Placental inflammation is not increased in inflammatory bowel disease.

BACKGROUND: Women with inflammatory bowel disease (IBD) are at increased risk for adverse birth outcomes such as preterm delivery and small for gestational age (SGA) infants. Most recognized cases of fetal growth restriction in singleton pregnancies have underlying placental causes. However, studies in IBD examining poor birth outcomes have focused on maternal factors. We examined whether women with IBD have a higher rate of placental inflammation than non-IBD controls. METHODS: Between 2008 and 2011, the placental tissue of 7 ulcerative colitis, 5 Crohn's disease, and 2 IBD-unclassified subjects enrolled in the Pregnancy in Inflammatory Bowel Disease and Neonatal Outcome (PIANO) registry were evaluated for villitis, deciduitis, and chorioamnionitis with/without a fetal inflammatory response. The history and birth outcomes of all IBD subjects were reviewed and matched to 26 non-IBD controls by gestational age at delivery. RESULTS: Of women with IBD, 29% delivered preterm infants and 21% delivered SGA infants. Half of the IBD patients had mild-moderate disease flares during pregnancy. Five (36%) patients required corticosteroids, 2 (14%) were maintained on an immunomodulator, and 3 (21%) others received tumor necrosis factor-alpha inhibitors during their pregnancy. Chorioamnionitis was the only identified placental pathology present in the placentas reviewed, occurring less frequently in cases compared to controls (7% vs. 27%, P=0.32). CONCLUSIONS: Placental inflammatory activation does not appear to be responsible for the increase in adverse birth outcome in women with IBD. Further studies are necessary to validate these findings in IBD to explain poor birth outcomes.

Hepatitis B in pregnancy: challenges and treatment.

Hepatitis B virus (HBV) during pregnancy presents unique management challenges. Varying aspects of care must be considered, including the effects of HBV on maternal and fetal health, effects of pregnancy on the course of HBV infection, treatment of HBV during and after pregnancy, and prevention of perinatal infection. Antiretroviral therapy has not been associated with increased risk of birth defects or toxicity, but despite studies designed to elucidate the drug efficacy and safety in affected individuals and the developing fetus, recommendations are inconclusive. Clinicians and patients must make individualized decisions after carefully evaluating the risks and benefits summarized in this article.

Gastroenterology consultations in pregnancy.

BACKGROUND: Training in gastrointestinal (GI) disorders in pregnancy is required for all gastroenterology fellows. Nevertheless, the actual role of the gastroenterologist in the management of pregnant patients is unknown. Establishing the characteristics of GI consultations in pregnancy can help focus trainee education and prepare gastroenterologists for future practice. The purpose of this study was to determine the indications for consultations in pregnancy and the gastroenterologist's role in the evaluation and management of the pregnant patient. METHODS: A chart review was performed of all consecutive outpatient GI consultations for pregnant women at a high-volume obstetrics hospital over a 3-year period. Referring source, patient characteristics, indication(s) for consultation, diagnosis(es), change in management after consultation, and need for follow-up were recorded. RESULTS: We reviewed 370 charts. The mean age (±standard deviation [SD]) at referral was 28.7 years ± 6.5, and mean weeks of gestation (±SD) was 21.3 ± 8.8. Obstetrician/gynecologists requested most consultations (70.1%). New GI symptoms arising in pregnancy comprised 35.4% of consultations, and worsening of a preexisting GI disorder comprised 24.4%. The most common indications for consultation were viral hepatitis (20.2%), nausea and vomiting (18.9%), and nonspecific abdominal pain (13.5%). The most common diagnoses were acute or chronic viral hepatitis (17.8%), hyperemesis gravidarum (15.1%), gastroesophageal reflux disease (14.3%), and constipation (13.0%). Consultation changed the diagnosis in 25.1% of patients and changed management in 78.6%. Follow-up was required in 77.3% of cases during pregnancy and 37.8% postpartum. CONCLUSIONS: GI consultation in pregnancy is sought more frequently for the evaluation and management of GI disorders not unique to pregnancy than for pregnancy-unique disorders. Although GI consultation changed the diagnosis in a minority of cases, it changed management in the majority. Gastroenterologists should be familiar with the most common indications for consultation in pregnancy and be prepared to evaluate and manage pregnant women with GI disorders.

Feeding jejunostomy for the treatment of severe hyperemesis gravidarum: a case series.

BACKGROUND: Hyperemesis gravidarum is severe nausea and vomiting during pregnancy leading to dehydration, nutrition deficiency, and fetal morbidity and mortality. Treatment must maintain fluid and electrolyte balance and caloric intake. Parenteral nutrition is often attempted; however, complication rates are high. Nutrition via nasoenteric and percutaneous endoscopic gastrostomy tubes is limited by poor patient tolerance, tube dislodgement, and altered anatomy in pregnancy. METHODS: Women with hyperemesis gravidarum who failed standard therapy were offered jejunostomy. All patients underwent surgical jejunostomy in the second trimester. Isotonic tube feeds were administered to a goal caloric factor calculated by the Harris-Benedict equation with a correction added for pregnancy. Patients were monitored until delivery. RESULTS: Five women underwent jejunostomy placement at our institution between 1998 and 2005. One patient underwent jejunostomy placement twice for consecutive pregnancies. The mean body weight loss from prepregnancy was 7.9% (range, 4.0%-15.9%). Patients underwent jejunostomy placement between 12 and 26 weeks of gestation (median 14 weeks). Twelve to 16 Fr catheters were placed in the proximal jejunum. Maternal weight gain occured in 5 of 6 pregnancies. The mean duration of tube placement was 19 weeks (range, 8-28 weeks). All pregnancies ended with term deliveries (range, 36-40 weeks of gestation). The mean infant birth weight was 2885 g (range, 2270-4000 g). Tube-related complications were limited to dislodgement in 2 patients in the third trimester. No cases of infection, bleeding, or preterm labor occured. CONCLUSIONS: Feeding via jejunostomy is a potentially safe, effective, and well-tolerated mode of nutrition support therapy in hyperemesis gravidarum.