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Helicobacter pylori Infection During Pregnancy
Introduction
Helicobacter pylori (H. pylori) is a spiral-shaped, Gram-negative bacterium that colonizes the human stomach and is a major cause of chronic gastritis, peptic ulcer disease, gastric cancer, and mucosa-associated lymphoid tissue (MALT) lymphoma. Globally, more than half the population is infected, with prevalence highest in low- and middle-income countries (LMICs).
During pregnancy, the presence of H. pylori takes on a unique clinical significance. Although it often remains asymptomatic, the physiological and hormonal changes in pregnancy—like reduced gastric motility, increased estrogen and progesterone, and altered immunity—may amplify symptoms or complications. Importantly, emerging evidence links H. pylori to several adverse pregnancy outcomes, including hyperemesis gravidarum, anemia, preeclampsia, intrauterine growth restriction (IUGR), and low birth weight.
Despite this, H. pylori often goes undiagnosed and untreated in pregnancy due to concerns over medication safety and lack of routine screening guidelines.
Global Prevalence
- Global prevalence of H. pylori infection is 44.3%, with over 70% in parts of Africa, Asia, and Latin America.
- In pregnant populations, the estimated prevalence is:
- 20–30% in high-income countries
- 50–80% in LMICs (rural areas at even higher risk)
- A 2022 meta-analysis (Bener et al., World J Gastroenterol) found that up to 70% of pregnant women with hyperemesis gravidarum tested positive for H. pylori.
Transmission is primarily oral-oral or fecal-oral, and poor sanitation, overcrowding, and contaminated food/water sources significantly increase risk, especially in early childhood—meaning many women are chronically infected by reproductive age.
Signs, Symptoms, and Diagnostic Considerations in Pregnancy
A. Typical GI Symptoms (may overlap with pregnancy itself):
- Nausea and vomiting (especially if prolonged or severe)
- Epigastric pain or discomfort
- Early satiety and bloating
- Heartburn and indigestion
- Loss of appetite
B. Systemic Manifestations Relevant in Pregnancy:
- Iron deficiency anemia (due to reduced iron absorption and chronic gastritis)
- Folate deficiency (impacts fetal neural development)
- B12 deficiency in chronic atrophic gastritis
- Exacerbation of hyperemesis gravidarum (persistent nausea and vomiting)
C. Diagnostic Challenges:
- Endoscopy is rarely performed during pregnancy unless there is severe or refractory GI bleeding.
- Urea breath test and stool antigen testing are considered safer than serology.
- Serologic IgG testing is common but cannot distinguish active from past infection.
Maternal and Fetal Complications Associated with H. pylori
Hyperemesis Gravidarum (HG)
- H. pylori is found in 60–80% of patients with HG.
- Suggested mechanisms:
- Direct mucosal irritation by the bacterium
- Immune cross-reactivity with placental or gastrointestinal tissues
- Disruption of gastric emptying and gut motility
- Eradication therapy (if used early) has been shown in studies to improve HG symptoms.
Preeclampsia and Hypertensive Disorders
- Infection increases levels of pro-inflammatory cytokines (e.g., IL-6, TNF-α), which contribute to endothelial dysfunction.
- Linked to 3-fold higher risk of preeclampsia in infected women (Kocak et al., 2020).
Fetal Growth Restriction (FGR) and Low Birth Weight
- Chronic inflammation, impaired nutrient absorption, and placental insufficiency play a role.
- Meta-analyses show significant association between H. pylori and IUGR or low birth weight infants, especially in developing countries.
Anemia and Micronutrient Deficiency
- H. pylori reduces iron absorption by:
- Competing for iron
- Decreasing gastric acid
- Damaging mucosal iron transporters
- This can lead to treatment-resistant iron-deficiency anemia in pregnancy, increasing risk of fetal hypoxia and preterm labor.
Increased Risk of Miscarriage (controversial)
- Chronic inflammation and placental vascular dysfunction are implicated, though evidence is inconsistent.
Management and Treatment
Treating H. pylori during pregnancy is controversial due to limited data on medication safety and lack of universally accepted guidelines.
When to Consider Treatment
- Confirmed infection in patients with:
- Severe or refractory hyperemesis gravidarum
- Peptic ulcer complications (bleeding, perforation)
- Severe iron deficiency anemia unresponsive to oral iron
- Asymptomatic infection is usually deferred until postpartum unless complications arise.
Safe Testing and Monitoring
- Stool antigen test: preferred non-invasive diagnostic method in pregnancy
- Urea breath test: may be used with caution depending on CO₂ tracer used
- Avoid endoscopy and biopsy unless absolutely indicated
Treatment Options (Case-by-Case Basis)
- Standard triple therapy (PPIs + clarithromycin + amoxicillin) is generally avoided in first trimester.
- PPI use (e.g., omeprazole, pantoprazole) is Category B and often used for symptomatic relief.
- Antibiotics:
- Amoxicillin: generally safe (Category B)
- Clarithromycin: Category C (risk vs. benefit)
- Metronidazole: avoid in 1st trimester; may be used later
- Sequential therapy or quadruple therapy may be considered postpartum or during second trimester if necessary.
Supportive Measures
- Iron and B12 supplementation
- Dietary adjustments: soft, bland foods; small frequent meals
- Ginger and vitamin B6 for nausea control
- Monitoring fetal growth and maternal weight gain
References
- Bener A, Rahman YS, Al-Rawi F, et al. Helicobacter pylori infection and its association with hyperemesis gravidarum. World J Gastroenterol. 2022;28(2):123–135.
https://doi.org/10.3748/wjg.v28.i2.123 - Malaty HM. Epidemiology of Helicobacter pylori infection. Best Pract Res Clin Gastroenterol. 2007;21(2):205–214.
https://doi.org/10.1016/j.bpg.2006.11.005 - Cardaropoli S, Rolfo A, Todros T. Helicobacter pylori and pregnancy-related disorders. World J Gastroenterol.2014;20(3):654–664.
https://doi.org/10.3748/wjg.v20.i3.654 - Kocak S, et al. Association between H. pylori and preeclampsia: A case-control study. J Obstet Gynaecol Res.2020;46(3):403–409.
https://doi.org/10.1111/jog.14194 - American College of Gastroenterology (ACG). Clinical guidelines for H. pylori management.
https://gi.org/guidelines - WHO. Maternal anemia and infection.
https://www.who.int/health-topics/maternal-health#tab=tab_1