What is the recommended treatment approach for gastro‑esophageal reflux disease in pregnant women, including lifestyle measures and pregnancy‑compatible medications?

GERD Treatment in Pregnancy

Start with lifestyle modifications and calcium-containing antacids, then escalate stepwise through H2-receptor antagonists (ranitidine preferred), and reserve PPIs only for severe, intractable symptoms that fail all other therapies. 1, 2

Stepwise Treatment Algorithm

Step 1: Lifestyle and Dietary Modifications (First-Line for All Patients)

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

Step 2: Antacids (First-Line Medication)

• Calcium carbonate is the preferred antacid due to minimal fetal exposure from nonsystemic absorption and strong safety data 2
• Aluminum/magnesium hydroxide combinations are also safe alternatives 1
• Use on-demand for breakthrough symptoms 3, 4

Step 3: Sucralfate (If Symptoms Persist)

• Administer sucralfate 1g orally three times daily if symptoms continue despite lifestyle modifications and antacids 2
• Sucralfate is considered safe throughout pregnancy due to minimal systemic absorption 5, 4

Step 4: H2-Receptor Antagonists (Before Escalating to PPIs)

• Ranitidine 150mg twice daily is the preferred H2RA due to documented efficacy and safety profile, even in the first trimester 2, 4
• H2RAs are more effective than placebo and should be used before considering PPIs 2
• Avoid nizatidine during pregnancy 5

Step 5: Proton Pump Inhibitors (Reserved for Severe Cases)

• PPIs should only be used for intractable symptoms or complicated reflux disease that has failed all other therapies 2, 4
• Lansoprazole may be the preferred PPI based on favorable animal safety studies and human case reports 2, 4
• Use at the lowest effective dose for the shortest duration necessary 1
• Pantoprazole is also considered acceptable when clinically indicated, dosed based on actual body weight 1

Medications to Avoid

• Do not use metoclopramide as it has an unfavorable risk-benefit profile and is not recommended for GERD (Grade D recommendation) 1, 2
• Avoid metoclopramide and ondansetron before 10 weeks gestation due to possible teratogenic risks 2

Trimester-Specific Considerations

First Trimester

• Prioritize lifestyle modifications, antacids, and sucralfate 2
• Use H2RAs only if clearly needed 2
• Exercise particular caution with PPIs 2

Second and Third Trimesters

• Ranitidine can be safely used for severe symptoms 2
• PPIs remain reserved for intractable cases 2

When to Escalate Care

• Alarm symptoms (dysphagia, bleeding, weight loss) require multidisciplinary team involvement 1
• Troublesome dysphagia warrants endoscopy with biopsy to evaluate for eosinophilic esophagitis 2
• Symptoms persisting despite twice-daily H2RA therapy should prompt consideration of PPI therapy or further evaluation 2
• Severe epigastric pain, persistent vomiting with weight loss, or dehydration require immediate evaluation for hyperemesis gravidarum 2

Endoscopy Considerations

• Upper endoscopy can be performed safely during pregnancy, preferably in the second trimester 1
• Position patient in left lateral decubitus 1
• Use cautious midazolam dosing if sedation is needed 1

Critical Pitfalls to Avoid

• Do not withhold treatment entirely out of excessive caution, as untreated severe symptoms can progress to hyperemesis gravidarum with maternal and fetal risks 2
• Do not assume all heartburn requires medication, as many cases (30-90% of pregnancies) respond to lifestyle modifications alone 1, 2
• Do not use twice-daily PPI dosing empirically—if symptoms require this level of suppression, consider the patient a treatment failure requiring further evaluation 2
• Delaying treatment of severe symptoms can lead to dehydration, malnutrition, and adverse pregnancy outcomes 1

Prognosis and Follow-Up

• Most reflux symptoms resolve after delivery as progesterone effects on the lower esophageal sphincter normalize 1
• Serious reflux complications during pregnancy are rare 2, 3
• Review patients at least monthly during first and second trimesters, increasing frequency as needed 1
• Reassess symptom control and taper medications to lowest effective dose when adequate response is achieved 1