What are the guidelines for H. pylori (Helicobacter pylori) testing and treatment in pregnant women?

H. pylori Testing and Treatment in Pregnant Women

H. pylori testing should be deferred until after pregnancy unless there are compelling clinical indications such as active peptic ulcer disease, as there are no specific guidelines for routine H. pylori testing during pregnancy.

Diagnostic Approach for H. pylori in Pregnancy

Non-invasive Testing Options

• Serology (ELISA) is the preferred testing method during pregnancy if testing is necessary 1
  • Serology is not affected by recent use of antibiotics or PPIs 2
  • Only validated IgG serology tests with >90% accuracy should be used 2

Tests to Avoid During Pregnancy

• Urea Breath Test (UBT) - requires ingestion of labeled urea
• Stool Antigen Test (SAT) - acceptable but less convenient
• Endoscopic-based tests - should be avoided unless absolutely necessary 2

When to Test During Pregnancy

Testing for H. pylori during pregnancy should be limited to specific clinical scenarios:

1. Active peptic ulcer disease with complications
2. Severe refractory symptoms not responding to standard treatment
3. Unexplained iron deficiency anemia not responding to iron supplementation 2

Imaging Considerations

If imaging is needed during pregnancy:

• Ultrasound is the safest imaging technique 2
• MRI without gadolinium is acceptable if ultrasound is insufficient 2
• Endoscopy should only be performed when there is a strong indication and clear clinical benefit 2

Treatment Approach

First Trimester

• Defer treatment until after pregnancy whenever possible 2

Second and Third Trimester (if treatment is essential)

• Triple therapy with amoxicillin, clarithromycin, and PPI is generally considered safest if treatment cannot be deferred 2
• Standard dosing:
  • PPI standard dose twice daily
  • Amoxicillin 1000 mg twice daily
  • Clarithromycin 500 mg twice daily 2

Post-Delivery

• Confirm eradication at least 4 weeks after completion of therapy using UBT or SAT 2, 1
• Not serology as antibodies remain elevated for months after eradication 2

Special Considerations

Iron Deficiency Anemia

• If H. pylori is identified in a pregnant woman with iron deficiency anemia:
  • Treat with iron supplementation during pregnancy
  • Consider H. pylori eradication post-partum 2
  • In patients with recurrent iron deficiency anemia and normal endoscopy, H. pylori should be eradicated if present 2

Medication Safety

• Metronidazole should be avoided in the first trimester 2
• Tetracycline and quinolones are contraindicated throughout pregnancy 2

Clinical Pitfalls to Avoid

1. Unnecessary testing during pregnancy when results won't change management
2. Failing to stop PPIs before testing (if using non-serological tests)
3. Using serology to confirm eradication (remains positive for months after successful treatment)
4. Overlooking iron deficiency which may be exacerbated by H. pylori infection

The management of H. pylori during pregnancy requires careful consideration of risks and benefits. When possible, deferring testing and treatment until after delivery is the safest approach unless there are compelling clinical indications that require immediate intervention.