What are the recommended treatments for acidity in a pregnant woman in her third trimester with no significant medical history?

Treatment of Acidity (Heartburn/GERD) During Pregnancy

For a pregnant woman in her third trimester experiencing heartburn, begin with lifestyle modifications and antacids, escalate to ranitidine 150mg twice daily if symptoms persist, and reserve PPIs only for severe refractory cases. 1, 2, 3

Stepwise Treatment Algorithm

First-Line: Lifestyle Modifications (Start Here)

• Elevate the head of the bed by 6-8 inches to reduce nighttime reflux and regurgitation 1
• Consume small, frequent meals (5-6 per day instead of 3 large meals) to reduce gastric distension and lower esophageal sphincter pressure 1
• Avoid trigger foods including spicy, fatty, acidic, and fried foods, as well as coffee, alcohol, chocolate, citrus, and carbonated beverages 1
• Avoid lying down for 2-3 hours after meals to minimize reflux episodes 1

Second-Line: Antacids and Sucralfate

• Nonparticulate antacids (sodium citrate or sodium bicarbonate) are effective in decreasing gastric acidity and are safe throughout pregnancy 4
• Alginate-based raft-forming agents create a protective foam barrier above gastric contents, physically preventing reflux; these are safe with no restrictions during all trimesters and have shown no adverse effects on mother or fetus 5
• Sucralfate 1g orally three times daily can be used if symptoms persist despite lifestyle modifications and antacids 1

Third-Line: H2-Receptor Antagonists

• Ranitidine 150mg twice daily is the preferred H2RA due to documented efficacy and safety profile even in the first trimester 1, 2, 3
• H2RAs are more effective than placebo and should be used before escalating to PPIs 1
• The FDA drug label confirms ranitidine is Pregnancy Category B, with reproduction studies in rats and rabbits at doses up to 160 times the human dose showing no evidence of harm to the fetus 6
• Ranitidine is secreted in human milk, so caution should be exercised during breastfeeding 6

Fourth-Line: Proton Pump Inhibitors (Reserve for Refractory Cases)

• PPIs should be reserved exclusively for women with intractable symptoms or complicated reflux disease that has failed all other therapies 1, 2, 3
• Lansoprazole may be the preferred PPI due to its safety profile in animal studies and case reports in human pregnancies 1, 3
• Use PPIs with particular caution in the first trimester 1
• All PPIs except omeprazole are FDA category B drugs during pregnancy 2

Critical Safety Considerations

• Metoclopramide should be avoided before 10 weeks gestation due to possible risks, though it may be considered for hyperemesis gravidarum in later pregnancy 1
• Metoclopramide is not recommended as monotherapy or adjunctive therapy for GERD (Grade D recommendation) 1
• Do not use twice-daily PPI dosing empirically; if symptoms require this level of acid suppression, the patient should be considered a treatment failure and evaluated further 1

Pathophysiology Context

• Heartburn affects approximately 30-90% of pregnant women, most commonly in the second half of pregnancy 1
• The predominant cause is decreased lower esophageal sphincter pressure caused by progesterone 2, 3, 7
• The gravid uterus mechanically displaces the stomach upward and leftward, contributing to symptoms 1
• Serious reflux complications during pregnancy are rare 1, 2, 3

Common Pitfalls to Avoid

• Do not assume all heartburn requires medication, as many cases respond adequately to lifestyle modifications alone 1
• Do not withhold treatment entirely out of excessive caution, as untreated severe symptoms can progress to hyperemesis gravidarum, which carries its own maternal and fetal risks 1
• Do not skip the stepwise approach and jump directly to PPIs without trying H2RAs first 1, 2, 3

When to Escalate Care

• Troublesome dysphagia warrants endoscopy with biopsy to evaluate for eosinophilic esophagitis or other pathology 1
• Symptoms persisting despite twice-daily H2RA therapy should prompt consideration of PPI therapy or further evaluation 1
• Red flags such as severe epigastric pain, persistent vomiting with weight loss, or signs of dehydration require immediate evaluation for hyperemesis gravidarum or other complications 1

Prognosis

• Heartburn during pregnancy usually resolves soon after delivery 2, 7