方法:美国胃肠病学协会(AGA)研究所临床实践更新的目的是审查有关妊娠相关胃肠道和肝病患者的临床管理的现有已发表证据和专家建议。
方法:本专家审查由AGA研究所临床实践更新委员会和AGA管理委员会委托并批准,以就对AGA会员具有高临床重要性的主题提供及时指导,并通过临床实践更新委员会进行内部同行审查,并通过胃肠病学的标准程序进行外部同行审查。本文根据现有的最佳证据,为胃肠道和肝病孕妇的管理提供实用建议。最佳实践建议声明来自对已发表文献的回顾和专家意见。因为没有进行正式的系统审查,这些最佳实践建议声明没有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:在怀孕前优化胃肠道和肝脏疾病,应鼓励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。最佳实践建议2:程序,药物,和其他优化孕产妇健康的干预措施不应仅仅因为患者怀孕而保留,并且应在评估风险和收益后进行个性化。最佳实践建议3:复杂炎症性肠病孕妇的出生协调,晚期肝硬化,或者肝移植应该由多学科团队管理,最好在三级护理中心。最佳实践建议4:妊娠恶心和呕吐的早期治疗可以减少妊娠剧吐的进展。除了标准的饮食和生活方式措施,逐步治疗包括用维生素B6和多西拉明控制症状,水合作用,和足够的营养;昂丹司琼,甲氧氯普胺,异丙嗪,在中度至重度病例中可能需要静脉注射糖皮质激素。最佳实践建议5:孕妇便秘可能是由于荷尔蒙,药物相关,和生理变化。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:选择性内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评估,和治疗,食管静脉曲张;建议在妊娠中期进行上消化道内镜检查(如果在怀孕前1年内未进行),以指导考虑非选择性β受体阻滞剂治疗或内镜下静脉曲张结扎术。最佳实践建议7:在炎症性肠病患者中,受孕前的临床缓解,怀孕期间,在产后对改善妊娠结局至关重要。在整个怀孕和产后期间应继续使用生物制剂;使用甲氨蝶呤,沙利度胺,和奥扎尼莫德必须在受孕前至少6个月停止。最佳实践建议8:怀孕期间可以进行内窥镜逆行胰胆管造影术,用于紧急适应症,比如胆总管结石,胆管炎,和一些胆结石性胰腺炎的病例。理想情况下,应在妊娠中期进行内镜逆行胰胆管造影术,但是如果推迟手术可能对病人和胎儿的健康有害,应召集一个多学科小组来决定内镜逆行胰胆管造影术的可取性.最佳实践建议9:怀孕期间胆囊切除术是安全的;无论孕期如何,腹腔镜方法都是标准护理,但理想情况下是在妊娠中期。最佳实践建议10:妊娠肝内胆汁淤积症的诊断基于瘙痒时血清胆汁酸水平>10μmol/L,通常在第二或第三个三个月。治疗应口服熊去氧胆酸,每日总剂量为10-15mg/kg。最佳实践建议11:妊娠特有的肝脏疾病的管理,如先兆子痫;溶血,肝酶升高,和低血小板综合征;妊娠急性脂肪肝需要计划分娩并及时评估是否可能进行肝移植。每日阿司匹林预防先兆子痫或溶血风险患者,肝酶升高,低血小板综合征建议从妊娠12周开始。最佳实践建议12:慢性乙型肝炎病毒感染患者,应订购血清乙型肝炎病毒DNA和肝脏生化检查水平。未接受治疗但妊娠晚期血清乙型肝炎病毒DNA水平>200,000IU/mL的患者应考虑使用富马酸替诺福韦酯治疗。最佳实践建议13:在慢性肝病免疫抑制治疗或肝移植后的患者中,在怀孕期间应以最低有效剂量继续治疗.霉酚酸酯不应在怀孕期间服用。
METHODS: 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.