Management of Heartburn During Pregnancy
Start with dietary and lifestyle modifications, then escalate through antacids/sucralfate, followed by H2-receptor antagonists (ranitidine preferred), and reserve proton pump inhibitors only for severe refractory cases. 1, 2, 3
Step 1: Dietary and Lifestyle Modifications (First-Line)
Begin all pregnant women with heartburn on non-pharmacologic interventions:
- Reduce intake of spicy, fatty, acidic, and fried foods 1, 4
- Consume small, frequent meals throughout the day rather than large meals 1, 4
- Identify and avoid specific food triggers, particularly those with strong odors 1
- Elevate the head of the bed and avoid lying down immediately after eating 2, 3
The American College of Obstetricians and Gynecologists (ACOG) recommends these modifications as the initial approach before any medication 4. These interventions address the underlying pathophysiology: progesterone-induced relaxation of the lower esophageal sphincter, which affects 30-90% of pregnant women 1, 2.
Step 2: Antacids or Sucralfate (Second-Line)
If lifestyle modifications fail after 1-2 weeks:
- Calcium-containing antacids are the preferred first-line medication (Recommendation Grade A) 3
- Magnesium and aluminum hydroxide combinations can provide complete heartburn relief (RR 1.85,95% CI 1.36-2.50) compared to placebo 5
- Sucralfate 1g orally three times daily is highly effective, with one trial showing 2.41 times greater complete relief compared to dietary advice alone (RR 2.41,95% CI 1.42-4.07) 5, 3
Antacids and sucralfate are considered safe throughout pregnancy as they act locally without significant systemic absorption 2, 6. Use these medications on-demand for breakthrough symptoms 6.
Step 3: H2-Receptor Antagonists (Third-Line)
For persistent symptoms despite antacids/sucralfate:
- Ranitidine is the preferred H2-receptor antagonist due to documented efficacy and safety profile, even in the first trimester 2
- Any H2-receptor antagonist can be used if ranitidine is unavailable (Recommendation Grade B) 3
- Continue antacids as rescue medication for breakthrough symptoms 3
H2-receptor antagonists have been extensively studied in pregnancy and are considered safe when lifestyle modifications and antacids prove inadequate 2, 6, 7.
Step 4: Proton Pump Inhibitors (Reserved for Severe Cases)
Reserve PPIs exclusively for women with intractable symptoms or complicated reflux disease that fails to respond to H2-receptor antagonists 2, 3, 6:
- Lansoprazole may be the preferred PPI based on animal safety data and human case reports 2
- Use PPIs only after consultation with a physician (Recommendation Grade C) 3
- Continue antacids as rescue medication alongside PPI therapy 3
PPIs represent the final escalation step because serious reflux complications during pregnancy are rare, making aggressive therapy unnecessary in most cases 2, 6, 7.
Important Clinical Considerations
Early treatment is critical to prevent progression to hyperemesis gravidarum, which affects 0.3-2% of pregnancies and can cause severe dehydration, weight loss, and electrolyte imbalances 8, 4.
Avoid metoclopramide and ondansetron before 10 weeks gestation due to potential teratogenic risks 1. These medications are reserved for nausea/vomiting management, not routine heartburn 4.
Symptoms typically resolve soon after delivery as progesterone levels normalize and mechanical pressure from the gravid uterus is relieved 6, 7.
Evidence Quality Note
The Cochrane review found only moderate-quality evidence for pharmaceutical treatments, with most trials being small and at mixed risk of bias 5. However, the consistent step-up approach across multiple guidelines 1, 2, 3, 6 and the excellent safety profile of first-line agents support this algorithmic management strategy in real-world practice.