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Gastrointestinal Motility Disorders during Pregnancy

Todd H. Baron, MD; Belinda Ramirez, MD; and Joel E. Richter, MD
[+] Article and Author Information

From the University of Alabama at Birmingham, Birmingham, Alabama. Requests for Reprints: Joel E. Richter, MD, Division of Gastroenterology, University of Alabama at Birmingham, UAB Station, Birmingham, AL 35294. Acknowledgments: The authors thank Mrs. Linda Pugh for preparation of the manuscript and Richard O. Davis, MD, for review of the manuscript and assistance in Table preparation.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1993;118(5):366-375. doi:10.7326/0003-4819-118-5-199303010-00008
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Purpose: To review the pathophysiology of gastrointestinal motility disorders during pregnancy, their clinical manifestations, and their management.

Data Sources: Studies published from 1963 to 1992 identified by computerized literature searches of Index Medicus and MEDLINE; hand searches; contact with pharmaceutical representatives for information on drug therapy during pregnancy; and selected texts on drugs and obstetrics.

Study Selection: Selected studies were those involving controlled design of physiology related to pregnancy or to hormonal effects on the gastrointestinal tract or both, and clinical studies or previous reviews that contributed to the understanding of the gastrointestinal effects of pregnancy.

Data Extraction: Data concerning the epidemiology, causes, clinical manifestations, and complications of altered gastrointestinal motility during pregnancy as well as the strength of association between gastrointestinal disorders of pregnancy and hormonal changes were evaluated and used to develop a practical approach to evaluate and manage these patients.

Results of Data Synthesis: Effects on the gastrointestinal tract during pregnancy are caused primarily by hormonal changes and not the physical effects of the gravid uterus. Motility changes occur throughout the gastrointestinal tract, including a reduction in lower esophageal sphincter pressure and its physiologic function with resulting gastroesophageal reflux and the risk for aspiration; alterations in gastric motor function associated with nausea and vomiting; and a decrease in the rate of small-bowel and colonic transit manifested primarily as abdominal bloating and constipation. These effects are mediated by progesterone, with estrogen probably acting as a primer.

Conclusions: Given the large number of pregnancies each year complicated by gastrointestinal motility disorders, many physicians (including internists and gastroenterologists) must manage these problems. Knowledge of the underlying physiologic alterations in gastrointestinal motility during pregnancy and of safe treatment options is essential to the care of the pregnant patient.

Figures

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Figure 1.
Lower esophageal sphincter pressures.

Data were recorded in four volunteer women during pregnancy and in the postpartum period. Area between the dotted lines shows the range of lower esophageal sphincter pressures in normal nonpregnant women. Horizontal bars represent the mean ± SE for each period. Lower esophageal sphincter pressure declined progressively during pregnancy but returned to normal in the postpartum period. (Adapted from Van Thiel DH, Gravaler JS, Joshi SN, et al. Heartburn of pregnancy. Gastroenterology. 1977; 72:666-8, with permission.).

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Figure 2.
Nausea scores and gastric rhythms in pregnant women.P

Mean nausea scores ± SE were significantly greater ( < 0.05) in women with flat-line dysrhythmias, 1- to 2-cpm waves, and 4-to 9-cpm tachygastrias compared with pregnant women with normal 3-cpm electrogastrogram rhythms. Differences in nausea scores among women in the various gastric dysrhythmias did not differ significantly. (From Koch KL, Stern RM, Vasey JJ, et al. Gastric dysrhythmias and nausea of pregnancy. Dig Dis Sci. 1990;35:961-8, with permission.).

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Figure 3.
Lactulose hydrogen breath test.

Results from two women studied during the third trimester of pregnancy and after delivery. Breath hydrogen on the ordinate is shown plotted against time on the abscissa for two representative women, each of whom was studied twice. The open circles and broken lines represent studies done in late pregnancy, whereas the closed circles and solid lines represent studies performed in the postpartum period. Time is recorded from the moment of lactulose ingestion. Small bowel transit time was significantly greater during pregnancy compared to the postpartum period. (From Wald A, Van Thiel DH, Hoeschstetter L, et al. Effect of pregnancy on gastrointestinal transit. Dig Dis Sci. 1982; 27: 1015-8, with permission.).

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Figure 4.
The effect of progesterone on canine colonic smooth muscle.Top panel.Bottom panel.

Increasing progesterone concentrations inhibited the contractile force (closed circles;) but not the frequency ▴ of circular smooth muscle as compared with the force (○) and frequency (▵) of controls. Increasing progesterone concentrations inhibited both the contractile force and frequency of longitudinal smooth muscle as compared with controls (Adapted from Gill RC, Bowes KL, Kingma YJ. Effect of progesterone on canine colonic smooth muscle. Gastroenterology. 1985; 88:1941-7, with permission.).

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