What is the recommended treatment for acute gastroenteritis in pregnancy?

Treatment of Acute Gastroenteritis in Pregnancy

Pregnant women with acute gastroenteritis require aggressive intravenous hydration for severe dehydration, antimicrobial therapy for bacterial infections (avoiding fluoroquinolones), and supportive care with antiemetics, while antiperistaltic agents should be avoided. 1, 2, 3

Initial Assessment and Diagnostic Workup

Hydration Status Evaluation:

• Assess for orthostatic hypotension, decreased skin turgor, dry mucous membranes, and obtain accurate body weight 3
• Check for adequate bowel sounds before initiating oral therapy 3
• Laboratory studies (serum electrolytes) are rarely needed but should be measured when clinical signs suggest abnormal sodium or potassium concentrations 3

Microbiological Testing:

• Obtain stool cultures for enteroinvasive bacterial infections (Salmonella, Shigella, Campylobacter) 2, 3
• Test for Clostridioides difficile 2, 3
• Review travel and contact history carefully, with appropriate testing for amoebic or Shigella dysentery in patients with relevant travel exposure 2, 3

Hydration and Supportive Care

Severe Dehydration:

• Hospitalize for intravenous fluid replacement and close monitoring 2, 3
• Dextrose saline may be more effective at reducing nausea than normal saline 4

Anticoagulation:

• Pregnant women hospitalized for gastroenteritis should receive anticoagulant thromboprophylaxis during hospitalization 3
• Outpatients with active inflammatory bowel disease should receive VTE prophylaxis during the third trimester, unless contraindicated 1, 3

Antimicrobial Therapy

Salmonella Gastroenteritis:

• Treatment is recommended to prevent extraintestinal spread of the pathogen, which can infect the placenta and amniotic fluid, potentially resulting in pregnancy loss 1, 2, 3
• Appropriate antibiotic choices include ampicillin, cefotaxime, ceftriaxone, or trimethoprim-sulfamethoxazole (TMP-SMZ) 1, 2, 3
• Fluoroquinolones must be avoided during pregnancy 1, 2, 3

Household Contact Screening:

• Evaluate household contacts of pregnant women with salmonellosis or shigellosis for asymptomatic carriage to prevent recurrent transmission 2, 3

Symptom Management

Antiemetics:

• Metoclopramide can be used for nausea and vomiting with less drowsiness, dizziness, and dystonia compared to promethazine 3
• Ondansetron may enhance compliance with oral rehydration therapy and decrease hospitalization rates, but use should be considered carefully before 10 weeks of pregnancy due to potential risks 3
• Vitamin B6 (pyridoxine) supplementation for mild cases 3

Antiperistaltic Agents:

• Antiperistaltic drugs (loperamide, diphenoxylate) are not recommended for pregnant women with diarrhea 1, 3
• These agents shift focus away from appropriate fluid and electrolyte therapy and can cause serious side effects, including ileus 3

Nutritional Support

Thiamine Supplementation:

• Give thiamine 100 mg daily for a minimum of 7 days, then 50 mg daily maintenance, to prevent refeeding syndrome and Wernicke encephalopathy until adequate oral intake is established 3

Imaging Considerations

When Imaging is Required:

• Limit radiologic investigations to ultrasound and MRI where possible 2
• Avoid gadolinium as part of MR imaging during pregnancy 1, 2, 3
• Cross-sectional imaging should be performed as required, with emphasis on minimizing radiation exposure 1

Special Considerations for Inflammatory Bowel Disease

If Gastroenteritis Occurs in IBD Patients:

• Continue 5-ASA therapy throughout pregnancy if already on maintenance therapy 2
• Continue thiopurine maintenance therapy throughout pregnancy 2
• Continue anti-TNF therapy in pregnant women on maintenance therapy 2
• Flexible sigmoidoscopy or colonoscopy may be used if the results will affect antenatal management 2

Critical Pitfalls to Avoid

• Never use fluoroquinolones during pregnancy due to potential fetal risks 1, 2, 3
• Do not delay urgent surgery to manage complications solely due to pregnancy 2, 3
• Avoid antiperistaltic agents as they can cause serious complications 1, 3
• Do not withhold necessary interventions solely because the patient is pregnant 1

Mental Health Screening

• Perform mental health screening with appropriate referral to support services, given the increased burden of mental health issues during pregnancy 2, 3