupting acid contact with the ulcerated tissue. Since the drug is absorbed negligibly from the digestive tract and has been shown to have no adverse effect on the fetus, it is an effective drug that can be used safely in the treatment of ulcers during pregnancy.
The H2RA group of drugs is the group of drugs used safely in the treatment of ulcer disease, except for the nizatidine group as mentioned earlier. They can be used from the first trimester of pregnancy. Ranitidine is safely recommended in this group and has been shown to have no harmful effects on the fetus.
PPI group drugs are the group of drugs that heal ulcers at a higher rate and in a shorter time, as in reflux disease. Since omeprazole in this group can cause anomalies in the fetus, it is not recommended in pregnancy except for short-term use to prevent Mendelson Syndrome, which is seen only during labor.
Although there is no data showing that the use of other drugs of the group during pregnancy increases the risk of fetal anomalies, there are insufficient clinical studies showing that these drugs can be used safely during pregnancy. Among the drugs in this group, lansoprazole is recommended in cases that do not respond well to conventional treatment, starting in the second trimester of pregnancy. Misoprostol is a highly effective ulcer drug in non-pregnant ulcer patients. However, since it is well known to cause premature birth or miscarriage, it is a drug that should never be used during pregnancy. Antibiotic treatments used against the ulcer-causing bacteria called H. pylori, which is the main cause of ulcer in classical ulcer disease, are not used during pregnancy due to their high negative effects on the fetus in pregnant women.
