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

Treatment of Diarrhea in Pregnancy

For pregnant women with diarrhea, aggressive oral rehydration therapy is the cornerstone of treatment, with hospitalization for intravenous fluids if severe dehydration develops, while antiperistaltic agents like loperamide must be avoided entirely. 1, 2

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, 2

For mild to moderate dehydration:

• Initiate oral rehydration therapy immediately using oral rehydration salts in small, frequent volumes 1, 2
• Continue regular diet including starches, cereals, yogurt, fruits, and vegetables while avoiding foods high in simple sugars and fats 1

For severe dehydration:

• Hospitalize immediately for intravenous fluid replacement and close monitoring 1, 2
• Implement anticoagulant thromboprophylaxis during hospitalization, preferably with low-molecular-weight heparin over unfractionated heparin 1, 2

Diagnostic Evaluation

Obtain stool cultures for enteroinvasive bacterial infections and Clostridioides difficile testing. 1, 2 Review travel and contact history carefully, testing for amoebic or Shigella dysentery in patients with relevant exposures. 1, 2

If diarrhea persists beyond 5 days, high fever develops, or dysentery occurs, consider bacterial pathogens that require antibiotic treatment. 1, 2

Antimicrobial Therapy When Indicated

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

Appropriate antibiotic choices include:

• Ampicillin
• Cefotaxime
• Ceftriaxone
• Trimethoprim-sulfamethoxazole 1, 2

Fluoroquinolones must be completely avoided during pregnancy due to potential fetal risks. 1, 2

Symptom Management for Nausea and Vomiting

When nausea accompanies diarrhea, metoclopramide can be used with less drowsiness, dizziness, and dystonia compared to promethazine. 1, 2 Ondansetron may enhance compliance with oral rehydration therapy and decrease hospitalization rates, though use should be considered carefully before 10 weeks of pregnancy. 1, 2

For mild cases, supplement with vitamin B6 (pyridoxine). 1, 2 If severe vomiting occurs, give thiamine 100 mg daily for a minimum of 7 days, then 50 mg daily maintenance to prevent refeeding syndrome and Wernicke encephalopathy. 1

Special Considerations for Inflammatory Bowel Disease

For pregnant women with known IBD experiencing a flare, flexible sigmoidoscopy or colonoscopy may be performed if results will affect antenatal management. 1, 2 Continue maintenance therapy with 5-ASA, thiopurines, systemic corticosteroids, or anti-TNF therapy throughout pregnancy. 2

For pregnant women with ulcerative colitis who have mild to moderate disease flare while on 5-ASA maintenance therapy, optimize combination 5-ASA oral and rectal therapy to induce symptomatic remission. 3

For pregnant women with IBD who have a disease flare on optimal 5-ASA or thiopurine maintenance therapy, treat with systemic corticosteroids or anti-TNF therapy to induce symptomatic remission. 3

Limit radiologic investigations to ultrasound and MRI where possible, avoiding gadolinium. 1, 2 Do not delay urgent surgery to manage complications solely due to pregnancy. 1, 2

Thromboprophylaxis Requirements

Outpatients with active inflammatory bowel disease should receive VTE prophylaxis during the third trimester unless contraindicated. 1, 2

Critical Pitfalls to Avoid

Do not use antiperistaltic agents like loperamide as they shift focus away from appropriate fluid and electrolyte therapy and can cause serious side effects including ileus. 1 While one study of 105 pregnancies found no increased risk of major malformations with loperamide use 4, current guidelines from the CDC explicitly recommend against antiperistaltic drugs in pregnant women with diarrhea. 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

Prevention of Recurrent Transmission

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