What is the best management approach for a pregnant woman with Irritable Bowel Syndrome (IBS)?

Management of IBS in Pregnancy

For pregnant women with IBS, start with dietary modifications including soluble fiber supplementation (such as ispaghula) and regular exercise, while avoiding insoluble fiber like wheat bran, and use loperamide cautiously for diarrhea or antispasmodics for pain only when symptoms significantly impact quality of life. 1

First-Line Management Approach

Dietary and Lifestyle Modifications

• Begin with soluble fiber supplementation (such as ispaghula), starting at a low dose and gradually increasing to minimize bloating. 1
• Recommend regular exercise to all pregnant patients with IBS, as it helps manage symptoms without medication risks. 1
• Avoid insoluble fiber (such as wheat bran), which may worsen symptoms during pregnancy. 1
• Ensure adequate hydration and nutritional optimization, including daily vitamin D and folic acid (400 μg/day, or 5 mg/day if taking sulfasalazine). 2

Important Nutritional Considerations

• Pregnant women with IBS often fall short of recommended dietary nutrients, particularly iron (only 3% meet goals), choline (23% meet goals), magnesium (38% meet goals), and calcium (48% meet goals). 3
• Do not use iron tablets in those with active inflammatory symptoms, as systemic inflammation inhibits absorption; in patients with inactive disease, limit to no more than 100 mg elemental iron daily. 2, 1

Symptom-Specific Pharmacologic Management

For IBS with Diarrhea

• Loperamide may be used cautiously when dietary measures fail, but monitor closely for side effects including abdominal pain, bloating, nausea, and constipation. 1
• Avoid antiperistaltic drugs routinely, as they shift focus away from appropriate management. 4

For IBS with Constipation

• Soluble fiber supplementation is particularly beneficial and should be the primary approach. 1

For Abdominal Pain

• Certain antispasmodics may be considered when pain significantly impacts quality of life, though counsel patients about potential side effects such as dry mouth, visual disturbance, and dizziness. 1

Second-Line Approaches

Low-FODMAP Diet

• Consider a low-FODMAP diet as second-line therapy for global symptoms and abdominal pain when first-line measures fail. 1
• Implementation must be supervised by a trained dietitian to ensure nutritional adequacy during pregnancy. 1

Neuromodulators for Refractory Symptoms

• Tricyclic antidepressants used as gut-brain neuromodulators may be considered for refractory symptoms after careful risk-benefit discussion. 1
• Selective serotonin reuptake inhibitors may serve as an alternative to tricyclic antidepressants for global symptom management. 1

Critical Exclusions and Red Flags

Rule Out Infectious Causes

• Obtain stool cultures for enteroinvasive bacterial infections and Clostridioides difficile in pregnant women with new or worsening gastrointestinal symptoms. 5, 1
• Review travel and contact history carefully, with appropriate testing for amoebic or Shigella dysentery in patients with relevant exposures. 5, 1

Assess for Severe Dehydration

• Hospitalize for intravenous fluid replacement if severe dehydration is present, with close monitoring. 4, 1

Special Pregnancy Considerations

Thromboembolism Prophylaxis

• Provide VTE prophylaxis during the third trimester for outpatients with active symptoms, unless contraindicated. 2, 1

Mental Health Screening

• Perform mental health screening with appropriate referral to support services, given the increased burden of mental health disease in people with IBS and during pregnancy. 2, 1

Imaging When Needed

• Limit radiologic investigations to ultrasound and MRI where possible. 2
• Avoid gadolinium as part of MR imaging during pregnancy. 2, 1

Common Pitfalls to Avoid

• Do not recommend food elimination diets based on IgG antibodies, as these are not evidence-based for IBS management. 1
• Do not routinely recommend gluten-free diets unless celiac disease is confirmed. 1
• Probiotics may help with global symptoms and abdominal pain, but no specific species or strain can be recommended; a 12-week trial is reasonable. 1
• Do not delay urgent surgery to manage complications solely due to pregnancy. 2, 1

Multidisciplinary Approach

Management should emphasize patient education about the benign nature of IBS, the importance of dietary modifications, and judicious use of pharmacologic options deemed relatively safe during pregnancy. 6 The approach requires coordination between gastroenterology and obstetrics, particularly for patients with severe or refractory symptoms. 6, 7