Reflux in pregnancy is common due to both hormonal and mechanical factors. Increased levels of progesterone slow the digestive system and can relax the lower oesophageal sphincter. This, combined with the pressure of a growing baby pressing on the stomach, causes stomach acid to pass into the oesophagus.
Approximately 30–50% of women suffer from heartburn at some point during their pregnancy, but erosive oesophagitis, bleeding and strictures sometimes occur in rare cases. Symptoms may start at any point during pregnancy, but are more common in the third trimester. In addition to causing considerable discomfort, reflux symptoms in pregnancy can contribute to patient stress and can significantly impact quality of life.
About the patient
Sarah is 30-weeks pregnant and has been suffering from progressively worsening reflux over the last three weeks. Now she is getting symptoms every day, which are causing her substantial discomfort. Her symptoms are especially bad at night, making it harder to get a good night’s sleep and making her tired during the day.
In pregnant women, the main aim of treating reflux is to provide symptomatic relief with the hope that this will improve how the patient is feeling. Stress can have negative effects on the unborn baby, therefore it is important that these symptoms are acknowledged and women are given the confidence to use appropriate medication to treat their symptoms.
Pregnant women are often cautious about taking medications in pregnancy out of concerns for the health of their baby. While clinicians are rightfully wary of prescribing some classes of medication, many are overly cautious, resulting in pregnant women experiencing discomfort unnecessarily. Multiple drugs providing symptomatic relief from reflux are available and should not be withheld from pregnant women.
To address the woman’s concerns around their condition and the effect of any medications on their baby, they should be provided with verbal and written information on the symptoms and management of reflux. Patients should be reassured that, although the symptoms are unpleasant, acid reflux may not affect their baby. As well as potentially harming the unborn child, stress can also worsen reflux symptoms, so women may benefit from being taught relaxation techniques.
The investigation of reflux in pregnant women is the same as in the general adult population and should include taking a detailed clinical history. Certain medications are possible causes of reflux, so clinicians should check whether patients are taking any of the following classes of drug:
- Non-steroidal anti-inflammatory drugs
- Calcium channel blockers
- Tricyclic antidepressants.
As a first approach, clinician should give women advice on how they can improve their reflux symptoms through lifestyle changes. Women should be advised to:
- Eat smaller portions more frequently, and not less than three hours before bedtime
- Maintain a balanced diet containing lots of fruit and vegetables, dairy and carbohydrates, while avoiding caffeine, tomatoes, peppermint tea, spicy foods and foods high in fat and sugar
- Some women may qualify for the Healthy Start programme, which will provide them with vouchers to spend on bread, milk, vegetables and vitamins
- Avoid smoking and drinking alcohol as this can worsen reflux symptoms and, more importantly, can cause life-threatening complications for the baby
- Prop up their upper body while they sleep to decrease the amount of acid rising up into the oesophagus
- People should avoid using additional pillows as this can increase intra-abdominal pressure and worsen symptoms. Instead, they can prop up the head of the bed by 10&endash;15 cm using bricks, books or something similar
- Return if symptoms do not resolve with lifestyle changes, or if worsening/new symptoms develop.
If symptoms do not improve with lifestyle changes
NICE recommends antacids and alginates as the first-line pharmacological intervention if symptoms are mild and remain uncontrolled following lifestyle changes. Women can be reassured that these medications are used frequently in pregnancy and there is no evidence of harm to their unborn baby. Clinical trials in more than 500 pregnant women have shown that alginates can be used in pregnancy and their use does not result in birth defects (‘congenital malformations’), fetotoxicity or neonatal complications.
Severe or persistent symptoms
For some women, lifestyle changes and alginates or antacids may not be sufficient. If symptoms are severe, or persist despite antacid or alginate therapy, NICE recommends considering acid-supressing drugs, such as proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs). Like alginates, PPIs are safe in pregnancy and are not linked with any birth defects.
If symptoms become so bad that the patient can no longer eat sufficiently, or if symptoms do not respond to lifestyle changes or medications, the patient should be referred to a gastroenterologist.
In most pregnant women, reflux will rapidly resolve after giving birth and continued treatment is not necessary.
- Individuals presenting with reflux symptoms with gastrointestinal bleeding (a sign of Helicobacter pylori infection) should be referred for a specialist appointment the same day
- Individuals with features suggestive of malignancy should be referred urgently
- Women with new abdominal pain in pregnancy without other symptoms of reflux warrant thorough assessment for other conditions before a diagnosis of reflux can be made. Pregnancy-specific diagnoses such as pre-eclampsia and HELLP syndrome (haemolysis, elevated liver enzymes and low platelets) should be considered and women should be referred urgently to an obstetrician if these are suspected.
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This content hub is funded by RB. The view and opinions presented here represent those of the doctors and do not reflect those of RB.
Date of preparation: January 2020