••• Chapter 15^ Gastrointestinal Disorders in Pregnancy^165
❍ Which malformations are associated with immunosuppressive therapy after liver transplantation?
The occurrence of meningocele, urogenital defects, cleft palate, hypospadias, multicystic dysplastic kidneys, and
membranous ventricular septal defect has been associated with immunosuppression after a liver transplant.
No consistent pattern has, however, been identified in these patients.
❍ What is the most common cause of upper GI hemorrhage during pregnancy?
Mallory-Weiss tear, followed by erosive esophagitis.
❍ What is the most common cause of lower GI bleeding during pregnancy?
Hemorrhoids.
❍ What are the abdominal causes of acute volume loss (with or without abdominal pain) during pregnancy?
(1) Ruptured ectopic pregnancy.
(2) Placental abruption.
(3) Ruptured liver.
(4) Ruptured splenic artery aneurysm.
❍ What causes of pancreatitis may be exacerbated during pregnancy?
The incidence of gallstones is increased during pregnancy although pancreatitis is rare (occurring in 0.03%
of pregnancies.^6 Pregnancy may worsen underlying hypertriglyceridemia and precipitate pancreatitis.
Hyperparathyroidism may first become manifest during pregnancy and cause pancreatitis.
❍ At what stage of pregnancy, is pancreatitis most likely to occur?
During the third trimester and the postpartum period.
❍ What presentations of gallstone disease are common during pregnancy? Which are rare?
Biliary colic and acute cholecystitis are common; jaundice and acute pancreatitis are rare.
❍ When is cholecystectomy safe during pregnancy?
Laparoscopic cholecystectomy is the most common laparoscopic procedure in pregnancy. Several studies have
shown no increased risk of preterm delivery or adverse outcome after first trimester laparoscopic cholecystectomy.
The laparoscopic approach is also feasible in the third trimester. Nonoperative management of symptomatic
cholelithiasis is associated with higher recurrence of symptoms necessitating hospitalization, increased risk of
gallstone pancreatitis (associated with a 10–20% rate of fetal loss), increased risk of miscarriage, preterm labor and
preterm delivery compared with those undergoing laparoscopic cholecystectomy. Furthermore, such nonsurgical
approaches like bile acid therapy, lithotripsy, and dissolution with methyl terbutyl ether are not recommended
during pregnancy due to the lack of safety data.
❍ What is the most frequent cause of an acute abdomen in pregnancy?
Acute appendicitis, which approximates 1 in 1500 deliveries, can occur at any time, with a slight predominance
during the second trimester. Maternal mortality is rare, but the rate of fetal loss is 10% to 20%, due to preterm
labor or IUFD. Preterm labor usually occurs within 5 days of surgery, and could either be due to the disease or the
inflammatory response to surgery. The differential diagnosis includes pyelonephritis, cholecystitis, renal or ureteral
calculi, adnexal torsion, degenerating myoma, extrauterine pregnancy, and placental abruption.