What is the management of diarrhea in pregnant women?

Management of Diarrhea in Pregnancy

Pregnant women with diarrhea should receive supportive care with oral rehydration therapy as first-line treatment, while avoiding antiperistaltic agents like loperamide, and those with severe dehydration or suspected bacterial infections require hospitalization for IV fluids and appropriate antimicrobial therapy. 1

Initial Assessment and Hydration

Assess hydration status systematically by evaluating for orthostatic hypotension, decreased skin turgor, dry mucous membranes, and obtain accurate body weight before initiating therapy. 1 Laboratory studies such as serum electrolytes are rarely needed but should be measured when clinical signs suggest abnormal sodium or potassium concentrations. 1

• For mild to moderate dehydration: Initiate oral rehydration therapy with small, frequent volumes using oral rehydration salts to prevent progression to severe dehydration. 1
• For severe dehydration: Hospitalize immediately for intravenous fluid replacement and close monitoring. 1

Diagnostic Evaluation

Obtain stool cultures for enteroinvasive bacterial infections and Clostridioides difficile testing in 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
• For pregnant women with known inflammatory bowel disease and suspected flare, flexible sigmoidoscopy or colonoscopy may be performed if results will affect antenatal management. 3, 1

Antimicrobial Therapy

For pregnant women with 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

• 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. 3, 1, 2
• Azithromycin is an alternative for travelers to countries with high fluoroquinolone resistance or when fluoroquinolones are contraindicated. 3

Symptom Management

Antiperistaltic drugs such as loperamide are NOT recommended for pregnant women with diarrhea. 3, 1 The FDA warns that loperamide can cause serious cardiac adverse reactions including QT prolongation, Torsades de Pointes, and cardiac arrest, particularly at higher doses. 4 Additionally, these agents shift focus away from appropriate fluid and electrolyte therapy and can cause serious side effects including ileus. 1

• Ondansetron may enhance compliance with oral rehydration therapy in pregnant women with nausea and vomiting accompanying diarrhea, though its use should be considered on a case-by-case basis before 10 weeks of pregnancy due to potential risks. 1
• Metoclopramide can be used for nausea and vomiting with less drowsiness, dizziness, and dystonia compared to promethazine. 1

Nutritional Support

Continue regular diet during diarrhea with foods 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
• 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

Pregnant women hospitalized for gastroenteritis should receive anticoagulant thromboprophylaxis during hospitalization, with low-molecular-weight heparin preferred over unfractionated heparin. 3, 1 This is particularly important given the increased thrombotic risk in pregnancy combined with dehydration and immobility. 3

When to Escalate Care

Return immediately or call if the patient develops:

• Decreased urine output or inability to maintain hydration orally 1
• Persistent high fever or bloody diarrhea 1
• Signs of severe dehydration 1

Prevention and Follow-up

• 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
• Healthcare providers should direct educational efforts toward pregnant women as they have increased risk of complications from diarrheal disease. 3

Critical Pitfalls to Avoid

• Never use loperamide or other antiperistaltic agents in pregnant women with acute diarrhea. 3, 1
• Never use fluoroquinolones during pregnancy despite their effectiveness for traveler's diarrhea in non-pregnant patients. 3, 1, 2
• Do not delay urgent interventions or surgery solely because the patient is pregnant. 3, 1
• Avoid gadolinium as part of MR imaging during pregnancy. 3, 1