What is the recommended treatment for a pregnant woman experiencing diarrhea?

Treatment of Diarrhea in Pregnancy

For pregnant women with diarrhea, the cornerstone of management is aggressive oral or intravenous rehydration with electrolyte replacement, while antiperistaltic agents should be avoided and antimicrobial therapy reserved for confirmed bacterial infections requiring treatment to prevent extraintestinal spread.

Initial Assessment and Hydration Strategy

The first priority is evaluating hydration status by checking for orthostatic hypotension, decreased skin turgor, dry mucous membranes, and obtaining accurate body weight 1.

• Mild to moderate dehydration: Initiate oral rehydration therapy with small, frequent volumes using oral rehydration salts 1
• Severe dehydration: Hospitalize immediately for intravenous fluid replacement and close monitoring 1
• Serum electrolytes should be measured when clinical signs suggest abnormal sodium or potassium concentrations 1

Diagnostic Evaluation

Obtain stool cultures for enteroinvasive bacterial infections and Clostridioides difficile testing in all pregnant women with gastroenteritis 1. This is critical because certain bacterial infections require specific antimicrobial therapy during pregnancy.

• 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, strongly 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 2, 1

Antimicrobial Therapy When Indicated

For pregnant women with confirmed Salmonella gastroenteritis, treatment is mandatory to prevent extraintestinal spread to the placenta and amniotic fluid, which can result in pregnancy loss 2, 1.

• Appropriate antibiotic choices: Ampicillin, cefotaxime, ceftriaxone, or trimethoprim-sulfamethoxazole 2, 1
• Fluoroquinolones must be avoided during pregnancy due to potential fetal risks 2, 1

Symptom Management

Antiperistaltic drugs are contraindicated in pregnant women with diarrhea 2, 1. This is a critical pitfall to avoid, as these agents shift focus away from appropriate fluid and electrolyte therapy and can cause serious side effects including ileus 1.

For nausea and vomiting accompanying diarrhea:

• 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 before 10 weeks of pregnancy should be considered cautiously 1
• Vitamin B6 (pyridoxine) supplementation for mild nausea 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 2, 1.

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 requiring IV fluid replacement 1

Prevention of Recurrent Transmission

Household contacts of pregnant women with salmonellosis or shigellosis should be evaluated for asymptomatic carriage to prevent recurrent transmission 2, 1.

Critical Pitfalls to Avoid

• Never use loperamide or other antiperistaltic agents in pregnant women with acute diarrhea 2, 1
• Never use fluoroquinolones during pregnancy 2, 1
• Do not delay necessary diagnostic procedures or interventions solely because the patient is pregnant 1
• Avoid gadolinium as part of MR imaging during pregnancy 2, 1