What medication is recommended for heartburn during pregnancy?

Medication for Heartburn During Pregnancy

Start with calcium-containing antacids as first-line medication, then escalate to ranitidine (H2-receptor antagonist) if symptoms persist, and reserve proton pump inhibitors for severe refractory cases.

Treatment Algorithm

Step 1: Lifestyle and Dietary Modifications (Always Start Here)

• Reduce intake of spicy, fatty, acidic, and fried foods 1
• Consume small, frequent meals rather than large portions 1
• Identify and avoid specific food triggers, particularly those with strong odors 1
• These modifications should be attempted first, though early pharmacologic intervention may prevent progression to more severe disease 1

Step 2: First-Line Pharmacologic Therapy - Antacids

• Calcium-containing antacids are the preferred first-line medication 2
• Antacids provide rapid symptom relief and have an established safety profile in pregnancy 3, 2
• If antacids alone are insufficient, add sucralfate 1g orally three times daily 2

Step 3: Second-Line Therapy - H2-Receptor Antagonists

• Ranitidine is the preferred H2-receptor antagonist due to documented efficacy and safety profile throughout pregnancy, including the first trimester 3
• The FDA label classifies ranitidine as Pregnancy Category B, with reproduction studies in rats and rabbits at doses up to 160 times the human dose showing no evidence of harm to the fetus 4
• H2-receptor antagonists should be used when symptoms persist despite antacids 2
• Continue antacids as rescue medication for breakthrough symptoms 2

Step 4: Third-Line Therapy - Proton Pump Inhibitors

• Reserve PPIs for women with intractable symptoms or complicated reflux disease 3
• Lansoprazole may be the preferred PPI based on its safety profile in animal studies and case reports in human pregnancies 3
• Use PPIs only after inadequate control with H2-receptor antagonists plus antacids 2

Important Clinical Considerations

Safety Profile

• Serious reflux complications during pregnancy are rare, so invasive diagnostic procedures like endoscopy are infrequently needed 3
• Ranitidine is secreted in human milk, so caution should be exercised when administered to nursing mothers 4
• All three medication classes (antacids, H2RAs, PPIs) have been studied in pregnancy with favorable safety data 2

Pathophysiology Context

• Heartburn affects 30-90% of pregnant women, with approximately two-thirds developing symptoms 1, 3
• The primary mechanism is decreased lower esophageal sphincter pressure caused by progesterone 1, 3
• Symptoms typically present in the first trimester and progress throughout pregnancy 2

Common Pitfalls to Avoid

• Don't delay pharmacologic treatment if lifestyle modifications are insufficient—early treatment prevents progression to severe disease 1
• Don't skip the step-up approach—always start with lifestyle modifications and antacids before escalating 2
• Don't use PPIs as first-line therapy—they should be reserved for refractory cases only 3, 2
• Don't assume all antacids are equal—calcium-containing formulations are specifically recommended 2

Monitoring Considerations

• False-positive urine protein tests may occur with ranitidine when using MULTISTIX®; use sulfosalicylic acid testing instead 4
• Monitor for adequate symptom control at each step before escalating therapy 2