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