What is the treatment for diarrhea in pregnant women?

Treatment of Diarrhea in Pregnant Women

For acute diarrhea in pregnancy, prioritize hydration and supportive care first, obtain stool cultures for bacterial pathogens and C. difficile testing, and treat bacterial gastroenteritis with pregnancy-safe antibiotics (ampicillin, cefotaxime, ceftriaxone, or TMP-SMZ) while avoiding fluoroquinolones. 1

Initial Assessment and Diagnostic Workup

Obtain stool cultures for enteroinvasive bacterial infections and Clostridioides difficile testing in all pregnant women presenting with diarrhea. 1 This is critical because bacterial gastroenteritis requires different management than viral or other causes.

• Take a detailed travel and contact history, with specific testing for amoebic or Shigella dysentery in patients with relevant travel exposure. 1
• Evaluate household contacts for asymptomatic carriage of Salmonella or Shigella to prevent recurrent transmission. 2

Hydration and Supportive Care (First-Line Treatment)

Fluid and electrolyte replacement is the cornerstone of diarrhea management in pregnancy. 3 Dehydration poses significant risks to both mother and fetus.

• For mild to moderate dehydration, encourage oral rehydration with water and electrolyte-containing solutions. 3
• Hospitalize pregnant women with severe dehydration for intravenous fluid replacement and close monitoring. 1
• During hospitalization, implement anticoagulant thromboprophylaxis to prevent venous thromboembolism. 2

Antimicrobial Therapy for Bacterial Gastroenteritis

Pregnant women with Salmonella gastroenteritis should receive antimicrobial treatment to prevent extraintestinal spread, which can lead to placental and amniotic fluid infection resulting in pregnancy loss. 2, 1

Pregnancy-Safe Antibiotic Options:

• Ampicillin 2, 1
• Cefotaxime 2, 1
• Ceftriaxone 2, 1
• TMP-SMZ (trimethoprim-sulfamethoxazole) 2, 1

Critical Medication Avoidance:

Fluoroquinolones (including ciprofloxacin) must be avoided during pregnancy despite their effectiveness in non-pregnant patients. 2, 1 While ciprofloxacin is commonly used for Salmonella in non-pregnant adults, the teratogenic risks outweigh benefits during pregnancy.

• For perianal sepsis in pregnant women with Crohn's disease, metronidazole and/or ciprofloxacin may be considered, though this represents a specific exception requiring risk-benefit discussion. 2

Antidiarrheal Medications

Loperamide can be used cautiously in pregnancy for symptomatic relief, though data are limited. 4

• A prospective study of 105 pregnant women exposed to loperamide showed no increased risk of major malformations, though babies born to women taking loperamide throughout pregnancy weighed approximately 200g less. 4
• The FDA warns that loperamide should not be used when inhibition of peristalsis should be avoided, and must be discontinued if constipation, abdominal distention, or ileus develop. 3
• Antiperistaltic drugs are not recommended for children and should be used with extreme caution in pregnancy. 2

Special Considerations for Inflammatory Bowel Disease

Pregnant women with IBD who develop diarrhea or disease flare should continue their maintenance medications, as uncontrolled IBD poses greater risks than medication exposure. 2

• Continue 5-ASA (mesalamine) therapy throughout pregnancy. 2, 1
• Continue thiopurine maintenance therapy throughout pregnancy. 2, 1
• Continue anti-TNF therapy in pregnant women on maintenance treatment. 2, 1
• For pregnant women with IBD flare not responding to maintenance therapy, treat with systemic corticosteroids or anti-TNF therapy. 2

Imaging When Needed

Limit radiologic investigations to ultrasound and MRI when imaging is necessary to guide management. 2, 1

• Avoid gadolinium contrast during MRI in pregnancy. 2, 1
• Flexible sigmoidoscopy or colonoscopy may be performed if results will affect antenatal management decisions. 2, 1

Common Pitfalls and Critical Warnings

Never delay urgent surgery for complications of diarrheal illness solely because of pregnancy. 2, 1 Maternal mortality from untreated surgical emergencies far exceeds risks of appropriately timed intervention.

Avoid the temptation to use fluoroquinolones despite their superior efficacy in non-pregnant patients—the teratogenic risks are unacceptable. 2, 1

Do not assume all diarrhea is benign—bacterial gastroenteritis in pregnancy can lead to extraintestinal spread with serious maternal and fetal consequences. 2

Loperamide carries FDA warnings about cardiac adverse reactions at higher-than-recommended doses and should be used at the lowest effective dose for the shortest duration. 3