From the Guidelines
Reflux during pregnancy can be effectively managed through a combination of lifestyle modifications and medications when necessary, with the initial approach focusing on dietary changes and non-pharmacologic interventions. The management of reflux in pregnancy should prioritize minimizing symptoms while ensuring the safety of both the mother and the fetus. According to the most recent guidelines, including the expert review published in Gastroenterology in 2024 1, the first step in managing reflux symptoms during pregnancy involves diet and lifestyle modification. This includes reducing spicy, fatty, acidic, and fried foods to help reduce heartburn, and eating small, frequent, and bland meals, such as the BRAT (bananas, rice, applesauce, and toast) diet, which can also be helpful in nausea and vomiting of pregnancy (NVP).
Key lifestyle modifications include:
- Eating smaller, more frequent meals to reduce symptoms of reflux
- Avoiding trigger foods that can exacerbate heartburn and NVP
- Not eating within 2-3 hours of bedtime to reduce nighttime reflux
- Elevating the head of the bed by 6-8 inches to prevent stomach acid from flowing back into the esophagus
- Avoiding tight clothing around the abdomen, which can increase pressure on the stomach and worsen reflux
For mild symptoms, non-medication approaches should be tried first. If these are insufficient, antacids containing calcium carbonate or aluminum hydroxide (like Tums) are generally safe as first-line medication therapy. However, it's crucial to consult with a healthcare provider before starting any medication during pregnancy. The American College of Obstetricians and Gynecologists (ACOG) recommends ginger (a 250-mg capsule 4 times daily) and vitamin B6 (pyridoxine, 10–25 mg every 8 hours) for NVP, which can sometimes be associated with reflux symptoms 1.
In cases where symptoms persist, H2-blockers such as ranitidine or famotidine can be considered, though their use should be guided by the healthcare provider, taking into account the severity of symptoms and the gestational age of the pregnancy. For severe cases, proton pump inhibitors like omeprazole may be prescribed, but their use should be at the lowest effective dose for the shortest duration possible, due to potential concerns regarding their safety in pregnancy 1. Always, the decision to start any medication during pregnancy should be made in consultation with a healthcare provider to ensure the chosen treatment balances symptom relief with pregnancy safety concerns.
From the FDA Drug Label
14.3 Symptomatic Gastroesophageal Reflux Disease (GERD) Orally-administered Famotidine was compared to placebo in a U.S. trial that enrolled patients with symptoms of GERD and without endoscopic evidence of esophageal erosion or ulceration.
14.4 Erosive Esophagitis Due to GERD Healing of endoscopically-verified erosion and symptomatic improvement were studied in a U.S. and an international double-blind trials.
Treatment of GERD. Symptomatic relief commonly occurs within 24 hours after starting therapy with ranitidine 150 mg twice daily.
Treatment of endoscopically diagnosed erosive esophagitis Symptomatic relief of heartburn commonly occurs within 24 hours of therapy initiation with ranitidine 150 mg 4 times daily.
Treatment of Reflux in Pregnancy is not directly addressed in the provided drug labels. However, the labels do provide information on the treatment of GERD and erosive esophagitis with Famotidine and Ranitidine.
- Famotidine has been shown to be effective in treating symptomatic GERD and erosive esophagitis.
- Ranitidine is also indicated for the treatment of GERD and erosive esophagitis. It is essential to consult the FDA drug label for the specific medication and condition being treated, as well as consult with a healthcare professional for guidance on treatment during pregnancy 2, 2, 3.
From the Research
Treatment Approach
- The treatment of reflux in pregnancy should follow a step-up approach, starting with lifestyle modification as the first step 4, 5, 6.
- If heartburn is severe, medication should be started after consultation with a physician 4.
Lifestyle Modifications
- Lifestyle and dietary modifications may be all that are required in mild cases of reflux 7, 6.
- These modifications are helpful for the majority of patients, but are not sufficient to control symptoms in many cases, and medication is required 6.
Medication Options
- The preferred choice of antacids is calcium-containing antacids 4.
- If symptoms persist with antacids, sucralfate can be introduced 4, 7, 8.
- Histamine-2 receptor antagonists (H2RAs) can be used if symptoms persist, with ranitidine being a preferred option due to its documented efficacy and safety profile in pregnancy 7, 5, 8.
- Proton pump inhibitors (PPIs) are reserved for women with intractable symptoms or complicated reflux disease, and should be used with caution, considering the benefit-harm ratio for the mother and fetus 4, 7, 5, 8.
- Lansoprazole may be the preferred PPI due to its safety profile in animals and case reports of safety in human pregnancies 7, 5.