Management of Acute Gastroenteritis in Pregnancy
Pregnant women with acute gastroenteritis require aggressive intravenous hydration for severe dehydration, oral rehydration therapy for mild-to-moderate cases, and antimicrobial therapy only for specific bacterial pathogens, while avoiding antiperistaltic agents entirely. 1
Initial Assessment and Hydration Strategy
Assess hydration status by checking for orthostatic hypotension, decreased skin turgor, dry mucous membranes, and obtain accurate body weight before initiating therapy. 1 Laboratory studies including serum electrolytes are rarely needed but should be measured when clinical signs suggest abnormal sodium or potassium concentrations. 1
Mild-to-Moderate Dehydration
- Initiate oral rehydration therapy with small, frequent volumes using oral rehydration salts 1
- Continue regular diet including starches, cereals, yogurt, fruits, and vegetables while avoiding foods high in simple sugars and fats 1
- Supplement with vitamin B6 (pyridoxine) for mild cases 1
Severe Dehydration
- Hospitalize immediately for intravenous fluid replacement and close monitoring 1
- Give thiamine 100 mg daily for minimum 7 days, then 50 mg daily maintenance to prevent refeeding syndrome and Wernicke encephalopathy until adequate oral intake is established 1
Diagnostic Evaluation
Obtain stool cultures for enteroinvasive bacterial infections and Clostridioides difficile testing in all pregnant women with gastroenteritis. 1, 2 Carefully review travel and contact history, with appropriate testing for amoebic or Shigella dysentery in patients with relevant travel exposure. 1
If diarrhea persists beyond 5 days, high fever is present, or dysentery occurs, consider bacterial pathogens requiring antibiotic treatment. 1
Antimicrobial Therapy
For pregnant women with Salmonella gastroenteritis, treatment is mandatory to prevent extraintestinal spread to the placenta and amniotic fluid, which can result in pregnancy loss. 1, 2
Appropriate Antibiotic Choices:
Critical Contraindication:
Fluoroquinolones must be avoided during pregnancy due to potential fetal risks. 1, 2 This is a common pitfall as fluoroquinolones are frequently used in non-pregnant populations but are absolutely contraindicated in pregnancy.
Symptom Management
Antiemetics
- Metoclopramide can be used for nausea and vomiting with less drowsiness, dizziness, and dystonia compared to promethazine 1
- Ondansetron may enhance compliance with oral rehydration therapy and decrease hospitalization rates, but use should be considered on a case-by-case basis before 10 weeks of pregnancy due to potential risks 1
What NOT to Use:
Do not use antiperistaltic drugs (such as loperamide) in pregnant women with diarrhea, as they shift focus away from appropriate fluid and electrolyte therapy and can cause serious side effects including ileus. 1 This is a critical pitfall to avoid.
Thromboprophylaxis
Pregnant women hospitalized for gastroenteritis should receive anticoagulant thromboprophylaxis during hospitalization. 1 Outpatients with active inflammatory bowel disease should receive VTE prophylaxis during the third trimester unless contraindicated. 1
Red Flags Requiring Immediate Return or Escalation
Return immediately or call if the patient develops:
- Decreased urine output or inability to maintain hydration orally 1
- Persistent high fever 1
- Bloody diarrhea 1
Infection Control and Prevention
Household contacts of pregnant women with salmonellosis or shigellosis should be evaluated for asymptomatic carriage to prevent recurrent transmission. 1 This is often overlooked but critical for preventing reinfection cycles.
Multidisciplinary Approach
Mental health screening should be performed with appropriate referral to support services, given the increased burden of mental health issues during pregnancy. 1 A multidisciplinary team including obstetricians and gastroenterologists should be involved when symptoms are severe or complications arise. 3
Key Clinical Pitfalls to Avoid
- Never delay treatment of severe symptoms, as this can lead to dehydration, malnutrition, and adverse pregnancy outcomes 1
- Do not withhold necessary interventions solely because the patient is pregnant 2
- Avoid relying on antidiarrheal agents as they distract from appropriate fluid and electrolyte therapy 1