How to manage Irritable Bowel Syndrome (IBS) symptoms during early pregnancy?

Managing Irritable Bowel Syndrome (IBS) During Early Pregnancy

For pregnant women with IBS, first-line management should focus on lifestyle modifications and dietary changes, with careful consideration of medication safety profiles during pregnancy.

General Management Principles

• Pregnant women with IBS should be managed by a multidisciplinary team including a gastroenterologist and an obstetrician, preferably one affiliated with a high-risk obstetrics program 1
• Mental health screening should be performed with appropriate referral to support services, given the increased burden of mental health issues during pregnancy 2
• Careful review of travel and contact history should be taken, with appropriate testing for infectious causes in patients with worsening symptoms 3

First-Line Approaches

Dietary Modifications

• Regular exercise should be advised to all patients with IBS, as it helps manage symptoms 3
• First-line dietary advice should include:
  • Soluble fiber supplementation (such as ispaghula) starting at a low dose (3-4 g/day) and gradually increasing to avoid bloating 3
  • Avoiding insoluble fiber (e.g., wheat bran) as it may worsen symptoms 3

Symptom-Specific Management

• For IBS with diarrhea:

  • Loperamide may be used cautiously, but patients should be monitored for side effects such as abdominal pain, bloating, nausea, and constipation 3
  • Careful dose titration is recommended to minimize adverse effects 3

• For IBS with constipation:

  • Increased fluid intake and dietary modifications should be the first approach 1
  • Soluble fiber supplementation is particularly beneficial 3

• For abdominal pain:

  • Certain antispasmodics may be considered, though patients should be counseled about potential side effects such as dry mouth, visual disturbance, and dizziness 3

Second-Line Approaches

Low-FODMAP Diet

• A low-FODMAP diet may be considered as a second-line dietary therapy for global symptoms and abdominal pain in IBS 3
• Implementation should be supervised by a trained dietitian 3
• FODMAPs should be reintroduced according to tolerance after the elimination phase 3, 4

Medication Considerations

• Tricyclic antidepressants (TCAs) used as gut-brain neuromodulators may be considered for refractory symptoms 3
• If used, TCAs should be started at a low dose (e.g., 10 mg amitriptyline once daily) and titrated slowly 3
• Selective serotonin reuptake inhibitors (SSRIs) may be considered as an alternative to TCAs for global symptom management 3

Special Considerations During Pregnancy

• Pregnant women with severe dehydration should be hospitalized for intravenous fluid replacement and close monitoring 2
• Iron tablets should not be used in those with active disease as systemic inflammation inhibits absorption 3, 2
• Avoid gadolinium as part of MR imaging during pregnancy 3, 2
• Do not delay urgent surgery to manage complications solely due to pregnancy 3, 2

Monitoring and Follow-up

• Stool cultures should be obtained for enteroinvasive bacterial infections and Clostridioides difficile testing in pregnant women with worsening gastrointestinal symptoms 2
• Outpatients with active symptoms should receive VTE prophylaxis during the third trimester, unless contraindicated 3, 2
• The nutritional status of the mother and the fetus needs close monitoring throughout pregnancy 1

Common Pitfalls and Caveats

• Food elimination diets based on IgG antibodies are not recommended in patients with IBS 3
• Gluten-free diets are not routinely recommended for IBS management unless celiac disease is confirmed 3, 4
• Probiotics as a group may help with global symptoms and abdominal pain, but no specific species or strain can be recommended; a 12-week trial is reasonable 3
• Most IBS symptoms typically improve to pre-pregnancy state after delivery 1