Treatment of Acute Gastroenteritis in Pregnancy
Oral rehydration therapy is the cornerstone of treatment for acute gastroenteritis in pregnancy, with aggressive intravenous hydration reserved for severe dehydration, while antimicrobial therapy should be initiated for bacterial infections (particularly Salmonella) to prevent extraintestinal spread and pregnancy complications. 1
Immediate Assessment and Hydration Strategy
Assess hydration status systematically by checking for orthostatic hypotension, decreased skin turgor, dry mucous membranes, and obtain accurate body weight before initiating therapy 1. Laboratory studies (serum electrolytes) are rarely needed unless clinical signs suggest significant abnormalities 1.
Rehydration Protocol
- 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
- Propose oral rehydration solution ad libitum as long as diarrhea continues 2
- Continue regular diet during diarrhea with starches, cereals, yogurt, fruits, and vegetables, while avoiding foods high in simple sugars and fats 1
Diagnostic Evaluation
Obtain stool cultures for enteroinvasive bacterial infections and Clostridioides difficile testing 1. Carefully review travel and contact history, with appropriate testing for amoebic or Shigella dysentery in patients with relevant travel exposure 1.
Antimicrobial Therapy
For Salmonella gastroenteritis, treatment is mandatory to prevent extraintestinal spread to the placenta and amniotic fluid, which can result in pregnancy loss 1.
Antibiotic Selection Algorithm
- Safe options: Ampicillin, cefotaxime, ceftriaxone, or trimethoprim-sulfamethoxazole 1
- Absolutely avoid: Fluoroquinolones during pregnancy due to potential fetal risks 1
- Consider antibiotics if diarrhea persists beyond 5 days, high fever is present, or dysentery occurs 1
Symptom Management
Antiemetics
- Ondansetron may enhance compliance with oral rehydration therapy and decrease hospitalization rates 1
- Consider use cautiously before 10 weeks of pregnancy due to potential risks 1
- Metoclopramide can be used for nausea and vomiting with less drowsiness, dizziness, and dystonia 1
Critical Medication Restrictions
- 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
- Antidiarrheal agents are not recommended for pregnant women with diarrhea 1
Nutritional Support
- Supplement with vitamin B6 (pyridoxine) for mild cases 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
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.
Indications for Hospitalization
Escalate care immediately for:
- Severe dehydration requiring IV fluid replacement 1
- Decreased urine output or inability to maintain hydration orally 1
- Persistent high fever or bloody diarrhea 1
- Weight loss >5% of prepregnancy weight 3
- Electrolyte imbalances 3
Infection Control and Prevention
Evaluate household contacts of pregnant women with salmonellosis or shigellosis for asymptomatic carriage to prevent recurrent transmission 1.
Critical Pitfalls to Avoid
- Never withhold necessary interventions solely because the patient is pregnant 4, 1
- Avoid gadolinium as part of MR imaging during pregnancy 1
- Do not delay urgent surgery to manage complications solely due to pregnancy 1
- Do not rely on antidiarrheal agents as primary therapy 1
- Fluoroquinolones must be avoided during pregnancy 1
Follow-Up Monitoring
Perform mental health screening with appropriate referral to support services, given the increased burden of mental health issues during pregnancy 1.