What is the recommended treatment algorithm for heartburn in a pregnant woman?

Treatment Algorithm for Heartburn in Pregnancy

Start with lifestyle modifications and calcium-containing antacids, then escalate stepwise through sucralfate, H2-receptor antagonists (ranitidine preferred), and reserve PPIs only for severe refractory cases, prioritizing fetal safety while effectively managing symptoms that affect 30-90% of pregnant women. 1

First-Line: Lifestyle Modifications

Begin immediately with non-pharmacologic interventions before considering medications. 1

• Elevate the head of the bed by 6-8 inches to reduce nighttime heartburn and regurgitation 1
• Consume 5-6 small, frequent meals daily rather than 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
• Weight loss is recommended for overweight or obese patients to prevent or postpone the need for acid suppression 1

Second-Line: Calcium-Containing Antacids

If lifestyle modifications fail to control symptoms, initiate calcium carbonate antacids as first-line pharmacologic therapy. 1

• Calcium-containing antacids (such as calcium carbonate) are safe throughout pregnancy due to minimal fetal exposure from nonsystemic absorption 1
• These agents are recommended by major gastroenterology and obstetric societies with high-level evidence supporting safety and efficacy 1, 2
• Nonparticulate antacids (sodium citrate or sodium bicarbonate) are also effective in decreasing gastric acidity and safe throughout pregnancy 1

Third-Line: Sucralfate

If symptoms persist despite lifestyle modifications and antacids, escalate to sucralfate. 1, 3, 4

• Sucralfate 1g orally three times daily is the next step 1
• One trial demonstrated that sucralfate provided complete relief of heartburn more effectively than dietary/lifestyle advice alone (RR 2.41,95% CI 1.42 to 4.07) 5
• Sucralfate is considered safe throughout pregnancy as a first-line medical therapy 3, 4

Fourth-Line: H2-Receptor Antagonists

H2-receptor antagonists should be used before escalating to PPIs, as they are more effective than placebo and have documented safety profiles. 1, 3

• Ranitidine 150mg twice daily is the preferred H2RA due to its documented efficacy and safety profile in pregnancy, even in the first trimester 1, 3
• In the first trimester, use H2RAs only if clearly needed 1
• In the second and third trimesters, ranitidine can be safely used if symptoms are severe 1
• All H2RAs (except nizatidine) are safe during lactation 4

Fifth-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, 3, 4

• 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 caution, particularly in the first trimester 1
• All PPIs except omeprazole are FDA category B drugs during pregnancy 4
• Do not use twice-daily PPI dosing empirically; if symptoms require this level of suppression, the patient should be considered a treatment failure and evaluated further 1

Evidence Quality and Supporting Data

The moderate-quality evidence from two RCTs involving 256 women demonstrates that pharmaceutical treatment provides complete heartburn relief more often than placebo (RR 1.85,95% CI 1.36 to 2.50) 5. However, the evidence base remains limited, with only small-scale trials available 5.

Pathophysiology Context

Heartburn affects approximately 30-90% of pregnant women, most commonly in the second half of pregnancy 1. The predominant mechanism is progesterone-induced direct relaxation of the lower esophageal sphincter, with the gravid uterus mechanically displacing the stomach upward and leftward 1, 3, 4.

Critical Safety Considerations

• Metoclopramide and ondansetron should be avoided before 10 weeks gestation due to possible risks, though they may be considered for hyperemesis gravidarum in later pregnancy 1
• Metoclopramide is not recommended as monotherapy or adjunctive therapy for GERD syndromes (Grade D recommendation) 1
• Serious reflux complications during pregnancy are rare 1, 3, 4

Common Pitfalls to Avoid

• Do not assume all heartburn requires medication—many cases respond adequately to lifestyle modifications alone 1
• Do not withhold treatment entirely out of excessive caution—untreated severe symptoms can progress to hyperemesis gravidarum, which carries its own maternal and fetal risks 1
• Do not skip steps in the algorithm—always attempt lifestyle modifications and antacids before advancing to H2RAs or PPIs 1, 3, 4, 6

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