Pregnancy and portal hypertension a pathology view of physiologic changes

López-Méndez, Eric; Avila-Escobedo, Lourdes

doi:10.1016/s1665-2681(19)32016-2

Cited by 22 publications

(20 citation statements)

References 33 publications

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“…Pregnancy exacerbates portal hypertension mostly from gestational increases in plasma volume [25] . Almost one-third of pregnant patients with portal hypertension developed de novo varices during pregnancy, whereas about two-thirds of patients with antecedent varices experience variceal bleeding during pregnancy [26] . Patients administered betaadrenergic receptor antagonists, such as propranolol, to prophylax against variceal bleeding should be maintained on these drugs during pregnancy.…”

Section: Upper Endoscopymentioning

confidence: 99%

Gastrointestinal endoscopy in the pregnant woman

Friedel

Stavropoulos

Iqbal

et al. 2014

WJGE

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About 20000 gastrointestinal endoscopies are performed annually in America in pregnant women. Gastrointestinal endoscopy during pregnancy raises the critical issue of fetal safety in addition to patient safety. Endoscopic medications may be potentially abortifacient or teratogenic. Generally, Food and Drug Administration category B or C drugs should be used for endoscopy. Esophagogastroduodenoscopy (EGD) seems to be relatively safe for both mother and fetus based on two retrospective studies of 83 and 60 pregnant patients. The diagnostic yield is about 95% when EGD is performed for gastrointestinal bleeding. EGD indications during pregnancy include acute gastrointestinal bleeding, dysphagia > 1 wk, or endoscopic therapy. Therapeutic EGD is experimental due to scant data, but should be strongly considered for urgent indications such as active bleeding. One study of 48 sigmoidoscopies performed during pregnancy showed relatively favorable fetal outcomes, rare bad fetal outcomes, and bad outcomes linked to very sick mothers. Sigmoidoscopy should be strongly considered for strong indications, including significant acute lower gastrointestinal bleeding, chronic diarrhea, distal colonic stricture, suspected inflammatory bowel disease flare, and potential colonic malignancy. Data on colonoscopy during pregnancy are limited. One study of 20 pregnant patients showed rare poor fetal outcomes. Colonoscopy is generally experimental during pregnancy, but can be considered for strong indications: known colonic mass/stricture, active lower gastrointestinal bleeding, or colonoscopic therapy. Endoscopic retrograde cholangiopancreatography (ERCP) entails fetal risks from fetal radiation exposure. ERCP risks to mother and fetus appear to be acceptable when performed for ERCP therapy, as demonstrated by analysis of nearly 350 cases during pregnancy. Justifiable indications include symptomatic or complicated choledocholithiasis, manifested by jaundice, cholangitis, gallstone pancreatitis, or dilated choledochus. ERCP should be performed by an expert endoscopist, with informed consent about fetal radiation risks, minimizing fetal radiation exposure, and using an attending anesthesiologist. Endoscopy is likely most safe during the second trimester of pregnancy.

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Section: Upper Endoscopymentioning

confidence: 99%

Gastrointestinal endoscopy in the pregnant woman

Friedel

Stavropoulos

Iqbal

et al. 2014

WJGE

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“…Approximately 30% of patients with portal hyper tension develop de novo variceal hemorrhage, and about 75% of patients with pre-existing esophageal varices develop variceal hemorrhage during pregnancy. 69 The risk of variceal hemorrhage is greatest during the second trimester when portal hypertension peaks, and during labor when venous collateral resistance abruptly increases upon performance of the Valsalva maneuver to push the fetus through the birth canal. In a study by Aggarwal et al, 70 12 of 17 pregnant patients undergoing endoscopic sclerotherapy, with either absolute alcohol or 1.5% sodium tetradecyl sul fate, for acute esopha geal variceal bleeding (EVB) required multi ple thera peutic sessions, and 2 patients required endo scopic variceal banding after failure of endoscopic sclero therapy to ob literate esophageal varices.…”

Section: Endoscopic Hemostasis For Variceal Bleedingmentioning

confidence: 99%

Risks versus benefits of gastrointestinal endoscopy during pregnancy

Cappell

2011

Nat Rev Gastroenterol Hepatol

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Although gastrointestinal endoscopy is generally safe, its safety must be separately analyzed during pregnancy with regard to fetal safety. Fetal risks from endoscopic medications are minimized by avoiding FDA category D drugs, minimizing endoscopic medications, and anesthesiologist attendance at endoscopy. Esophagogastroduodenoscopy seems to be relatively safe for the fetus and may be performed when strongly indicated during pregnancy. Despite limited clinical data, endoscopic banding of esophageal varices and endoscopic hemostasis of nonvariceal upper gastrointestinal bleeding seems justifiable during pregnancy. Flexible sigmoidoscopy during pregnancy also appears to be relatively safe for the fetus and may be performed when strongly indicated. Colonoscopy may be considered in pregnant patients during the second trimester if there is a strong indication. Data on colonoscopy during the other trimesters are limited. Therapeutic endoscopic retrograde cholangiopancreatography seems to be relatively safe during pregnancy and should be performed for strong indications (for example, complicated choledocholithiasis). Endoscopic safety precautions during pregnancy include the performance of endoscopy in hospital by an expert endoscopist and only when strongly indicated, deferral of endoscopy to the second trimester whenever possible, and obstetric consultation.

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“…The pregnant woman has a 20-27% chance of esophageal bleed which increases markedly in case she has demonstrable varices. 5 Active variceal bleeding may occur at all stages of the pregnancy through second and third trimester, risk of variceal bleeding being the maximum in 2 nd stage of labor.…”

Section: Discussionmentioning

confidence: 99%

Pregnancy with portal hypertension: a case report

Dhingra

Ahmad

2018

Int J Reprod Contracept Obstet Gynecol

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Even though pregnancy is rare with cirrhosis and advanced liver disease, it may co-exist in the setting of non- cirrhotic portal hypertension as liver function is preserved. When encountered together it presents a complex clinical dilemma. Physiological hemodynamic changes associated with pregnancy, needed for meeting demands of the growing fetus, worsen the portal hypertension thereby putting mother at risk of potentially life-threatening complications like variceal hemorrhage. Pregnancy also predisposes the patient to develop hepatic decompensation. Thus, management of such cases requires multidisciplinary approach involving obstetricians experienced in dealing with high risk cases, hepatologists, anesthetists and neonatologists. Here through the case report of a 23 year old primigravida with Non Cirrhotic portal hypertension with 33 weeks gestational age in preterm labor we intend to focus upon different aspects of pregnancy with portal hypertension, its complications and management strategies.

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Pregnancy and portal hypertension a pathology view of physiologic changes

Cited by 22 publications

References 33 publications

Gastrointestinal endoscopy in the pregnant woman

Gastrointestinal endoscopy in the pregnant woman

Risks versus benefits of gastrointestinal endoscopy during pregnancy

Pregnancy with portal hypertension: a case report

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