What is the management for diarrhea in a pregnant patient?

Management of Diarrhea in Pregnancy

For pregnant women with diarrhea, prioritize oral rehydration therapy with small, frequent volumes using oral rehydration salts, continue a regular diet with starches and cereals while avoiding simple sugars and fats, and obtain stool cultures if diarrhea persists beyond 5 days, high fever develops, or dysentery occurs to guide antibiotic therapy when indicated. 1

Initial Assessment and Hydration

Assess hydration status systematically by checking for orthostatic hypotension, decreased skin turgor, dry mucous membranes, and obtain accurate body weight before initiating therapy. 1

• For mild to moderate dehydration, initiate oral rehydration therapy immediately with small, frequent volumes using oral rehydration salts. 1
• Pregnant women with severe dehydration require hospitalization for intravenous fluid replacement and close monitoring. 1, 2
• Laboratory studies such as serum electrolytes are rarely needed but should be measured when clinical signs suggest abnormal sodium or potassium concentrations. 1

Diagnostic Evaluation

Obtain stool cultures and testing strategically based on clinical presentation:

• If diarrhea persists beyond 5 days, high fever is present, or dysentery occurs, obtain stool cultures for enteroinvasive bacterial infections and Clostridioides difficile testing. 1, 2
• Review travel and contact history carefully, with appropriate testing for amoebic or Shigella dysentery in patients with relevant travel history. 1, 2
• For pregnant women with known inflammatory bowel disease (IBD) and suspected flare, flexible sigmoidoscopy or colonoscopy may be performed if results will affect antenatal management. 3

Antimicrobial Therapy When Indicated

For bacterial gastroenteritis requiring treatment:

• Pregnant women with Salmonella gastroenteritis should receive treatment to prevent extraintestinal spread to the placenta and amniotic fluid, which can result in pregnancy loss. 1, 2
• Appropriate antibiotic choices include ampicillin, cefotaxime, ceftriaxone, or trimethoprim-sulfamethoxazole (TMP-SMZ). 1, 2
• Fluoroquinolones must be avoided during pregnancy due to potential fetal risks. 1, 2, 4

Symptom Management

For nausea and vomiting accompanying diarrhea:

• Ondansetron may enhance compliance with oral rehydration therapy and decrease hospitalization rates, though its use should be considered carefully before 10 weeks of pregnancy due to potential risks. 1
• Metoclopramide can be used with less drowsiness, dizziness, and dystonia compared to promethazine. 1
• Supplement with vitamin B6 (pyridoxine) for mild cases. 1

Antiperistaltic drugs (such as loperamide) are not recommended for pregnant women with diarrhea, as they shift focus away from appropriate fluid and electrolyte therapy and can cause serious side effects including ileus. 1, 4 While one prospective study of 105 pregnancies found no increased risk of major malformations with loperamide use 5, the FDA label warns of cardiac adverse reactions and the drug should be avoided when inhibition of peristalsis could lead to significant sequelae. 4

Nutritional Support

Continue regular diet during diarrhea:

• Include starches, cereals, yogurt, fruits, and vegetables. 1
• Avoid foods high in simple sugars and fats. 1
• 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. 1

Thromboprophylaxis for Hospitalized Patients

Pregnant women hospitalized for gastroenteritis or IBD flare should receive anticoagulant thromboprophylaxis during hospitalization, as pregnancy and active gastrointestinal disease both increase VTE risk. 3, 1 Low-molecular-weight heparin is preferred over unfractionated heparin. 3

When to Escalate Care

Return immediately or call if:

• Decreased urine output or inability to maintain hydration orally develops. 1
• Persistent high fever or bloody diarrhea occurs. 1
• Signs of severe dehydration persist despite oral rehydration attempts. 1

Follow-up and Prevention

• Household contacts of pregnant women with salmonellosis or shigellosis should be evaluated for asymptomatic carriage to prevent recurrent transmission. 1, 2
• Mental health screening should be performed with appropriate referral to support services, given the increased burden of mental health issues during pregnancy. 1, 2

Critical Pitfalls to Avoid

• Do not use antiperistaltic agents (loperamide) as they can cause ileus and serious cardiac adverse reactions. 1, 4
• Do not prescribe fluoroquinolones during pregnancy due to fetal risks. 1, 2
• Do not delay necessary diagnostic procedures (such as flexible sigmoidoscopy) solely because the patient is pregnant if results will affect management. 3
• Do not rely solely on dietary modifications when severe dehydration is present—hospitalize for IV fluids. 1