What are the best management options for heartburn in pregnancy?

From the Guidelines

Management of heartburn during pregnancy should begin with lifestyle modifications, including eating smaller, more frequent meals, avoiding trigger foods, and elevating the head of the bed, before considering medications, as recommended by the American College of Obstetricians and Gynecologists (ACOG) 1. The goal of these modifications is to reduce symptoms of heartburn, which is common in the latter part of pregnancy, affecting 30%–90% of pregnant women, and is attributed to increased levels of progesterone causing relaxation of the lower esophageal sphincter 1. Key lifestyle modifications include:

• Eating smaller, more frequent meals to reduce pressure on the stomach
• Avoiding lying down for 2-3 hours after eating
• Elevating the head of the bed by 6-8 inches to prevent stomach acid from flowing back up into the esophagus
• Avoiding trigger foods like spicy, fatty, or acidic items, caffeine, and chocolate When medications are needed, antacids containing calcium carbonate (Tums) or aluminum hydroxide (Maalox) are first-line options and can be taken as needed, however, the most recent evidence does not specifically address the use of these medications for heartburn in pregnancy 1. It's essential to note that while the provided evidence focuses on nausea and vomiting of pregnancy, the principles of lifestyle modification and stepwise treatment can be applied to managing heartburn during pregnancy, with the aim of improving maternal comfort and nutrition, potentially benefiting both mother and baby 1.

From the FDA Drug Label

In 2 multicenter, double-blind, placebo-controlled, 6-week trials performed in the United States and Europe, ranitidine 150 mg twice daily was more effective than placebo for the relief of heartburn and other symptoms associated with GERD. The US trial indicated that ranitidine 150 mg twice daily significantly reduced the frequency of heartburn attacks and severity of heartburn pain within 1 to 2 weeks after starting therapy. In 2 additional US multicenter, double-blind, placebo-controlled, 2-week trials, ranitidine 150 mg twice daily was shown to provide relief of heartburn pain within 24 hours of initiating therapy and a reduction in the frequency of severity of heartburn

The best management options for heartburn in pregnancy are not explicitly stated in the provided drug labels. However, ranitidine may be considered for the relief of heartburn symptoms associated with GERD. The recommended dosage is 150 mg twice daily. It is essential to note that these trials were not specifically conducted in pregnant women, and the safety and efficacy of ranitidine in this population are not directly addressed in the provided labels 2.

From the Research

Management Options for Heartburn in Pregnancy

The management of heartburn in pregnancy involves a step-up approach, starting with lifestyle modifications and dietary changes.

• Lifestyle modifications include avoiding trigger foods, eating smaller meals, and avoiding lying down after eating 3, 4.
• Dietary changes include avoiding citrus fruits, tomatoes, and spicy foods 3, 4.

Medical Therapy

If lifestyle modifications and dietary changes are not effective, medical therapy may be necessary.

• The first-line medical therapy is antacids or sucralfate 3, 5, 4.
• If symptoms persist, histamine-2 receptor antagonists (H2RAs) may be used 3, 5, 4.
• Proton pump inhibitors (PPIs) are reserved for women with intractable symptoms or complicated reflux disease 3, 5, 4.
• Lansoprazole may be the preferred PPI due to its safety profile in animals and case reports of safety in human pregnancies 5, 4.

Safety and Effectiveness of Interventions

The safety and effectiveness of interventions to relieve heartburn in pregnancy have not been established 6.

• A Cochrane review found that there was little information to draw conclusions on the overall effectiveness of interventions to relieve heartburn in pregnancy 6.
• However, a review of recent evidence on the management of heartburn in pregnant and breastfeeding women found that lifestyle modifications, dietary modifications, and pharmaceutical drugs can be effective in reducing GERD symptoms 7.

Treatment Algorithm

A recommended treatment algorithm for pregnant and breastfeeding women has been developed 7.

• The algorithm involves a step-up approach, starting with lifestyle modifications and dietary changes, and progressing to medical therapy if necessary.
• The choice of medical therapy depends on the severity of symptoms and the suitability of each treatment for use during pregnancy and lactation.