What are the latest guidelines for managing diarrhea in pregnancy?

Management of Diarrhea in Pregnancy

The cornerstone of managing diarrhea in pregnancy is oral rehydration therapy with reduced osmolarity ORS as first-line treatment, while avoiding antimotility agents and using antimicrobials only for specific bacterial infections like Salmonella. 1, 2

Immediate Assessment and Hydration Strategy

The primary focus should be on assessing hydration status and preventing maternal-fetal complications from dehydration:

Mild to Moderate Dehydration

• Administer reduced osmolarity oral rehydration solution (ORS) as first-line therapy until clinical dehydration is corrected 3, 1
• Continue ORS to replace ongoing stool losses until diarrhea resolves 3, 1
• If oral intake is not tolerated, consider nasogastric administration of ORS 3, 1

Severe Dehydration

• Hospitalize immediately for intravenous fluid replacement with isotonic fluids (lactated Ringer's or normal saline) 2, 1
• Continue IV rehydration until pulse, perfusion, and mental status normalize 3, 1
• Transition to ORS once stabilized to replace remaining fluid deficit 3, 1

Diagnostic Evaluation

While rehydrating, obtain targeted diagnostic testing:

• Obtain stool cultures for enteroinvasive bacterial infections (Salmonella, Shigella, Campylobacter) and Clostridioides difficile testing 2
• Review travel history carefully and test for amoebic dysentery or Shigella if relevant travel exposure 2
• Assess for signs of inflammatory diarrhea (fever, bloody stools, severe abdominal pain) that would alter management 3

Antimicrobial Therapy - Use Selectively

Empiric antibiotics are NOT recommended for routine acute watery diarrhea in pregnancy 1. However, specific exceptions exist:

When to Treat with Antibiotics

• Salmonella gastroenteritis in pregnancy requires treatment to prevent extraintestinal spread and bacteremia 2

  • Use ampicillin, cefotaxime, or ceftriaxone
  • Avoid fluoroquinolones during pregnancy 2
  • TMP-SMZ can be used but avoid in first trimester and near term

• Shigella dysentery with fever and bloody diarrhea 3

• Suspected bacterial infection with fever ≥38.5°C or signs of sepsis 1

• Perianal sepsis in inflammatory bowel disease patients: use metronidazole and/or ciprofloxacin (though ciprofloxacin should generally be avoided in pregnancy, this represents a specific exception for severe perianal disease) 3

When NOT to Use Antibiotics

• Never use antibiotics for STEC O157 or Shiga toxin-producing E. coli as this increases risk of hemolytic uremic syndrome 1
• Routine viral gastroenteritis 1
• Uncomplicated watery diarrhea without fever or systemic symptoms 3

Medications to AVOID

Do not use antimotility agents (loperamide) in pregnant women with diarrhea 2. While loperamide may be given to immunocompetent adults with acute watery diarrhea in general populations 3, antiperistaltic drugs are specifically not recommended during pregnancy 2.

Nutritional Management

• Resume age-appropriate usual diet immediately after rehydration - do not withhold food 3, 1
• Continue normal eating throughout the illness once adequately hydrated 3
• Maintain adequate caloric intake to support pregnancy 4

Thromboprophylaxis - Critical in Pregnancy

Pregnant women hospitalized for diarrhea/gastroenteritis should receive anticoagulant thromboprophylaxis during hospitalization 2. Pregnancy is a hypercoagulable state, and dehydration from diarrhea further increases VTE risk 3.

Adjunctive Therapies

• Antiemetics (ondansetron) may be used to facilitate oral rehydration if vomiting is prominent 3
• Probiotics may be offered to reduce symptom severity and duration, though specific strains cannot be definitively recommended 3, 1
• Zinc supplementation is not routinely indicated in developed countries unless signs of malnutrition are present 3

Infection Control

• Evaluate household contacts for asymptomatic carriage if Salmonella or Shigella is identified to prevent recurrent transmission 2
• Emphasize hand hygiene after toilet use, before food preparation, and before eating 3

Common Pitfalls to Avoid

• Do not use fluoroquinolones - these are contraindicated in pregnancy despite being first-line in non-pregnant adults 2
• Do not give loperamide or other antimotility agents to pregnant women 2
• Do not neglect rehydration while focusing on antimicrobial therapy - hydration is the priority 1
• Do not use antibiotics for bloody diarrhea if STEC is suspected 1
• Do not delay hospitalization for severe dehydration - maternal dehydration compromises fetal perfusion 2