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Gerd In Pregnant Women

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Gastroesophageal Reflux Disease

And Dysphagia

In Pregnancy

Gastroesophageal Reflux Disease (GERD) is a common disorder among the general adult population. GERD is a backflow of contents of the stomach into the esophagus that is often due to the result of weakness of the lower esophageal sphincter (LES). This backflow of gastric acids may often produce a burning pain in the esophagus, commonly known as heartburn. Repeated episodes of reflux may cause esophagitis, peptic esophageal strictures, esophageal ulcers, and dysphagia.

Dysphagia, or difficulty swallowing, is a major symptom of GERD . Dysphagia may be caused by primary or secondary esophageal motor dysfunction (Ogorek, 1989). In one study, it was found that out of 1000 patients with GERD, 51.3 percent experienced dysphagia. Aspiration, secondary to food obstruction, occurred in 30 percent of these patients. Some patients even developed respiration problems (Henderson, 1977).

In uncomplicated cases of GERD, treatment consists of elevation of the head of the bed, avoidance of acid-stimulating foods, and regular administration of antacids and promotility agents(Richter, 1997). In more extreme cases of GERD, surgical repair may provide relief. One example of a surgical repair is an anti-reflux surgery, called fundoplication. Fundoplication involves wrapping the stomach fundus around the distal esophagus to improve LES pressure. However, this procedure had been shown to interfere with LES relaxation which may not allow food to enter the stomach from the esophagus (Richter, 1997). Many surgical methods can cause serious side effects. One major side effect is dysphagia, so the surgery can help solve GERD, but may cause other problems as well.

GERD during pregnancy is a very common occurrence, effecting up to two thirds of all pregnancies (Marrero, 1992). The clinical features of GERD do not appear to be different of that in the general population (Katz, 1998). Symptoms of GERD usually start appearing at about the fifth month of gestation and may increasingly become worse with progression on gestation, even though there have been cases where symptoms start as early as the first trimester. Symptoms of GERD normally subside soon after delivery. Dysphagia is a symptom of complicated reflux, including motility abnormalities, esophageal stricture, esophageal ulceration, or esophageal cancer. However, these complications are rare in pregnancy (Katz, 1998).

The origin of GERD is multifactoral, including the loss of intra-abdominal portion of the LES combined with an elevated intra-gastric pressure secondary to the gravid uterus, altered esophageal mucosal resistance, delayed gastric emptying and quantity of acid secretion (Baron, 1992). Another factor of the decreased LES pressure during pregnancy is due to the increased levels of the female sex organs estrogen, and progesterone. Studies were performed on opossums to identify whether the decrease in LES function is due to estrogen, progesterone, or both causes the smooth muscle relaxation of the LES. The results of the study showed that progesterone appeared to be the mediator of smooth muscle relaxation of the LES, however, estrogen may be needed for progesterone to act on LES (Day, 1990). Another factor that may contribute to GERD is an alteration in gastrointestinal transit time. Studies were done on 15 women in the third trimester of pregnancy, and four weeks postpartum to study the length of time bolus took to travel from the mouth to the stomach. Nine out of 15 women had prolonged transit times during pregnancy. These results show that there also may be delayed gastric emptying, which may promote reflux of gastric contents by increasing the quantity and duration of pooling of gastric secretions (Katz, 1998). In esophageal peristalsis, pregnant women exhibited a slower wave velocity and lower amplitude than women that were not pregnant. These changes in esophageal peristalsis may decrease acid clearance, adding to reflux (Baron, 1992). Decreased acid clearance in the esophagus may lead to esophageal strictures, which is a narrowing of the esophagus due to inflammation, and esophageal ulcers, which is a lesion in the esophagus due to the prolonged exposure of acid in the esophagus These may add to motility problems of the esophagus(Katz, 1998). Most pregnant women who experience GERD have had no previous problems with reflux prior to pregnancy, and decreased LES pressure will return to normal postpartum (Katz, 1998). After gastric contents have refluxed into the esophagus, several events occur to reduce the esophageal injury from the reflux. The esophagus can rapidly clear the reflux by swallow-induced esophageal peristaltic contractions (Bremner, 1993). Also, the acidic reflux in the esophagus can be diluted by fluid in swallowed saliva can be neutralized by bicarbonate in swallowed saliva. Abnormalities in these defense mechanisms could potentially contribute to esophageal injury from gastroesophageal reflux (Katz, 1998).

Several questions can be addressed regarding pregnant women experiencing GERD. Can the dysphagia associated with GERD affect the well being of the fetus? Do swallowing difficulties impair the adequacy of nutrition to mother and fetus? Does medical treatment put the mother or fetus in any risk? Although symptoms of GERD are often mild and easily controlled in pregnancy. In some cases, symptoms may be severe enough to interfere with diet and create a risk of malnutrition for mother and fetus because the mother may eat less frequently, or stop eating all together because of reflux pain or difficulty swallowing. Also, sleep as well as quality of life may be interfered with due to the pain and discomfort from GERD, which can add stress to mother and fetus (Katz, 1998).

Treatment of GERD in pregnant women is somewhat limited due to potential tetragenicity of systemic drugs taken during pregnancy. First,



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