What is the recommended treatment for gastroesophageal reflux disease (GERD) in pregnant women?

Treatment of Gastroesophageal Reflux Disease (GERD) in Pregnancy

The recommended treatment for GERD in pregnancy follows a step-up approach, starting with lifestyle modifications, followed by antacids, then sucralfate, H2-receptor antagonists, and finally proton pump inhibitors for refractory cases. 1

First-Line Approach: Lifestyle and Dietary Modifications

• Elevate the head of bed 6-8 inches
• Avoid eating 2-3 hours before lying down
• Consume smaller, more frequent meals
• Avoid trigger foods (spicy, acidic, fatty foods, chocolate, caffeine)
• Maintain adequate hydration
• Weight management (if applicable)
• Smoking cessation (if applicable)

These modifications are often sufficient for mild cases and pose no risk to the mother or fetus 1, 2.

Medication Step-Up Algorithm

Step 1: Antacids

• Calcium-containing antacids are the preferred choice 2
• Safe for use in pregnancy, including first trimester
• Can be used as needed for symptom relief
• Particularly appropriate for patients with preeclampsia 3

Step 2: Sucralfate

• Recommended dosage: 1g oral tablet, 3 times daily 2
• Minimal systemic absorption, making it safe during pregnancy
• Forms a protective barrier over inflamed esophageal tissue
• Can be used if symptoms persist despite antacids 1, 3

Step 3: H2-Receptor Antagonists

• Ranitidine is preferred due to its documented safety profile 4
• Safe even in first trimester based on available evidence
• Use when symptoms are not controlled with antacids and sucralfate
• Other H2-blockers may be used, but avoid nizatidine 5

Step 4: Proton Pump Inhibitors (PPIs)

• Reserved for severe, intractable cases unresponsive to other therapies 1
• Lansoprazole may be the preferred PPI due to better safety profile in animal studies and case reports 4
• Should be used at the lowest effective dose and only after the first trimester when possible 3
• Benefit-harm ratio must be carefully considered 5

Special Considerations

• Endoscopy can be safely performed during pregnancy with conscious sedation and careful monitoring if symptoms are intractable or atypical 5
• Reflux symptoms typically worsen as pregnancy progresses due to hormonal effects and increasing mechanical pressure 6
• Symptoms usually resolve after delivery in patients without a prior history of reflux 6
• Prokinetic agents (metoclopramide, cisapride) should be reserved for patients with more severe symptoms when other therapies fail 5

Monitoring and Follow-up

• Reassess symptoms regularly throughout pregnancy
• Adjust therapy to the lowest effective level that provides symptom relief
• If symptoms worsen significantly or alarm features develop (dysphagia, weight loss, anemia), further evaluation may be warranted

During Lactation

• Medications with minimal systemic absorption (sucralfate and alginic acid) are preferable during breastfeeding 3
• Most antacids, H2-blockers, and PPIs are considered compatible with breastfeeding, but use the lowest effective dose

The treatment approach should always use the least possible amount of systemic medication needed to control symptoms, prioritizing the safety of both mother and fetus while providing effective symptom relief.