What is the recommended treatment for dyspepsia in pregnancy?

Treatment of Dyspepsia in Pregnancy

First-line therapy for dyspepsia in pregnancy should include lifestyle modifications, dietary changes, and antacids, followed by vitamin B6 (pyridoxine) alone or in combination with doxylamine if symptoms persist. 1

Initial Management

Lifestyle and Dietary Modifications

• Small, frequent, bland meals
• High-protein, low-fat foods
• Avoid spicy, fatty, acidic, and fried foods
• Stay hydrated with small, frequent sips of fluid
• Avoid lying down immediately after meals
• Elevate head of bed

First-Line Pharmacological Therapy

1. Antacids or sucralfate

   • Preferred first-line medications due to minimal systemic absorption
   • Safe in pregnancy with no increased risk of congenital anomalies

2. Vitamin B6 (pyridoxine)

   • Dosage: 10-25 mg every 8 hours
   • Can be used alone or combined with doxylamine

Second-Line Therapy for Persistent Symptoms

For Ulcer-Like/Epigastric Pain Predominant Dyspepsia

• H2-receptor antagonists (except nizatidine)
  • Ranitidine or cimetidine preferred during pregnancy
  • FDA category B drugs (except nizatidine)

For Dysmotility-Like Symptoms (Fullness, Bloating, Early Satiety)

• Metoclopramide (10 mg every 6 hours)
  • Monitor for extrapyramidal side effects
  • Similar efficacy to promethazine but with fewer side effects 2

Third-Line Therapy for Refractory Symptoms

For Severe Acid-Related Symptoms

• Proton pump inhibitors (PPIs)
  • Reserved for intractable symptoms or complicated reflux disease
  • All except omeprazole are FDA category B drugs
  • Use with caution as human experience is limited
  • Should be used at the lowest effective dose for the shortest duration

For Severe Nausea/Vomiting with Dyspepsia

• Ondansetron (4-8 mg every 8 hours)
  • For moderate to severe cases
  • Should be used with caution before 10 weeks of pregnancy
  • Monitor ECG for QT prolongation
  • Use only as second-line therapy after failure of first-line options 2

Evaluation for Persistent Symptoms

If symptoms persist despite optimal therapy, consider:

1. H. pylori testing

   • Use non-invasive methods (fecal antigen or carbon-urea breath testing)
   • Eradication therapy if positive

2. Endoscopy

   • Consider flexible sigmoidoscopy or colonoscopy if results will affect management
   • Best performed in second trimester
   • Contraindicated in cases of placental abruption, imminent birth, ruptured membranes, or hypertensive disease of pregnancy 2

Special Considerations

For Hyperemesis Gravidarum

• Hospitalization may be necessary for:
  • Dehydration
  • Weight loss >5% of pre-pregnancy weight
  • Electrolyte imbalances
• Treatment includes:
  • IV fluid and electrolyte replacement
  • IV thiamine supplementation (100 mg daily for minimum 7 days)
  • IV ondansetron or metoclopramide 2, 1

Constipation with Dyspepsia

• Increase dietary fiber (aim for 30 g/day)
• Adequate fluid intake
• Safe options include:
  • Bulk-forming agents (psyllium husk, methylcellulose)
  • Osmotic laxatives (polyethylene glycol, lactulose)
  • Avoid stimulant laxatives 2, 3

Monitoring and Follow-up

• Assess response to therapy after 2-4 weeks
• If symptoms are controlled, consider trial of withdrawal
• For recurrent symptoms, resume the successful agent
• Consider "on-demand" therapy for intermittent symptoms

Common Pitfalls to Avoid

1. Delaying treatment due to unfounded concerns about medication safety
2. Using nizatidine (H2-blocker to avoid during pregnancy)
3. Starting with PPIs as first-line therapy
4. Using ondansetron in early first trimester (before 10 weeks) due to potential risk of cleft palate
5. Failing to recognize hyperemesis gravidarum requiring hospitalization
6. Overuse of stimulant laxatives which can cause dehydration or electrolyte imbalances

By following this stepwise approach, most pregnant women with dyspepsia can achieve symptom relief while minimizing risks to both mother and fetus.