Description

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available published evidence and expert advice regarding the clinical management of patients with pregnancy-related gastrointestinal and liver disease.

Methods

This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through the standard procedures of Gastroenterology. This article provides practical advice for the management of pregnant patients with gastrointestinal and liver disease based on the best available published evidence. The Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because formal systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations.Best Practice Advice Statements

Best Practice Advice 1

To optimize gastrointestinal and liver disease before pregnancy, preconception and contraceptive care counseling by a multidisciplinary team should be encouraged for reproductive-aged persons who desire to become pregnant.

Best Practice Advice 2

Procedures, medications, and other interventions to optimize maternal health should not be withheld solely because a patient is pregnant and should be individualized after an assessment of the risks and benefits.

Best Practice Advice 3

Coordination of birth for a pregnant patient with complex inflammatory bowel disease, advanced cirrhosis, or a liver transplant should be managed by a multidisciplinary team, preferably in a tertiary care center.

Best Practice Advice 4

Early treatment of nausea and vomiting of pregnancy may reduce progression to hyperemesis gravidarum. In addition to standard diet and lifestyle measures, stepwise treatment consists of symptom control with vitamin B6 and doxylamine, hydration, and adequate nutrition; ondansetron, metoclopramide, promethazine, and intravenous glucocorticoids may be required in moderate to severe cases.

Best Practice Advice 5

Constipation in pregnant persons may result from hormonal, medication-related, and physiological changes. Treatment options include dietary fiber, lactulose, and polyethylene glycol–based laxatives.

Best Practice Advice 6

Elective endoscopic procedures should be deferred until the postpartum period, whereas nonemergent but necessary procedures should ideally be performed in the second trimester. Pregnant patients with cirrhosis should undergo evaluation for, and treatment of, esophageal varices; upper endoscopy is suggested in the second trimester (if not performed within 1 year before conception) to guide consideration of nonselective β-blocker therapy or endoscopic variceal ligation.

Best Practice Advice 7

In patients with inflammatory bowel disease, clinical remission before conception, during pregnancy, and in the postpartum period is essential for improving outcomes of pregnancy. Biologic agents should be continued throughout pregnancy and the postpartum period; use of methotrexate, thalidomide, and ozanimod must be stopped at least 6 months before conception.

Best Practice Advice 8

Endoscopic retrograde cholangiopancreatography during pregnancy may be performed for urgent indications, such as choledocholithiasis, cholangitis, and some cases of gallstone pancreatitis. Ideally, endoscopic retrograde cholangiopancreatography should be performed during the second trimester, but if deferring the procedure may be detrimental to the health of the patient and fetus, a multidisciplinary team should be convened to decide on the advisability of endoscopic retrograde cholangiopancreatography.

Best Practice Advice 9

Cholecystectomy is safe during pregnancy; a laparoscopic approach is the standard of care regardless of trimester, but ideally in the second trimester.

Best Practice Advice 10

The diagnosis of intrahepatic cholestasis of pregnancy is based on a serum bile acid level >10 μmol/L in the setting of pruritus, typically during the second or third trimester. Treatment should be offered with oral ursodeoxycholic acid in a total daily dose of 10–15 mg/kg.

Best Practice Advice 11

Management of liver diseases unique to pregnancy, such as pre-eclampsia; hemolysis, elevated liver enzymes, and low platelets syndrome; and acute fatty liver of pregnancy requires planning for delivery and timely evaluation for possible liver transplantation. Daily aspirin prophylaxis for patients at risk for pre-eclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome is advised beginning at week 12 of gestation.

Best Practice Advice 12

In patients with chronic hepatitis B virus infection, serum hepatitis B virus DNA and liver biochemical test levels should be ordered. Patients not on treatment but with a serum hepatitis B virus DNA level >200,000 IU/mL during the third trimester of pregnancy should be considered for treatment with tenofovir disoproxil fumarate.

Best Practice Advice 13

In patients on immunosuppressive therapy for chronic liver diseases or after liver transplantation, therapy should be continued at the lowest effective dose during pregnancy. Mycophenolate mofetil should not be administered during pregnancy.

中文翻译：

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AGA 妊娠相关胃肠道和肝脏疾病临床实践更新：专家审查

 描述

本美国胃肠病协会 （AGA） 研究所临床实践更新的目的是回顾有关妊娠相关胃肠道和肝脏疾病患者临床管理的可用已发表证据和专家建议。

 方法

该专家审查由 AGA 研究所临床实践更新委员会和 AGA 管理委员会委托和批准，旨在就对 AGA 成员具有高度临床重要性的话题提供及时指导，并接受了临床实践更新委员会的内部同行评审和通过胃肠病学标准程序的外部同行评审.本文根据现有的最佳已发表证据，为患有胃肠道和肝脏疾病的妊娠患者的管理提供了实用建议。最佳实践建议声明来自对已发表文献的回顾和专家意见。由于未进行正式的系统评价，这些最佳实践建议声明不对证据质量或所提出考虑因素的强度进行正式评级。最佳实践建议声明

 最佳实践建议 1

为了在怀孕前优化胃肠道和肝脏疾病，应鼓励由多学科团队为希望怀孕的育龄人群提供孕前和避孕护理咨询。

 良好作业建议 2

不应仅仅因为患者怀孕而拒绝进行优化孕产妇健康的程序、药物和其他干预措施，而应在评估风险和益处后进行个体化治疗。

 最佳实践建议 3

患有复杂炎症性肠病、晚期肝硬化或肝移植的妊娠患者的分娩协调应由多学科团队管理，最好在三级医疗中心进行。

 最佳实践建议 4

妊娠期恶心和呕吐的早期治疗可能会减少进展为妊娠剧吐。除了标准的饮食和生活方式措施外，阶梯式治疗还包括使用维生素 B6 和多西拉敏控制症状、补水和充足的营养;中度至重度病例可能需要昂丹司琼、甲氧氯普胺、异丙嗪和静脉注射糖皮质激素。

 最佳实践建议 5

孕妇便秘可能是由荷尔蒙、药物相关和生理变化引起的。治疗选择包括膳食纤维、乳果糖和聚乙二醇类泻药。

 最佳实践建议 6

择期内窥镜手术应推迟到产后，而非紧急但必要的手术最好在妊娠中期进行。妊娠肝硬化患者应接受食管静脉曲张的评估和治疗;建议在妊娠中期进行上消化道内镜检查（如果在受孕前 1 年内未进行），以指导考虑非选择性 β 阻滞剂治疗或内镜下静脉曲张结扎术。

 最佳实践建议 7

对于炎症性肠病患者，受孕前、妊娠期间和产后临床缓解对于改善妊娠结局至关重要。生物制剂应在整个妊娠期和产后期间持续使用;必须在受孕前至少 6 个月停止使用甲氨蝶呤、沙利度胺和奥扎莫德。

 良好作业建议 8

妊娠期间内镜逆行胰胆管造影可用于紧急指征，例如胆总管结石、胆管炎和一些胆石性胰腺炎病例。理想情况下，内镜逆行胰胆管造影应在妊娠中期进行，但如果推迟手术可能对患者和胎儿的健康有害，则应召集一个多学科团队来决定内镜逆行胰胆管造影的可取性。

 良好作业建议 9

胆囊切除术在怀孕期间是安全的;腹腔镜入路是标准治疗，无论妊娠期如何，但最好是在妊娠中期。

 最佳实践建议 10

妊娠期肝内胆汁淤积症的诊断基于瘙痒情况下的血清胆汁酸水平 >10 μmol/L，通常在妊娠中期或晚期。治疗应口服熊去氧胆酸，每日总剂量为 10-15 mg/kg。

 良好作业建议 11

妊娠特有的肝病管理，如先兆子痫;溶血、肝酶升高和低血小板综合征;急性妊娠期脂肪肝需要计划分娩并及时评估可能的肝移植。对于有先兆子痫或溶血风险、肝酶升高和低血小板计数综合征风险的患者，建议从妊娠第 12 周开始每日预防使用阿司匹林。

 良好作业建议 12

对于慢性乙型肝炎病毒感染患者，应进行血清乙型肝炎病毒 DNA 和肝脏生化检测水平。对于未接受治疗但在妊娠晚期血清乙型肝炎病毒 DNA 水平 >200,000 IU/mL 的患者，应考虑使用富马酸替诺福韦二吡呋酯治疗。

 最佳实践建议 13

对于因慢性肝病而接受免疫抑制治疗的患者或肝移植后，妊娠期间应以最低有效剂量继续治疗。吗替麦考酚酯不应在怀孕期间给药。