Gastro-oesophageal reflux during pregnancy. Nigel Trudgill
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1 Gastro-oesophageal reflux during pregnancy Nigel Trudgill
2 Summary How common? Which pregnancies? Why? Are there complications? How do we treat reflux during pregnancy?
3 How common is reflux during 607 ante-natal women (cross sectional) pregnancy? Heartburn prepregnancy 14% 1 st trimester 22% 2 nd 39% 3 rd 72% Marrero 1992
4 How common is reflux during pregnancy? 263 pregnant women and controls (cohort) Heartburn pre-pregnancy 7% 1 st trimester 28% 2 nd 30% 3 rd 41% 1 year later 6% of pregnancy reflux still symptomatic Rey 2007
5 Which pregnancies?
6 Risk factors for pregnancy reflux Marrero 1992 Rey 2007
7 Risk factors for pregnancy reflux Marerro 1992 Rey 2007
8 Risk factors for pregnancy reflux Pre-existing reflux Gestational age Less clear Weight gain during pregnancy Parity Maternal age
9 Why?
10 Potential mechanisms for pregnancy Increase in reflux symptoms parallels plasma progesterone but not fundal height or urinary oestriol reflux Marrero 1992
11 Mechanisms of gastro-oesophageal TLOSR (not low basal LOS pressure) main mechanism gastro-oesophageal reflux reflux Increased reflux during TLOSR due higher intra-abdo pressure and gastro-oesophageal gradient due obesity Reduced oesophageal acid clearance after reflux in GORD No change in gastric emptying
12 Mechanisms of pregnancy reflux Mechanism reflux - pregnancy low LOS pressure (van Thiel 1977) but no TLOSR data Increased intra-abdo pressure and gastro-oesophageal gradient (Nagler 1960) causing more reflux during TLOSR? Reduced oesophageal acid clearance after reflux due impaired peristalsis? (Nagler 1960) No change in gastric emptying (MacFie 1991)
13 Complications?
14 Mendelson s syndrome Pulmonary aspiration gastric contents - 1 in 660 obstetric GAs (Mendelson 1946) Still commonest cause maternal anaesthetic death (up to 60% mort) 1 in (King 2010) iv H2 RA (not PPI) Clark 2009
15 Do complications of reflux develop during pregnancy? Endoscopy unusual during pregnancy - oesophagitis and stricture reportedly rare Pre-existing GORD Recurrent vomiting
16 Do complications of reflux develop during pregnancy? Vinson 1923
17 Upper GI adenocarcinoma Derakhshan 2009
18 Endoscopy database study 6 Hospitals 154,406 upper GI endoscopies Menon 2009
19 Animal model Collaboration with Faculty of Life Sciences, University of Manchester Acute oral wound model Oestrogen deprived and replenished states Assessment of inflammatory response
20 OVX 48h OVX + E
21 1.4 Diameter (48h) 4 Area (48h) * * OVX OVE+E 0 OVX OVE+E * p=0.02 * p=0.001
22 How do we treat reflux during pregnancy?
23 L'indigestion est chargée par Dieu pour imposer la moralité sur le ventre
24 Lifestyle measures Consider smaller meals with lower fat content Avoid acidic foods/drinks, coffee and chocolate if cause symptoms If nocturnal symptoms: Avoid eating late in evening Sleep on left side (Kapur 1998) Elevation of head of bed (Khan 2012)
25 Antacids and alginates Calcium, magnesium or aluminium based antacids all appear safe Avoid sodium bicarbonate (alkalosis) Avoid high dose long term gaviscon (foetal respiratory distress, renal stones + hypotonia reported)
26 Histamine H 2 antagonists n = 20 Larson 1997
27 Proton pump inhibitors
28 Safety of PPIs during pregnancy At doses similar to those used in humans, omeprazole produced dose-related embryonic and foetal mortality in pregnant rats and rabbits but no teratogenicity Omeprazole product information
29 Safety of PPIs during pregnancy Spontaneous abortions 1.29 (95%CI ) Pre-term deliveries 1.13 (95%CI ) Gill 2009
30 PPIs and major birth defects Danish population based study live births major birth defects Prescriptions linked Pasternak 2010
31 PPIs and major birth defects Pasternak 2010
32 PPIs and major birth defects Pasternak 2010
33 PPIs and major birth defects Pasternak 2010
34 Summary Highly prevalent (up to 70%) Pre-existing reflux and gestational age predispose Hormonal factors and gravid uterus probably contribute Complications unusual Therapy lifestyle measures, antacids, H 2 RAs, PPIs
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