How to manage heartburn and acidity during pregnancy?

Management of Heartburn and Acidity During Pregnancy

Diet and lifestyle modifications should be the first-line approach for managing heartburn and acidity during pregnancy, followed by a stepwise pharmacological approach starting with antacids if symptoms persist. 1

Understanding Heartburn in Pregnancy

Heartburn is extremely common during pregnancy, affecting 30-90% of pregnant women. It typically:

• Becomes more common in the latter part of pregnancy
• Is caused primarily by increased progesterone levels, which relax the lower esophageal sphincter
• Results from hormonal changes and delayed gastric emptying
• Usually resolves after delivery

Step-by-Step Management Approach

Step 1: Lifestyle and Dietary Modifications

• Dietary changes:

  • Reduce spicy, fatty, acidic, and fried foods
  • Eat small, frequent, bland meals
  • Consider BRAT diet (bananas, rice, applesauce, toast)
  • Choose high-protein, low-fat meals
  • Identify and avoid specific trigger foods 1

• Behavioral modifications:

  • Elevate the head of the bed for nighttime symptoms 1
  • Avoid lying down for 2-3 hours after meals
  • Avoid late meals
  • Weight loss if overweight or obese 1

Step 2: Non-Prescription Remedies

If lifestyle changes are insufficient:

• Ginger: 250 mg capsules 4 times daily 1
• Calcium-containing antacids as first-line medication therapy 2

Step 3: First-Line Medications

If symptoms persist despite the above measures:

• Vitamin B6 (pyridoxine): 10-25 mg every 8 hours 1
• Sucralfate: 1g three times daily 2, 3

Step 4: Second-Line Medications

For persistent symptoms:

• H2-receptor antagonists (H2RAs):
  • Famotidine: Inhibits gastric secretion with onset within 1 hour 4
  • Ranitidine: Provides symptomatic relief within 24 hours 5
  • Note: Ranitidine is generally preferred due to its documented safety profile in pregnancy 3

Step 5: Third-Line Medications

For intractable symptoms or complicated reflux disease:

• Proton pump inhibitors (PPIs):
  • Lansoprazole may be preferred due to better safety profile in pregnancy 3
  • PPIs are more effective than H2RAs for healing esophagitis and symptomatic relief 1, 6

Special Considerations

Severity Assessment

• Use the Motherisk Pregnancy-Unique Quantification of Emesis (PUQE) score to assess severity:
  • Mild: ≤6
  • Moderate: 7-12
  • Severe: ≥13 1

Warning Signs

• Weight loss >5% of pre-pregnancy weight
• Dehydration
• Electrolyte imbalances
• These may indicate progression to hyperemesis gravidarum, requiring more aggressive treatment 1

Medication Safety

• Most antacids are considered safe during pregnancy
• H2RAs (especially ranitidine) have established safety profiles
• PPIs should be reserved for severe cases unresponsive to other treatments
• Avoid metoclopramide as monotherapy for GERD 1

Pitfalls to Avoid

1. Delaying treatment: Early intervention may prevent progression to more severe symptoms or hyperemesis gravidarum 1

2. Overuse of medications: Follow the step-up approach rather than immediately starting with stronger medications 2

3. Ignoring nighttime symptoms: Elevating the head of the bed is particularly important for patients with nighttime heartburn 1

4. Assuming all symptoms will resolve immediately: While symptomatic relief may begin within 24 hours with medications like ranitidine, complete resolution may take longer 5

By following this stepwise approach, most pregnant women can achieve adequate relief of heartburn and acidity symptoms while minimizing risks to both mother and fetus.