What is the management of Gastroesophageal Reflux Disease (GERD) in pregnant women?

Management of GERD in Pregnancy

The management of GERD during pregnancy should follow a step-up approach, starting with lifestyle modifications and dietary changes, followed by antacids or sucralfate as first-line medication therapy, then H2-receptor antagonists, and finally proton pump inhibitors for intractable symptoms. 1

Pathophysiology and Prevalence

• GERD occurs in approximately two-thirds of all pregnancies, with around 25% of pregnant women experiencing heartburn daily 1
• The predominant factor causing GERD in pregnancy is decreased lower esophageal sphincter pressure due to female sex hormones, especially progesterone 2
• Symptoms typically present in the first trimester and progress throughout pregnancy 1

Step-Up Treatment Algorithm

First Line: Lifestyle and Dietary Modifications

• Implement small, frequent meals and avoid trigger foods 3
• Elevate the head of the bed for patients troubled with heartburn or regurgitation when recumbent 4
• Avoid late meals and recumbency for 2-3 hours after meals 4
• Weight management should be advised for overweight or obese patients 4
• Increase dietary fiber intake to approximately 30g/day through fruits, vegetables, whole grains, and legumes to help with associated constipation 3

Second Line: Antacids and Mucosal Protectants

• Antacids containing aluminum/magnesium hydroxide are safe as first-line medication 1
• Calcium-containing antacids are the preferred choice (Recommendation Grade A) 1
• If symptoms persist with antacids, sucralfate can be introduced at 1g orally three times daily 1

Third Line: H2-Receptor Antagonists

• If symptoms persist despite antacids and sucralfate, H2-receptor antagonists should be used 2
• Ranitidine is preferred due to its documented efficacy and safety profile in pregnancy, even in the first trimester 2
• All H2-receptor antagonists except nizatidine are safe to use during lactation 5

Fourth Line: Proton Pump Inhibitors

• PPIs are reserved for women with intractable symptoms or complicated reflux disease 2, 6
• Lansoprazole may be the preferred PPI because of its safety profile in animals and case reports of safety in human pregnancies 2
• All PPIs except omeprazole are FDA category B drugs during pregnancy 5

Special Considerations

Diagnostic Testing

• Serious reflux complications during pregnancy are rare; therefore, EGD and other diagnostic tests are infrequently needed 2
• If endoscopy is necessary, it should ideally be performed in the second trimester 4

Medication Safety

• The treatment goal is to alleviate heartburn and regurgitation without jeopardizing the pregnancy or its outcome 1
• Metoclopramide is not recommended as monotherapy or adjunctive therapy for GERD in pregnancy 4
• Avoid medications contraindicated in pregnancy and consider trimester-specific risks 3

Postpartum Management

• Most drugs used for GERD are excreted in breast milk 5
• Heartburn during pregnancy typically resolves soon after delivery, but some women may continue to experience GERD symptoms 7

Common Pitfalls to Avoid

• Delaying treatment of severe symptoms can lead to dehydration, malnutrition, and adverse pregnancy outcomes 3
• Failing to recognize when symptoms might indicate a more serious underlying condition requiring urgent intervention 3
• Using iron tablets in those with active inflammatory bowel disease as systemic inflammation inhibits absorption 4

By following this step-up approach and considering the safety profiles of medications during pregnancy, most pregnant women with GERD can achieve symptom relief without adverse effects on the pregnancy.