Heartburn during pregnancy

Heartburn is a common complaint during pregnancy; the incidence is reported to be between 17% and 45% (1):

• heartburn and regurgitation are the main symptoms of gastroesophageal reflux disease (GORD)(1,2)
• symptoms can progress throughout pregnancy but typically resolve after delivery
  • symptoms are often worse in the third trimester, with 10.1% of women having daily heartburn and 40.7% with weekly regurgitation (2)
• effect of GORD on pregnancy outcomes has been examined in several studies, with no significant differences in birth outcomes for women with (GORD) (2)
• GORD symptoms often occur after meals and in the supine position

GORD symptoms can occur very early in pregnancy because of elevation of progesterone, which relaxes smooth muscle, including the lower esophageal sphincter (LES).

Diagnosis of GORD in pregnancy

• is primarily based on symptoms reported, typically including symptoms of heartburn and/or regurgitation (2)
• exclude red flag features (such as upper or lower gastrointestinal tract bleeding, dysphagia, epigastric mass, weight loss) that would suggest more significant underlying disease
• typically, no laboratory tests are warranted unless possible significant underlying cause (2)

Management

Lifestyle management

• avoid eating late at night or within 3 hours of laying down and raising the head of the bed or sleeping on a wedge pillow maybe helpful particularly when nocturnal regurgitation is present (2)
  • reduction of fatty foods is recommended
  • avoidance of specific foods and drinks
    • meats, caffeine and carbonated beverages may be associated with reflux symptoms during pregnancy
    • alcohol and nicotine should be avoided to both control symptoms and to minimize maternal and fetal harm
    • specific food triggers, such as spicy foods, that correlate with symptoms should be minimized or avoided if they are troublesome
• smoking cessation advice (if applicable)

Pharmacological management

First-line intervention - antacids and alginates are recommended as first-line treatments if symptoms are not controlled adequately by lifestyle management:

• effectively and immediately relieve heartburn symptoms
• magnesium-containing, aluminum-containing, or calcium-containing antacids have not been found to be teratogenic in animal studies (2)
  • is not recommended to have products containing sodium bicarbonate or magnesium trisilicate during pregnancy
• sodium alginate antacids form a barrier in the stomach to prevent reflux of gastric contents into the oesophagus, in addition to antacid effects from their magnesium and calcium content, and are effective in pregnancy
  • alginates for heartburn examples include Gaviscon (alginic acid/sodium alginate) and Peptac (sodium alginate + antacids)
  • alginates are generally considered safe during pregnancy (2)

If symptoms are not controlled with first-line therapies then consider either an histamine-2 receptor antagonists (HrRA) or a proton pump inhibitor (PPI).

Histamine-2 receptor antagonists (H2RAs)

• study evidence assessing exposed and nonexposed pregnant patients did not identify a difference in fetal safety for congenital malformations, spontaneous abortions, preterm delivery, and small for gestational age or fetal growth (2)
• in the UK, the preferred H2 receptor antagonist option would be famotidine, but the manufacturer does not recommend use in pregnancy, and advises it should only be prescribed if clearly required
• a useful resource for shared decision making is the leaflet provided by the UK Teratology Information Service (UKTIS)
  • UKTIS, BUMPS: H2 receptor antagonists use in pregnancy

Proton pump inhibitors

• are considered the most effective antireflux medications
  • a large cohort study examining live births with exposure to PPIs between 4 weeks before conception and the end of the first trimester of pregnancy, the authors identified that there was no increased risk of major birth defects compared with the cohort of live births without PPI exposure (3)
• in the UK, the British National Formulary (BNF) notes that the use of omeprazole in pregnancy is not known to be harmful
• a useful resource for shared decision making is the leaflet provided by UKTIS
  • UKTIS, BUMPS: Omeprazole use in pregnancy

Reference:

1. Vazquez JC. Heartburn in pregnancy. BMJ Clin Evid. 2015 Sep 8;2015:1411.
2. Dunbar K, Yadlapati R, Konda V. Heartburn, Nausea, and Vomiting During Pregnancy. Am J Gastroenterol. 2022 Oct 1;117(10S):10-15.
3. Pasternak B, Hviid A. Use of proton-pump inhibitors in early pregnancy and the risk of birth defects. N Engl J Med 2010;363:2114–23