GI in Pregnancy

Any lab change that pregnancy itself does not cause is pathologic, and this episode applies that rule to a woman with twins at nine weeks who has hyperemesis gravidarum. It first defines hyperemesis and its risk factors. It then covers normal changes in blood count, creatinine, alkaline phosphatase, GGT, and the exam, and shows why a creatinine of 1.0 and an ALT of 240 are abnormal. Next come the usual causes of abnormal liver tests and the hyperemesis pattern, then imaging chosen for fetal safety. Treatment steps up from pyridoxine with doxylamine to ondansetron, then fluids with thiamine before glucose, then steroids after ten weeks.

This episode follows one pregnant woman who first has heartburn and then gallstones. Pregnancy causes reflux through lower esophageal sphincter pressure, a larger uterus, and slow gastric emptying, yet estrogen protects against ulcers. Treatment climbs from lifestyle changes to calcium carbonate, alginates, or sucralfate, then famotidine, then a proton pump inhibitor, while misoprostol is never given. Endoscopy is kept for alarm features, ideally in the second trimester, and H. pylori waits until after delivery. The gallstone half separates a first mild colic episode, which is watched, from recurrent or complicated disease, which leads to second-trimester cholecystectomy. It then covers ERCP with minimal radiation and the antibiotics that are safe in pregnancy.

The organizing idea is that each liver disease unique to pregnancy is sorted by trimester and by a few decisive findings, and that the dangerous ones end only with delivery. The episode starts with intrahepatic cholestasis of pregnancy: how itching with raised total bile acids and a normal GGT confirms it, how the bile acid level sets fetal risk and delivery timing, and what ursodeoxycholic acid, vitamin K, and later follow-up involve. It then covers HELLP syndrome, its Tennessee grading, and its management. Next is acute fatty liver of pregnancy, diagnosed by the Swansea criteria and separated from HELLP. It ends with hepatic infarction and rupture.

Viral hepatitis in pregnancy is organized around decisions that belong to pregnancy itself. The first patient has chronic hepatitis B found by screening. Her viral load sets whether and when tenofovir starts, her newborn's protection is planned ahead, and the reason for treatment sets when it stops. Her negative hepatitis C test leads to how that infection is screened for, why it is not treated during pregnancy, and how infants are tested. The second patient has acute hepatitis with fever and very high enzymes in the third trimester. Herpes simplex is treated first, before confirmation, and hepatitis A and hepatitis E are weighed, with travel history deciding how dangerous hepatitis E would be.

The organizing idea is that a woman with chronic liver disease keeps her disease controlled with drugs that are safe for the fetus, and her risk is planned before and after delivery. The episode starts with autoimmune hepatitis, where mycophenolate stops six months before conception, azathioprine and prednisone continue, and flares are watched for after birth. The same principle is applied to PBC, PSC, and Wilson disease. It then turns to compensated cirrhosis, covering risk by MELD, variceal screening, propranolol over nadolol, avoiding vasopressin, splenic artery screening, and delivery planning. It ends with timing and drug choices for pregnancy after liver transplant.

The first case teaches that active disease, not active medicine, is the greatest risk in IBD pregnancy. A woman with Crohn disease in remission keeps her adalimumab and azathioprine, while methotrexate, JAK inhibitors, and ozanimod are the drugs to stop or avoid. The episode then covers how IgG anti-TNF drugs cross the placenta and certolizumab does not, how activity is monitored, how delivery is chosen, and how vaccines and breastfeeding follow from the drug. The second case is a woman with severe pain at thirty weeks after Roux-en-Y bypass. It covers internal hernia, why the glucose tolerance test is avoided, and the timing and nutrition that bypass requires.