What is the recommended management for a 30-week pregnant patient with severe gastroesophageal reflux disease (GERD) and migraines?

Management of Severe Indigestion and Migraine in a 30-Week Pregnant Patient

An obstetrician should promptly call back a pregnant patient at 30 weeks with severe indigestion and migraine, as these symptoms require timely evaluation and management to prevent potential complications affecting maternal and fetal health. 1

Assessment and Initial Management of Severe Indigestion (GERD)

First-line Approaches:

• Implement dietary and lifestyle modifications including small frequent meals, avoiding trigger foods, and elevating the head of bed 1
• Increase dietary fiber intake to approximately 30g/day through fruits, vegetables, whole grains, and legumes to help with associated constipation 1
• Ensure adequate fluid intake, particularly water, to soften stools and ease bowel movements 1

Pharmacological Management:

• Antacids containing aluminum/magnesium hydroxide can be safely used as first-line medication 2
• If symptoms persist, omeprazole 20mg once daily can be administered for up to 4-8 weeks for symptomatic GERD 3
• Bulk-forming agents such as psyllium husk or methylcellulose are safe during pregnancy due to lack of systemic absorption 1
• Osmotic laxatives like polyethylene glycol or lactulose can be safely administered if constipation is contributing to discomfort 1

Cautions:

• Avoid stimulant laxatives as safety data during pregnancy are conflicting 1
• Be aware that excessive fiber and osmotic laxatives like lactulose may cause maternal bloating 1
• GI cocktails containing viscous lidocaine and anticholinergics should be used with caution, particularly after the first trimester 2

Management of Severe Migraine

Non-pharmacological Approaches:

• Prioritize non-drug therapies including relaxation techniques, adequate sleep, massage, ice packs, and biofeedback 4, 5
• Identify and avoid potential migraine triggers 6

Pharmacological Management:

• Acetaminophen (paracetamol) 1000mg is the first-choice medication for acute migraine attacks during pregnancy 5, 7
• If acetaminophen is insufficient, consider:
  • Metoclopramide for nausea, which is acceptable during the second and third trimesters 5
  • In severe cases that don't respond to acetaminophen, sumatriptan may be considered for sporadic use 7

Cautions:

• Avoid ergot alkaloids (including dihydroergotamine and ergotamine tartrate) as they are contraindicated during pregnancy 5, 6
• NSAIDs should be avoided in the third trimester due to associated risks 5, 7
• Prophylactic treatment is rarely indicated but if necessary, beta-blockers like propranolol or metoprolol can be considered 5, 8

Multidisciplinary Approach

• For patients with severe symptoms, involve a multidisciplinary team including obstetricians, gastroenterologists, and neurologists 1
• All pregnant patients with IBD or other complex conditions should be assessed at least once in a consultant-led obstetric clinic 1
• Mental health screening should be performed with onward referral to appropriate services as needed, given the increased burden of mental health issues in people with gastrointestinal disorders 1

Follow-up Recommendations

• Schedule close follow-up to monitor symptom improvement and medication efficacy 1
• If symptoms worsen or don't improve with initial management, consider hospitalization for IV hydration and replacement of electrolytes 1
• For persistent severe symptoms, endoscopy may be considered in the second trimester with appropriate precautions 1

Key Pitfalls to Avoid

• Delaying treatment of severe symptoms, which could lead to dehydration, malnutrition, and adverse pregnancy outcomes 1
• Using medications contraindicated in pregnancy or without considering the trimester-specific risks 2, 5
• Failing to recognize when symptoms might indicate a more serious underlying condition requiring urgent intervention 1