Management of GERD in Pregnancy
The management of GERD during pregnancy should follow a step-up approach, starting with lifestyle modifications and dietary changes, followed by antacids, sucralfate, H2-receptor antagonists, and proton pump inhibitors only for intractable symptoms. 1, 2
Prevalence and Pathophysiology
GERD is extremely common during pregnancy, affecting approximately two-thirds of pregnant women, with about 25% experiencing daily heartburn 2. Symptoms typically begin in the first trimester and progressively worsen throughout pregnancy due to:
- Decreased lower esophageal sphincter pressure caused by female sex hormones, especially progesterone
- Mechanical pressure from the enlarging uterus
- Delayed gastric emptying
Step-Up Management Algorithm
Step 1: Lifestyle and Dietary Modifications
- Weight management: For overweight or obese patients 1
- Elevation of the head of the bed (6-8 inches) for nighttime symptoms 1
- Avoid lying down for 2-3 hours after meals 1
- Avoid trigger foods that may precipitate reflux:
- Coffee, chocolate, fatty foods, spicy foods
- Citrus, carbonated drinks
- Smaller, more frequent meals rather than large meals 1
- Avoid late evening meals 1
Step 2: Antacids (First-Line Medication)
- Calcium-containing antacids are the preferred first-line pharmacological therapy 2
- Can be used on-demand for symptom relief
- Generally considered safe during all trimesters of pregnancy
Step 3: Sucralfate
- If symptoms persist despite antacids, add sucralfate 1g orally three times daily 2, 3
- Minimal systemic absorption, making it a safe option during pregnancy
- Acts locally by forming a protective barrier on the esophageal mucosa
Step 4: H2-Receptor Antagonists (H2RAs)
- Consider when symptoms are not controlled with antacids and sucralfate 2, 4
- Ranitidine is preferred due to its documented safety profile in pregnancy, even in the first trimester 4
- Can be used in combination with antacids for breakthrough symptoms
Step 5: Proton Pump Inhibitors (PPIs)
- Reserved for women with intractable symptoms or complicated reflux disease 1, 2
- Should only be used after failure of H2RAs and when benefits outweigh potential risks
- All PPIs except omeprazole are FDA category B drugs during pregnancy 5
- Lansoprazole may be preferred due to its safety profile in animal studies and case reports in human pregnancies 4
Special Considerations
Medication Safety in Pregnancy
- Antacids: Generally considered safe, calcium-containing preferred
- Sucralfate: Minimal systemic absorption, considered safe
- H2RAs: Ranitidine has the most data supporting safety
- PPIs: Use only when necessary; lansoprazole may be preferred
Warning Signs Requiring Further Evaluation
- Dysphagia (difficulty swallowing)
- Odynophagia (painful swallowing)
- Weight loss
- Gastrointestinal bleeding
- Persistent vomiting
Postpartum Considerations
- GERD symptoms typically resolve soon after delivery 3
- Most medications are excreted in breast milk
- H2RAs (except nizatidine) are generally safe during lactation 5
Common Pitfalls to Avoid
- Skipping steps in the algorithm: Always start with lifestyle modifications before advancing to medications
- Using PPIs as first-line therapy: Reserve for intractable symptoms only
- Failing to reassure patients: Most cases are self-limiting and resolve after delivery
- Overlooking non-GERD causes: Symptoms like nausea and vomiting in pregnancy could be due to hyperemesis gravidarum rather than GERD 1
- Performing unnecessary diagnostic tests: Serious reflux complications during pregnancy are rare, making endoscopy and other diagnostic tests infrequently needed 4
By following this step-up approach, most pregnant women with GERD can achieve symptom control while minimizing potential risks to the mother and fetus.