How is gastroparesis managed in pregnancy?

Management of Gastroparesis in Pregnancy

Metoclopramide is the first-line pharmacological treatment for gastroparesis in pregnancy, administered at 10 mg orally three times daily before meals for symptom control. 1

Diagnosis and Assessment

• Gastroparesis is defined as delayed gastric emptying in the absence of mechanical obstruction
• More common in women of childbearing age 2
• Symptoms include:
  • Nausea and vomiting
  • Early satiety
  • Postprandial fullness
  • Bloating
  • Abdominal pain

Management Algorithm

First-Line Approaches: Dietary Modifications

1. Dietary modifications (should be tried first as they pose minimal risk in pregnancy):

   • Small, frequent meals (5-6 per day)
   • Low-fat, low-fiber diet
   • Small particle size foods
   • Increased liquid calories
   • Complex carbohydrates for sustained energy
   • Avoid carbonated beverages, alcohol, and smoking 1

2. Early dietitian involvement to prevent nutritional deficiencies and overly restrictive diets 1

   • Consider multivitamin supplementation (iron, folate, calcium, vitamins D, K, and B12)

Pharmacological Management

1. First-line medication: Metoclopramide

   • Dosing: 10 mg orally, 30 minutes before meals (three times daily) 3, 1
   • Only FDA-approved medication for gastroparesis 3
   • Risk of tardive dyskinesia is lower than previously estimated (approximately 0.1% per 1000 patient-years) 1
   • For severe symptoms, may initiate with IV/IM administration before transitioning to oral 4

2. Antiemetics for symptom control

   • Ondansetron (4-8 mg 2-3 times daily)
   • Prochlorperazine (5-10 mg four times daily)
   • Trimethobenzamide (300 mg three times daily) 1

3. Alternative prokinetic: Erythromycin

   • Dosing: 40-250 mg orally three times daily 1
   • Consider for patients who don't respond to or cannot tolerate metoclopramide

Management of Refractory Cases

For patients with inadequate response to first-line therapies:

1. Stepwise nutritional approach:

   • Transition from solid food with modifications to blended/pureed foods
   • Liquid diet with oral nutritional supplements
   • Consider enteral nutrition via jejunostomy tube for severe cases with inadequate oral intake 1

2. Avoid medications that can worsen gastroparesis:

   • Opioids
   • Anticholinergics
   • Tricyclic antidepressants (when used for pain)
   • GLP-1 receptor agonists 1

Special Considerations in Pregnancy

• Pregnant women are typically excluded from clinical trials evaluating pharmacologic agents for gastroparesis, creating challenges in management 2
• Pregnancy itself can be associated with gastrointestinal neuromuscular dysfunction 5
• For diabetic gastroparesis in pregnancy, strict glycemic control is essential 1
• DPP-4 inhibitors can be considered for glucose-lowering therapy as they have a neutral effect on gastric emptying 1

Monitoring

• Regular assessment of nutritional status
• Monitor for medication side effects, particularly with metoclopramide
• Electrolyte monitoring, especially with persistent vomiting
• For diabetic patients, close monitoring of blood glucose levels 1

Clinical Pitfalls and Caveats

1. Metoclopramide should be used at the lowest effective dose in pregnancy due to potential risks
2. Dosage adjustment is necessary for patients with renal impairment (creatinine clearance below 40 mL/min) - start with half the recommended dose (5 mg three times daily) 1, 4
3. The diagnosis of gastroparesis must be confirmed with appropriate testing (gastric emptying scintigraphy) and not based solely on symptoms, which can overlap with other conditions like functional dyspepsia 3, 1
4. Patients with gastroparesis in pregnancy require a multidisciplinary approach involving gastroenterology, obstetrics, and nutrition specialists 2

By following this structured approach to managing gastroparesis in pregnancy, clinicians can help control symptoms, maintain adequate nutrition, and minimize risks to both mother and fetus.