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Helicobacter Pylori (HP) and
Hyperemesis Gravidarum (HG)
Aboubakr elnashar Benha university, Egypt
ABOUBAKR ELNASHAR
HG
•Usually a vexing problem for obstetricians
especially when conventional supportive
therapy fails.
•Is the most severe manifestation of the
spectrum of nausea and vomiting of
pregnancy.
•It complicates from 0.3 to 2% of all
pregnancies (Broussard & Richter, 1998 and Hod et al., 1994).
ABOUBAKR ELNASHAR
Materno-fetal Morbidity
1) Dehydration, electrolyte imbalance, and
acid base disturbances may lead to renal
and hepatic injury (Eliakim et al., 2000).
2) Patients who manifest continuous weight
loss and electrolyte disturbances may be at
risk for growth restriction, fetal anomalies and
decreased neonatal birth weight (Gross et al., 1989 and Tincello & Johnston, 1996).
ABOUBAKR ELNASHAR
Risk factors for HG
Pgda
Multiple pregnancy.
Young age (>24).
PH of HG.
Obesity.
Causes of HG
Theories:
High levels of hCG ( multiple – molar).
Increased estrogen levels.
Psychological factors.
High-fat diet.
PG.
ABOUBAKR ELNASHAR
What is HP?
a spiral-shaped gram negative rods found
on gastric mucosa particularly the antrum (Howden, 1996).
Prevalence
Very common all over the world 55% (WU et al 2000)
90% In peptic ulcer.
60% - 80% in gestritis without ulcer.
Developing > developed.
In Egypt very common at young age
(65%) (Bassily et al 1994)
ABOUBAKR ELNASHAR
Transmission
Oral – Oral.
Faecal – Oral.
Vectorial.
Iatrogenic.
Pathogenesis
Helicobacter Pylori causes a non-invasive
infection of the gastric epithelium and the
mucous layer that coats this epithelium.
The classical feature caused by this
organism is chronic active gastritis.
ABOUBAKR ELNASHAR
HG &HP Controversy Infection HP (Frigo et al., 1998&Kocak et al., 1999 and Kazarooni et al 2002).
No assocation between HP & H.G (Sahin et al., 2000).
Metanalysis (small n): Refractory HG & HP. Association
Speculations: The elevated serum steroid hormone and human hCG, which leads to a shift in pH. pregnancy-induced gastrointestinal dysmotility. Altered humoral and cell-mediated immunity in pregnancy. Suspicious HP as a cause of H.G
ABOUBAKR ELNASHAR
Refractory cases (0.6% HG)
↑↑Age.
High parity.
2nd trimester H.G (Emam et al. 2003).
Peptic ulcer.
Urticaria
Rosacea
ABOUBAKR ELNASHAR
DD of refractory HG
Gastrointestinal problems.
Thyroid problems and other metabolic disorders.
Liver problems.
Neurological disorders.
Molar pregnancy.
HELLP syndrome, in cases where the condition
appears later in the pregnancy.
HP???
ABOUBAKR ELNASHAR
Detection of HP Infection
Non invasive:
- Quantative Ig G (ELISA).
- Qualtative Ig G (Commercial kit).
- Urease test.
Invasive:
- Multiple biopsies (patchy)
Ig.G for HP
ABOUBAKR ELNASHAR
Value:
Allows economic screening for H.pylori infection.
Due to this noninvasive diagnostic method, it is
possible to detect H.pylori infection in pregnant
women and newborn (Blecker et al., 1994).
It samples the entire stomach whereas biopsy
only samples a small region (patchy).
Detected with a specific enzyme-linked immuno-
sorbent assay (ELISA) Kit.
Value higher than 40 Eu/ml positive.
Less than 30 negative.
30-40 equivocal (repeat within 2-4 W).
Eu/ml of Sample = (O.D ( Optical density) of
test sample / O.D of calibrator X Eu/ml of
calibrator) ABOUBAKR ELNASHAR
Conventional Regiemens to Treat H.G
Changes the diet:
- ↑PTN + CHO. - ↓Fat.
- Six small meals.
Drugs:
- Antihistamines. - Vit B6.
- Phenothiazines. - Metoclopramide.
- Antacids. - H2 receptor
antagonist.
ABOUBAKR ELNASHAR
Severe case: Hospitalization+ I.V. fluids……..
HP treatment (ttt)
(None pregnant)
One drug regimens.
Two drug regimens.
Three drug regimens.
Four drug regimens.
Combination.
(At least 10 – 14 Days)
ABOUBAKR ELNASHAR
Drugs in the Class Drug Class
Amoxicillin, Clarithromycin (Biaxin), Metronidazole,
Tetracycline, erthromythin
Antibiotics
Cimetidine (Tagamet), Famotidine (Pepcid),
Nizatidine (Axid), Ranitidine
H2-Blockers
Aciphex, Nexium, Prevacid, Prilosec, Protonix Proton Pump
Inhibitors (PPIs)
Bismuth subsalicylate, sucralfate Cytoprotective
Agents
Helidac, Prevpac, Helicocin Combination
Products
ABOUBAKR ELNASHAR
Treatment of HG associated with HP
Value:
Prevention of the prenatal transmission of
maternal infection with H.pylori to the
newborn.
Caustive not symptomatic ttt of HG.
HP ttt (Pregnant)
Risk / benefit ratio
Rationale of ttt HG associated with HP
Some reports have noted marked rapid
improvement of severe hyperemesis
gravidarum, on oral erythromycin and
amoxocillin therapy for other non related
conditions (El-Younis et al., 1998, Emam et al., 2002).
ABOUBAKR ELNASHAR
The centers for disease control and prevention are
recommending the use of metronidazole in all the
three trimesters of pregnancy when indicated (Frevel et al., 2000).
ABOUBAKR ELNASHAR
Suggestion of Drug Regimens for HP & HG (Emam et al 2002)
Three drug regiemens:
- Amoxicillin (B cateogry)
- Metronidazole (B cateogry)
- H2 receptors antognist
(10 – 14 days)
Starting IV infusion or rectal for 3 days then
oral
ABOUBAKR ELNASHAR
Conclusions
Chronic infection of HP is suggested to be one of
the important factors in the pathogenesis of HG,
even though it may not be the single cause of this
disorder. On ttt of HP, a specific and a causative treatment of HG, will be elicited and at the same time, the
perinatal transmission of this microorganism is
prevented.
ABOUBAKR ELNASHAR
Routine Helicobacter pylori IgG screening is not
practical in all cases of hyperemesis gravidarum but
is considered the culprit in:
- Refractory cases (0.6% HG)
- ↑↑Age. - High parity.
- 2nd trimester H.G. - Peptic ulcer.
- Urticaria. - Rosacea.
As the exact cause of HG is unknown & the risk
factors are very general → So prevention is difficult.
BUT
Eradication of HP before pregnancy could be
considered an important preventive measure.
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR