Review Article: The Management of Heartburn in Pregnancy

J.E. Richter

Disclosures

Aliment Pharmacol Ther. 2005;22(9):749-757. 

In This Article

Summary and Introduction

Summary

Heartburn is a normal consequence of pregnancy. The predominant aetiology is a decrease in lower oesophageal sphincter pressure caused by female sex hormones, especially progesterone. Serious reflux complications during pregnancy are rare; hence upper endoscopy and other diagnostic tests are infrequently needed. Gastro-oesophageal reflux disease during pregnancy should be managed with a step-up algorithm beginning with lifestyle modifications and dietary changes. Antacids or sucralfate are considered the first-line drug therapy. If symptoms persist, any of the histamine2-receptor antagonists can be used. Proton pump inhibitors are reserved for women with intractable symptoms or complicated reflux disease. All but omeprazole are FDA category B drugs during pregnancy. Most drugs are excreted in breast milk. Of systemic agents, only the histamine2-receptor antagonists, with the exception of nizatidine, are safe to use during lactation.

Introduction

Heartburn is estimated to occur in 30-50% of pregnancies, with the incidence approaching 80% in some populations.[1] Usually, heartburn during pregnancy resolves soon after delivery, however, sometimes it represents exacerbation of pre-existing gastro-oesophageal reflux disease. Most patients begin to note their symptoms late in the first trimester or second trimester of pregnancy with heartburn becoming more frequent and severe in the latter months of gestation. Although symptoms can be severe, oesophagitis is infrequent[2] and usually in patients with pre-existing disease. Reported risk factors for heartburn in pregnancy include gestational age, heartburn antecedent to the pregnancy and multiparity. Body mass index before pregnancy, weight gain during pregnancy, or race do not predict heartburn and older maternal age seems to have a protective effect.[3] Thus, heartburn is so common during pregnancy that patients and obstetricians both view it as a normal occurrence during a healthy pregnancy. Nevertheless, the challenge of heartburn during pregnancy is patient and doctor concerns about the potential teratogenicity of common antireflux medications and the approximate step-up therapy for troubling symptoms. This review will address the treatment of gastro-oesophageal reflux disease during pregnancy and breast feeding as well as briefly summarizing the pathogenesis of this syndrome, clinical presentation and diagnostic work-up.

The literature search for this review used online databases PubMed and MEDLINE, and relevant manuscripts published in English between 1966 and 2005 were reviewed. The search terms used included gastro-oesophageal reflux disease, heartburn in pregnancy, heartburn in lactation, antacids, Gaviscon, sucralfate, histamine2-receptor antagonists, proton-pump inhibitors and all the specific prescription drugs in the latter two drug classes. All abstracts were screened, potentially relevant articles were researched and bibliographies were reviewed.

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