What is the management of diarrhea in pregnant women?

Management of Diarrhea in Pregnant Women

Pregnant women with diarrhea should receive aggressive oral rehydration therapy as first-line treatment, with hospitalization for intravenous fluids if severe dehydration develops, while avoiding antiperistaltic agents entirely. 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

• For mild to moderate dehydration: Initiate oral rehydration therapy with small, frequent volumes using oral rehydration salts. 1
• For severe dehydration: Hospitalize immediately for intravenous fluid replacement and close monitoring. 1
• Laboratory studies (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 based on clinical presentation:

• Stool cultures should be obtained for enteroinvasive bacterial infections and Clostridioides difficile testing. 1
• Travel and contact history should be carefully reviewed, with appropriate testing for amoebic or Shigella dysentery in patients with relevant travel history. 1
• If diarrhea persists beyond 5 days, high fever is present, or dysentery occurs, consider bacterial pathogens requiring antibiotic treatment. 1

Antimicrobial Therapy When Indicated

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

• Appropriate antibiotic choices include: ampicillin, cefotaxime, ceftriaxone, or trimethoprim-sulfamethoxazole. 1
• Fluoroquinolones must be avoided during pregnancy due to potential fetal risks. 1
• Household contacts of pregnant women with salmonellosis or shigellosis should be evaluated for asymptomatic carriage to prevent recurrent transmission. 1

Symptom Management

Antiemetics for accompanying nausea/vomiting:

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

Critical pitfall: Do not use antiperistaltic agents (such as loperamide) as they shift focus away from appropriate fluid and electrolyte therapy and can cause serious side effects, including ileus. 1 While one study suggested loperamide is not associated with major malformations 2, current guidelines from the CDC explicitly recommend against antiperistaltic drugs in pregnant women with diarrhea. 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
• 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. 1

• Outpatients with active inflammatory bowel disease should receive VTE prophylaxis during the third trimester, unless contraindicated. 1

Special Considerations for Inflammatory Bowel Disease

If the pregnant patient has known IBD with suspected flare:

• Continue maintenance therapy with 5-ASA, thiopurines, systemic corticosteroids, or anti-TNF therapy throughout pregnancy. 3
• Flexible sigmoidoscopy or colonoscopy may be performed if results will affect antenatal management. 3
• Limit radiologic investigations to ultrasound and MRI where possible, avoiding gadolinium. 3
• Do not delay urgent surgery to manage complications solely due to pregnancy. 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

Follow-up

• Mental health screening should be performed with appropriate referral to support services, given the increased burden of mental health issues during pregnancy. 1