Stomach ulcer in pregnant women is a chronic recurrent disease detected during gestation, in which a local ulcerative defect forms in the gastric mucosa. It is manifested by epigastric pain, discomfort, heaviness in the epigastric region, dyspeptic phenomena, slowing weight gain. It is diagnosed using ultrasound of the stomach, gastroscopy, laboratory methods for detecting helicobacteriosis, supplemented by pH-metry and analysis of feces for latent blood. Antacids, enterosorbents, selective histamine blockers, myotropic antispasmodics are used for treatment.
K25 Stomach ulcer
Stomach ulcer is a rare extragenital pathology detected in 0.025% of pregnant women. These statistical indicators may be somewhat underestimated due to the difficulties of diagnosing the disease during gestation. Currently, the prevalence of gastric ulcer in the female population as a whole is 8-11%, while there is a tendency to increase the incidence. Most likely, this is due to growing stress loads, high social activity, and family disorder. Thanks to the appointment of modern methods of eradication therapy of Helicobacter pylori, a bacterium associated with gastric ulcer, the number of complicated forms of the disease has significantly decreased.
Usually, the disease occurs before the onset of gestation and is caused by a combination of several factors — hereditary predisposition, provoking endogenous and exogenous influences. The immediate cause of the formation of ulcers is the damaging effect of hydrochloric acid on the epithelium of the stomach. Additional contributing factors are:
- Helicobacter infection. An important role in the development of pathology is played by the contamination of the gastric mucosa with the acid-resistant spiral bacterium Helicobacter pylori (Helicobacter pylori), detected in 38% of pregnant women suffering from peptic ulcer disease. At the same time, the number of patients with HP-negative variant of gastric ulcer has been increasing in recent years.
- Genetic determinism. Local mucosal defect occurs more often in predisposed pregnant women. The genetic marker of the disease is blood type 0 (I), which is usually associated with hyperplasia of parietal cells producing hydrochloric acid. An increase in the serum concentration of pepsinogen-1, acetylcholine, cholinesterase, an increase in the number of antral G-cells producing gastrin, a low content of fucoglycoproteins in gastric mucus, the presence of HLA-B5, B15, B35 and other histocompatibility antigens, the inability of the mucous membrane to secrete glycoproteins are also hereditary.
- Mucosal damage. Factors provoking ulceration of the gastric mucosa in pregnant women are smoking, the use of strong alcohol in large quantities, caffeine-containing beverages, unsystematic nutrition, uncontrolled intake of NSAIDs, sulfonamides and a number of antibacterial drugs, violations of the integrity of the epithelium by foreign bodies. In rare cases, the ulcer develops against the background of diabetes mellitus, leiomyoma, adenocarcinoma, carcinoid, germination of malignant tumors of other gastrointestinal organs, Crohn’s disease, lymphoma, sarcoma, HIV infection, syphilis, tuberculosis.
Although pregnancy usually has a positive effect on the course of peptic ulcer disease, in 10% of patients the disease worsens. Most likely, this is caused by increased gastric secretion in the first trimester due to a physiological increase in the tone of the vagus nerve. A possible role in the exacerbation of peptic ulcer 2-4 weeks before the end of the gestational period is played by a stressful state caused by fear of impending childbirth. The increase in symptoms after childbirth is due to a decrease in the protective effect of progesterone and estrogens against the background of significant loads and often eating disorders.
The mechanism of ulceration of the gastric mucosa is based on the occurrence of an imbalance between aggressive and protective factors. The damaging effect is provoked by enzymes secreted by helicobacteria. Under the influence of urease, urea turns into ammonia, neutralizing the acidity of the stomach. In response to alkalinization, the secretion of gastrin, hydrochloric acid, pepsin increases, the production of bicarbonates is inhibited. Microbial phospholipase, mucinase, protease depolymerize and dissolve gastric mucus, opening access to mucosal hydrochloric acid and pepsin. As a result of a chemical burn and an inflammatory reaction, an ulcer is formed. The destruction of the epithelium is enhanced by vacuolization of cells under the influence of endotoxin VacA, the release of lysosomal enzymes, interleukins and other inflammatory mediators.
In 75-80% of pregnant women, destructive processes in the gastric mucosa slow down and the disease goes into remission, which is associated with increased secretion of protective mucus under the influence of progesterone, accelerated epithelial regeneration and improved blood supply to the gastroduodenal region due to estrogenic stimulation, a temporary decrease in the secretion of hydrochloric acid. An indirect effect of activation of the parasympathetic system is normalization of the motor evacuation function of the stomach with shortening of the contact time of aggressive factors and epithelial cells.
Symptoms of stomach ulcer in pregnant women
Since spontaneous remission occurs in most patients, peptic ulcer disease during gestation is usually asymptomatic. With exacerbation, the pregnant woman complains of discomfort, a feeling of heaviness, soreness in the epigastrium, which occurs, depending on the location of the ulcerative defect, immediately after eating or after 30 minutes-1 hour. Possible irradiation of pain in the left shoulder blade, precardial region, thoracic, lumbar spine. Some women note the appearance of acidic belching, nausea, bloating, constipation, less often — vomiting, which brings relief. Due to the digestive disorders associated with ulcers, weight gain often slows down in pregnant women.
Patients suffering from active peptic ulcer disease have more pronounced early toxicosis, iron deficiency anemia. Fetoplacental insufficiency, hypoxia and fetal development delay may occur. In 3.4% of cases, the recurrent disease is complicated by gastrointestinal bleeding, which poses a threat to the life of a pregnant woman and increases the probability of stillbirth of the child up to 10%. According to the observations of specialists in the field of gastroenterology and obstetrics, gastric ulcer perforation with the development of peritonitis and its penetration into neighboring organs (pancreas, intestinal loops, omentum, etc.) during gestation, they are extremely rare.
Timely detection of stomach ulcer in pregnant women is often difficult due to the asymptomatic or erased course, the limited use of a number of informative diagnostic methods (contrast and native stomach radiography, laterography with double contrast). To verify the diagnosis, patients with suspected peptic ulcer disease are recommended:
- Ultrasound. During ultrasound of the stomach, signs of increased secretion, inflammatory thickening of the gastric wall in the area of the ulcer, motor evacuation dysfunction are determined. Although sonography is less informative than EGDS, due to its safety for the fetus, it is used as a screening for increased uterine tone and other contraindications to endoscopy.
- Gastroscopy. The most accurate method of diagnosing stomach ulcers. Since the study can provoke an increase in uterine tone, it is prescribed only in complex diagnostic cases and if complications are suspected. Endoscopy allows you to visualize a mucosal defect, evaluate its parameters, perform a targeted biopsy for histological examination.
- Detection of Helicobacter pylori. Taking into account the role of the microorganism in the development of ulcers, pregnant women are prescribed tests to identify the pathogen. The most common methods of examination are rapid urease biopsy test, PCR diagnosis of helicobacter, enzyme immunoassay of antibodies to bacteria in the blood, non-invasive respiratory test.
As additional methods, intragastric pH-metry is used, which provides objective information about the acid-forming function of the stomach, fecal analysis for latent blood to exclude latent bleeding. Differential diagnosis is performed with vomiting of pregnant women, erosive gastroduodenitis, duodenal ulcer, cholecystitis, cholelithiasis, pancreatitis, acute appendicitis, Mallory-Weiss syndrome, stomach cancer, pulmonary bleeding, idiopathic thrombocytopenic purpura. According to the indications, the patient is consulted by a therapist, gastroenterologist, hepatologist, abdominal surgeon, infectious disease specialist, venereologist, phthisiologist, pulmonologist, hematologist, oncologist.
Treatment of stomach ulcer in pregnant women
Therapeutic tactics in patients with aggravated peptic ulcer disease are aimed at reducing gastric acidity, relieving pain syndrome and erosive processes. Non-drug treatment includes the appointment of therapeutic and protective ward or bed rest, drinking alkaline mineral waters, diet therapy with frequent fractional nutrition and restriction of products that stimulate gastric secretion or have a mechanical, thermal, chemical damaging effect on the gastric epithelium. Of the medications used for the treatment of pregnant women:
- Non-absorbable antacids. The therapeutic effect of antacid drugs is associated with a decrease in the acidity of gastric juice to a physiological level due to the binding of hydrochloric acid, protective enveloping of the mucosa, a decrease in the proteolytic activity of pepsin. Due to the absence of an alkalizing effect, antacids do not interfere with the digestion of food products.
- Sorbents based on diosmectite. Although enterosorbents do not affect the release of hydrochloric acid, they have a pronounced gastroprotective effect due to increased mucus secretion, strengthening of the glycoprotein matrix, adsorption of toxins produced by helicobacteria. Diosmectites are not absorbed by the mucous membranes, are excreted unchanged and are safe for the fetus.
- Blockers of H2-histamine receptors. In pregnant women, they are used only if antacid therapy is ineffective. They have a pronounced antisecretory and protective effect: they suppress the secretion of pepsin, hydrochloric acid, enhance the synthesis of prostaglandins, the secretion of bicarbonates. They are able to improve local microcirculation and accelerate the regeneration of ulcers.
- Myotropic antispasmodics. They are indicated when a pain syndrome associated with a violation of gastric motility occurs. Relax the spasmed smooth muscle fibers and thereby quickly eliminate the pain attack. To enhance the effect, they can be prescribed in combination with prokinetics, which improve the accommodation of the stomach floor and normalize gastrointestinal peristalsis.
To improve digestion and eliminate flatulence, it is possible to prescribe medications containing enzymes. Bismuth preparations, proton pump inhibitors and other means for the eradication of Helicobacter pylori are not prescribed to pregnant women because of possible toxic effects on the fetus. Surgical interventions are carried out only in case of complications (bleeding, perforation, penetration). Patients with gastric ulcer are shown natural childbirth under peridural anesthesia. Caesarean section is performed only in the presence of obstetric indications or severe concomitant pathology.
Prognosis and prevention
In most pregnant women, gestation contributes to the onset of remission. With an exacerbation of the disease, adequate antacid therapy allows for 3-5 days to relieve pain, and for 2-3 weeks of treatment in a hospital to achieve lasting improvement. In order to prevent the recurrence of ulcers on the eve of childbirth and in the postpartum period, patients with a history of peptic ulcer disease or who have had an exacerbation in this pregnancy are recommended to take preventive antacid drugs and enterosorbents at 37-38 weeks of gestational age. Primary prevention of the disease involves quitting smoking, alcohol, normalization of diet and diet, sufficient rest, exclusion of stressful loads.