What is the appropriate management for a third‑trimester pregnant woman presenting with acute gastroenteritis (diarrhea) without red‑flag features?

Management of Acute Gastroenteritis in Third Trimester Pregnancy

For a third-trimester pregnant woman with acute gastroenteritis without red flags, prioritize oral rehydration therapy as first-line treatment, continue regular diet as tolerated, avoid antimotility agents, and initiate VTE prophylaxis if hospitalization is required. 1, 2

Immediate Assessment

Evaluate hydration status systematically by checking for:

• Orthostatic hypotension 1
• Decreased skin turgor and dry mucous membranes 1
• Urine output (decreased output signals need for escalation) 2
• Accurate body weight 1

Laboratory studies (serum electrolytes, potassium, magnesium) should be obtained when clinical signs suggest abnormalities, as pregnant patients are at higher risk for electrolyte depletion. 1, 2

First-Line Treatment: Oral Rehydration

Initiate reduced osmolarity oral rehydration solution (ORS) immediately for mild to moderate dehydration. 2 This is the cornerstone of management and should be given in small, frequent volumes. 1 Continue ORS until clinical dehydration is corrected, then use for maintenance and to replace ongoing stool losses. 2

If the patient cannot tolerate adequate oral volumes, consider nasogastric administration of ORS rather than immediately escalating to IV fluids. 2 Glucose-containing drinks or electrolyte-rich soups serve as alternatives. 2

Dietary Management

Resume usual diet immediately after rehydration begins, with small, light meals guided by appetite. 2 Specifically recommend:

• Starches, cereals, yogurt, fruits, and vegetables 1
• 3-4 servings each of fruits and vegetables daily 3

Avoid fatty, heavy, spicy foods, caffeine, and foods high in simple sugars. 1, 2 Consider avoiding lactose-containing foods if diarrhea persists beyond a few days. 2

Symptom Management

Antiemetics may be considered once adequately hydrated, but are not a substitute for fluid and electrolyte therapy. 2 Ondansetron may enhance compliance with oral rehydration therapy, though its use should be considered carefully before 10 weeks of pregnancy. 1 Metoclopramide can be used for nausea with less drowsiness compared to promethazine. 1

Critical: Avoid antimotility drugs like loperamide, especially if fever or inflammatory diarrhea is suspected, as they shift focus away from appropriate fluid therapy and can cause serious side effects including ileus. 1, 2

Diagnostic Workup

Obtain stool cultures for enteroinvasive bacterial infections and Clostridioides difficile testing in pregnant women with gastroenteritis. 4, 1 Carefully review travel and contact history, with appropriate testing for amoebic or Shigella dysentery if relevant travel history exists. 4, 1

If diarrhea persists beyond 48-72 hours or warning signs develop (high fever, bloody stools), consider expanded stool studies for infectious pathogens. 2

When to Hospitalize and Escalate Care

Hospitalize for severe dehydration requiring intravenous fluid replacement with isotonic fluids (lactated Ringer's or normal saline). 1, 2 Specific indications include:

• Inability to maintain hydration orally 1
• Decreased urine output 1
• No improvement within 48 hours 2
• Development of high fever or frank blood in stools 1, 2
• Signs of shock or severe dehydration 2

Critical: Pregnant women hospitalized for gastroenteritis must receive anticoagulant thromboprophylaxis during hospitalization, with low-molecular-weight heparin preferred over unfractionated heparin. 1, 2 For outpatients with active disease in the third trimester, VTE prophylaxis should be initiated unless contraindicated. 4, 1

Antimicrobial Therapy

For most viral gastroenteritis, antibiotics are not indicated. 4 However, specific bacterial pathogens require treatment:

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 choices include:

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

Fluoroquinolones must be avoided during pregnancy due to potential fetal risks. 1, 2, 5

Adjunctive Therapies

Probiotics may be offered to reduce symptom severity and duration in immunocompetent pregnant patients with infectious diarrhea. 2

Supplement with vitamin B6 (pyridoxine) for mild nausea. 1 If severe vomiting has occurred, give thiamine 100 mg daily for minimum 7 days, then 50 mg daily maintenance, to prevent refeeding syndrome and Wernicke encephalopathy. 1

Prevention of Recurrent Transmission

Household contacts should be evaluated for asymptomatic carriage if Salmonella or Shigella is confirmed, to prevent recurrent transmission. 1, 2

Common Pitfalls to Avoid

• Never rely on antidiarrheal agents as primary therapy 1
• Do not withhold necessary interventions solely because the patient is pregnant 4
• Avoid gadolinium if MR imaging is needed 4, 1, 2
• Do not delay urgent evaluation for red flag symptoms (bloody diarrhea, high fever, severe dehydration) 1, 2

Mental Health Considerations

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