Management of GERD During Pregnancy
For pregnant women with GERD, the recommended first-line approach is lifestyle and dietary modifications, followed by a step-up medication approach starting with antacids (preferably calcium-containing), then sucralfate, H2-receptor antagonists, and finally proton pump inhibitors for refractory cases. 1, 2, 3
First-Line: Lifestyle and Dietary Modifications
- Elevate head of bed on 6-8 inch blocks 2
- Avoid recumbency for 2-3 hours after meals 2
- Sleep in left lateral decubitus position 2
- Avoid trigger foods: coffee, tea, chocolate, citrus, mints, fatty foods 2
- Limit fat intake to no more than 45g in 24 hours 2
- Avoid late evening meals (at least 2-3 hours before bedtime) 2
- Small, frequent meals rather than large meals 3
- Weight management (if appropriate) 2
Medication Therapy: Step-Up Approach
Step 1: Antacids
- Calcium-containing antacids are the preferred first-line medication 3
- Provide rapid but short-term symptom relief 2
- Can be used as needed for breakthrough symptoms
Step 2: Sucralfate
- If symptoms persist despite antacids, add sucralfate 1g three times daily 3
- Minimal systemic absorption, making it safe during pregnancy 4
Step 3: H2-Receptor Antagonists
- Add if symptoms persist despite antacids and sucralfate 3
- Ranitidine is preferred due to documented safety profile in pregnancy, even in first trimester 4
- Effective but less potent than PPIs 2
Step 4: Proton Pump Inhibitors (PPIs)
- Reserved for women with intractable symptoms or complicated reflux disease 3, 4, 5
- Lansoprazole may be preferred due to better safety profile in pregnancy 4
- Most PPIs (except omeprazole) are FDA category B drugs during pregnancy 6
Special Considerations
- GERD symptoms typically present in the first trimester and progress throughout pregnancy 3
- Approximately two-thirds of pregnant women develop heartburn, with 25% experiencing it daily 3
- The primary cause is decreased lower esophageal sphincter pressure due to progesterone 4, 5
- Serious reflux complications during pregnancy are rare 4
- Diagnostic testing (endoscopy, pH monitoring) is rarely needed during pregnancy unless complications are suspected 4
Breastfeeding Considerations
- Most H2-receptor antagonists (except nizatidine) are safe during lactation 6
- Consider the excretion of medications in breast milk when selecting therapy for postpartum women 6, 7
Common Pitfalls to Avoid
- Skipping lifestyle modifications: Many patients can achieve symptom control with lifestyle changes alone before resorting to medications 2
- Inadequate duration of therapy: Some patients may need continued treatment throughout pregnancy 3
- Overuse of PPIs: Reserve these for refractory cases after failing other therapies 2, 4
- Failing to reassure patients: Most GERD symptoms resolve soon after delivery 5
By following this step-up approach, most pregnant women with GERD can achieve adequate symptom control while minimizing potential risks to the pregnancy.