This is the second half of my blog regarding heartburn in pregnancy. The first half explained the causes and symptoms and together, hopefully, will quickly help you solve the burning symptoms of heartburn should they arise.
Therapy
As in most other conditions during pregnancy, behavioral modifications are always attempted initially. Drug therapy is reserved for the more severe cases. Avoidance of all medications during the first trimester, unless absolutely essential, is always considered sound advice.
- Lifestyle Changes
- Elevate the head of the bed.
- Avoid bending, stooping, or position changes that increase the reflux.
- Small frequent meals.
- Avoid late dinners or snacks within 3 hours of lying down.
- Avoid dietary fat and other spicy esophageal irritants such as citrus juices, tomato products, coffee, chocolate, and peppermint.
- Drug Therapy
- Antacids: The treatment of choice. The antacids neutralize the acid of the stomach juice and thus prevent its caustic effects on the lining of the esophagus.
- Antacids are best used in liquid form or chewable tablets.
- Antacids containing calcium, aluminum and magnesium are considered safe, as their absorption into the bloodstream is minimal.
- Preparations containing phosphates are less effective than carbonates, hydroxides, or oxides.
- Some antacids contain sodium bicarbonate and therefore are high in sodium. Those should be used in moderation as high sodium can contribute to fluid retention and overload in both mother and fetus.
- Poor absorption of iron is a side effect of all antacids and can lead to anemia. An increase in iron supplementation may be indicated.
- Some preparations combine antacids with other agents for a synergistic effect. Alginic acid (Gaviscon) coats the lining of the esophagus and prevents acid corrosion. It is considered safe in pregnancy. On the other hand, Simethicone, commonly found in some antacids, is best avoided in pregnancy despite its lack of absorption due to limited data on its effect on the fetus.
- Excessive doses of antacids can have major side effects. Chronic use of aluminum can have increased deep tendon reflexes and elevated calcium levels. And elevated magnesium can cause diarrhea, decreased muscle tone, and cardiovascular and respiratory depression.
- Dosages are generally 1 to 8 tablets chewed in divided dosages 3 to 4 times daily between meals and at bedtime. Liquid forms are 5 to 30 cc depending upon the particular medication used.
- Sucralfate: Sucralfate, (Carafate- 1 gram three times a day), similar to antacids, is an aluminum salt that inhibits gastric acid, and does not get absorbed. It is considered safe in pregnancy and in breast-feeding women.
- GI Stimulant or Prokinetic agents: Metoclopramide is a drug that raises lower esophageal pressure and is also an anti-emetic. It is very effective in controlling heartburn of pregnancy and considered safe in pregnancy. A recent study in The New England Journal of Medicine by Matok concluded that metoclopramide in the first trimester was not associated with increased risks of any major congenital malformations, perinatal death, preterm birth, low birth weight, or low Apgar scores.
- H2 Receptor Blockers: (Pepsid and Axid, Cimetidine, Famotidine, and Nizatidine) The drugs in this category inhibit gastric acid secretion. These drugs are used in women with severe heartburn. Even though animal studies have not shown any adverse effects of the fetus, very little data is available in humans. These drugs should therefore be avoided in pregnancy if possible.
- Proton pump inhibitors: (Prilosec, Lansoprazole) Similar to H2 Blockers, these drugs also block gastric acid secretion. These drugs are more effective and have more rapid onset of action in relieving the symptoms of GERD compared to H2 receptor blockers. Two recent articles, one published by The American College of Gastroenterology by Gill in 2009 and another published by New England Journal of Medicine in 2010 by Pasrternick confirmed the safety of the use of Prilosec during pregnancy. Further studies need to be done to determine the safety of use during lactation and also risks with other drugs in this category.
- Antacids: The treatment of choice. The antacids neutralize the acid of the stomach juice and thus prevent its caustic effects on the lining of the esophagus.
In summary: Reflux is common in pregnancy. In most cases the condition responds well to lifestyle changes. More severe cases may require drug therapy. Antacids alone or in combination with alginic acid used after meals or at bedtime provide excellent relief in most cases. In refractory cases, H2 receptor blockers should be considered but used sparingly (once a day rather than twice a day) after dinner. PPI’s as of recent data have now also been proven to be both safe and effective drug therapy.
Active management of heartburn can improve the pregnant woman’s quality of life.
