How should dyspepsia be assessed and managed in a pregnant patient, including evaluation for alarm features and safe pharmacologic options?

Dyspepsia in Pregnancy: Assessment and Management

Initial Assessment and Alarm Features

In pregnant patients with dyspepsia, begin with empirical lifestyle modifications and antacids or sucralfate, reserving endoscopy for those with alarm features or symptoms refractory to H2-receptor antagonists after the first trimester. 1

Key Clinical History Elements

When evaluating dyspepsia in pregnancy, focus on:

• Duration and character of symptoms: Epigastric pain or burning, early satiation, postprandial fullness, nausea, and vomiting 2
• Alarm features requiring urgent evaluation: 2, 3
  • Dysphagia at any age
  • Persistent vomiting despite treatment
  • Hematemesis or signs of gastrointestinal bleeding
  • Unexplained weight loss (obtain objective evidence)
  • Odynophagia (strongly associated with significant findings, OR = 7.81) 4

Important Clinical Context

• Most pregnant women with dyspepsia have functional disease or GERD, and known ulcer disease often improves during pregnancy 5
• Approximately 80% of non-pregnant patients with dyspepsia ultimately have functional dyspepsia after investigation 2, 3
• The frequency and complication rate of peptic ulcer disease decrease significantly during pregnancy 1

Management Algorithm

First-Line Therapy (All Pregnant Patients)

Start with dietary and lifestyle modifications plus antacids or sucralfate as first-line therapy for dyspepsia in pregnancy. 1

• These agents are safe throughout pregnancy and should be the initial approach 1
• Many pregnant women unnecessarily suffer due to unrealistic expectations about medication teratogenicity 5

Second-Line Therapy (Persistent Symptoms)

If symptoms persist despite lifestyle changes and antacids, prescribe H2-receptor antagonists, which are recommended as safe and effective during pregnancy. 1

• H2-receptor antagonists are the next step when first-line measures fail 1
• This approach is appropriate for symptom control without requiring endoscopy in most cases 1

Third-Line Evaluation (Refractory or Severe Symptoms)

For symptoms that persist into the late second trimester, are refractory to H2-receptor antagonists, or are severe, perform upper endoscopy during the second or third trimester to rule out H. pylori infection, ulcer complications, or underlying malignancy. 5, 1

Key indications for endoscopy in pregnancy:

• Symptoms persisting beyond the late second trimester despite pharmacologic treatment 5
• Severe or refractory symptoms despite H2-receptor antagonist therapy 1
• Any alarm features present 5, 1

Fourth-Line Therapy (Severe Refractory Cases)

Proton pump inhibitor therapy may be considered during the second or third trimester for severe symptoms that continue despite H2-receptor antagonists and when endoscopy has been performed or is planned. 1

• Reserve PPI therapy for severe cases after other measures have failed 1
• Use only in second or third trimester, not first trimester 1

Critical Clinical Pitfalls to Avoid

Undertreatment Due to Teratogenicity Concerns

Do not withhold appropriate pharmacologic treatment due to exaggerated concerns about teratogenicity—many commonly used medications are safe and effective during pregnancy. 5

• Pregnant women often adopt an unnecessarily stoic posture based on unrealistic expectations 5
• It is appropriate to alleviate pain and suffering when safe options exist 5

Delayed Investigation of Serious Disease

Do not delay endoscopy when symptoms are persistent into late second trimester, refractory to treatment, or severe—underlying serious pathology must be ruled out sequentially. 5

• H. pylori infection, ulcer complications, and cancer should be suspected and ruled out in refractory cases 5
• More timely workup of non-obstetric disease during pregnancy lowers perinatal complications 5

Age-Based Endoscopy Thresholds Do Not Apply

The standard age threshold of ≥55 years for urgent endoscopy in non-pregnant patients 2, 3 is not relevant in pregnancy—instead, base the decision on symptom severity, refractoriness to treatment, and presence of alarm features 5, 1

When to Suspect Serious Underlying Disease

Consider urgent evaluation for:

• Tachycardia, normocytic anemia, leukocytosis, or hypoalbuminemia on admission (strong predictors of significant endoscopic findings) 4
• Upper gastrointestinal bleeding (OR = 3.81 for significant findings) 4
• Persistent vomiting (OR = 1.75 for significant findings) 4
• Odynophagia (OR = 7.81 for significant findings) 4
• Unexplained weight loss (OR = 2.05 for malignancy) 4