Dyspepsia and gastro-esophageal reflux during pregnancy
Overview
Dyspepsia is a term used to describe a number of symptoms associated with the upper gastrointestinal tract that may include upper abdominal pain or discomfort, a feeling of upper abdominal 'fullness' or 'heaviness', reflux, heartburn, belching, nausea, and vomiting...
Causes
Dyspepsia in pregnancy is commonly due to gastro-esophageal reflux. The cause of gastro-esophageal reflux in pregnancy is thought to involve both mechanical and hormonal factors:
- A decrease in lower esophageal sphincter pressure is considered to be the predominant factor. Rising levels of progesterone and estrogen are thought to be responsible for the decreased pressure.
- Altered esophageal and gastric motility and increased abdominal pressure may also contribute, but the evidence to support their role is uncertain.
Risk factors
The following risk factors have been associated with gastro-esophageal reflux symptoms in pregnancy:
- Symptoms of gastro-esophageal reflux prior to pregnancy.
- Increasing gestational age.
- Parity. The evidence for the following risk factors is less certain:
- Pre-pregnancy body mass index (BMI).
- Weight gain during pregnancy.
- Maternal age.
Complications
Symptoms usually resolve without complications; however:
- Dyspepsia during pregnancy may increase the risk of developing subsequent gastro-esophageal reflux symptoms in the future.
- Heartburn and gastro-esophageal reflux is associated with an increased severity of nausea and vomiting in pregnancy; managing heartburn and reflux may improve the severity of nausea and vomiting in pregnancy.
- Quality of life can be affected by dyspepsia symptoms.
- Rarely, erosive esophagitis, strictures, and bleeding may occur.
Diagnosis
Dyspepsia in pregnancy is predominantly caused by gastro-esophageal reflux disease (GERD). The diagnosis can be made on symptoms alone, which do not differ from the non-pregnant population.
Medical history
Ask about presenting symptoms and how they are affecting the woman's quality of life: heartburn and acid reflux are common, but people may also describe other symptoms including upper abdominal discomfort and anorexia. Alarm features (for example hematemesis, weight loss, dysphagia) that might suggest more serious underlying disease. Previous history of dyspepsia or reflux symptoms. Aggravating factors such as lying supine, eating a meal, and use of medications which can contribute to dyspepsia, such as nonsteroidal anti-inflammatory drugs. Features suggesting an illness unrelated to pregnancy (for example symptoms of fever, rigors, vomiting, and malaise). For more information, see the section on Differential diagnosis (below). Treatments already tried, especially over-the-counter medication (for example antacids).
Examination
Usually normal, investigations are generally not necessary. Where they are required, they are usually carried out in secondary care and may include:
- Manometry and pH probes.
- An upper GI endoscopy.
- Non-invasive testing for Helicobacter pylori, which may be delayed until after delivery.
Differential diagnosis
- Nausea and vomiting of pregnancy, including hyperemesis gravidarum. For more information - see note, Nausea/vomiting in general practice.
- Pre-eclampsia.
- HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets).
- Acute fatty liver of pregnancy (rare).
- Disorders unrelated to pregnancy, for example: Gastric cancer, peptic ulcer disease, pancreatitis and irritable bowel syndrome.
Management
Nonpharmacologic treatment
Self-care advice should pharmacist give. Give lifestyle advice as first-line management. Advise the woman to eat smaller meals more frequently (every 3 hours), not eat late at night (or less than 3 hours before bedtime), and avoid known irritants (for example alcohol, caffeine, fruit juices and carbonated drinks, chocolate, and fatty and spicy foods). Keep a food diary to identify triggers. Try raising the head of their bed by 10–15 cm. Avoid medications that may cause or worsen symptoms, if appropriate (for example calcium-channel antagonists, antidepressants, and nonsteroidal anti-inflammatory drugs). Stop smoking (if applicable). Advise the woman to return if symptoms are not controlled by lifestyle changes, or if worsening or new symptoms develop.
Pharmacologic treatment
Antacids and alginates are recommended as first-line treatments if symptoms are relatively mild and are not controlled adequately by lifestyle changes. Antacid products containing combinations of aluminum and magnesium are recommended on an 'as required' basis, for example Maalox (off-label in pregnancy, not recommended for under 14 years of age) and Mucogel 5-10 mL after meals and at bedtime. Alginate products (Gaviscon Advance) are particularly useful if symptoms of gastro-esophageal reflux are dominant. Calcium-containing products are recommended for short-term or occasional use.Products containing sodium bicarbonate or magnesium trisilicate are not recommended in pregnancy.
If symptoms are severe, or persist despite treatment with an antacid or alginate, consider prescribing an acid-suppressing drug. For more information, see topic on Gastrointestinal agents during pregnancy and breastfeeding. Recommend ranitidine (Zantac) (off-label in pregnancy) or any H2RA. The usual dosage for gastro-esophageal reflux disease; 150 mg, twice a day. This is consistent with a randomized control trial which found a lower dosage (150 mg, once a day) to be ineffective. On April 1, 2020, the U.S. Food and Drug Administration (FDA) asked manufacturers to withdraw all prescription and over-the-counter (OTC) ranitidine drugs from the market immediately. OR, omeprazole (Losec) or any PPI (the recommended dose is 20 mg once daily, however, some people may have adequate relief of symptoms using 10 mg daily, so consider individual dose adjustment).
Referral criteria
Refer immediately (same-day) if there is dyspepsia and significant acute gastrointestinal bleeding. Refer urgently to a gastroenterologist if there are features suggestive of malignancy.
Refer to an obstetrician if symptoms suggest a pregnancy-related disorder other than dyspepsia, for example pre-eclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) — use clinical judgement regarding urgency of referral depending on the presenting problem.
References
- Body C, Christie JA. Gastrointestinal Diseases in Pregnancy: Nausea, Vomiting, Hyperemesis Gravidarum, Gastroesophageal Reflux Disease, Constipation, and Diarrhea. Gastroenterol Clin North Am. 2016;45(2):267-283.
- Ali RA, Egan LJ. Gastroesophageal reflux disease in pregnancy. Best Pract Res Clin Gastroenterol. 2007;21(5):793-806.
- Bor S, Kitapcioglu G, Dettmar P, Baxter T. Association of heartburn during pregnancy with the risk of gastroesophageal reflux disease. Clin Gastroenterol Hepatol. 2007;5(9):1035-1039.
- Gerson LB. Treatment of gastroesophageal reflux disease during pregnancy. Gastroenterol Hepatol (N Y). 2012;8(11):763-764.
