Management of Gastritis in Pregnant Women
Begin with dietary and lifestyle modifications as first-line therapy, followed by antacids containing aluminum/magnesium hydroxide, then H2-receptor antagonists if symptoms persist, reserving proton pump inhibitors only for severe, intractable cases. 1, 2
Initial Non-Pharmacologic Management
Dietary modifications are the essential first step:
- Reduce spicy, fatty, acidic, and fried foods to minimize lower esophageal sphincter relaxation 1, 2
- Eat small, frequent, bland meals (the BRAT diet: bananas, rice, applesauce, toast) 1
- Consume high-protein, low-fat meals 1
- Avoid eating within 3 hours of bedtime to minimize nocturnal symptoms 2
- Identify and avoid specific trigger foods with strong odors or activities that worsen symptoms 1, 2
Lifestyle adjustments:
- Elevate the head of the bed 2
- Increase dietary fiber intake to approximately 30g/day through fruits, vegetables, whole grains, and legumes 2
- Ensure adequate fluid intake, particularly water 2
Pharmacologic Management Algorithm
Step 1: First-Line Medications
Antacids containing aluminum/magnesium hydroxide are the safest initial pharmacologic option and should be used when lifestyle modifications fail 2. Calcium-containing antacids are also preferred 3.
Step 2: H2-Receptor Antagonists
If symptoms persist despite antacids, advance to H2-receptor antagonists (such as ranitidine), which are considered safe first-line pharmacologic therapy 1, 2. These medications have documented efficacy and safety profiles even in the first trimester 4.
Step 3: Proton Pump Inhibitors (Reserved for Severe Cases)
PPIs should only be considered after careful risk-benefit assessment for intractable symptoms or complicated disease 2, 4. Use at the lowest effective dose for the shortest duration necessary 2.
- Lansoprazole may be preferred among PPIs based on animal safety data and human case reports 5, 4, 6
- Available observational studies show no significant increase in major birth defects with PPI exposure (OR=1.12,95% CI 0.86-1.45) 5
- A meta-analysis of 1,530 pregnant women exposed to PPIs showed no significant increases in congenital malformations or spontaneous abortion 5
Additional Supportive Therapies
For persistent nausea and vomiting associated with gastritis:
- Ginger (250-mg capsule 4 times daily) 1
- Vitamin B6 (pyridoxine, 10-25 mg every 8 hours) 1, 7
- Doxylamine (FDA-approved, available in 10mg/10mg or 20mg/20mg combinations with pyridoxine) for refractory symptoms 1
When to Escalate Care
Hospitalization is indicated for:
- Severe dehydration requiring IV fluid replacement 2
- Weight loss >5% of prepregnancy weight 1
- Electrolyte imbalances 1
- Alarm symptoms such as dysphagia, bleeding, or significant weight loss 2
Involve a multidisciplinary team including obstetricians and gastroenterologists when alarm symptoms develop or symptoms remain intractable 2.
Critical Pitfalls to Avoid
- Do not use metoclopramide due to its unfavorable risk-benefit profile in pregnancy 2
- Avoid delaying treatment of severe symptoms, as this can lead to dehydration, malnutrition, and adverse pregnancy outcomes 2
- Do not discontinue necessary medications due to unfounded concerns about fetal safety 2
- Avoid bismuth-containing antacids (which contain salicylates) 7
Follow-Up Recommendations
- Review patients at least monthly during the first and second trimesters, increasing frequency as needed 2
- Reassess symptom control and taper medications to the lowest effective dose when adequate response is achieved 2
- Most gastritis and reflux symptoms resolve after delivery as hormonal effects normalize 2
- Close monitoring is essential to prevent progression to more severe conditions like hyperemesis gravidarum 1