Q: My wife is pregnant and she has been suffering from a lot of heartburn. Why is this happening and what can she do?
A: Assure your wife that she is not alone! Heartburn occurs in up to half of pregnant women. While it is usually mild, at times it can be very severe and treatment can be challenging. While heartburn in non-pregnant patients is typically easily treated with medications, it is still unclear just how safe these medications are to your developing baby.
Causes of heartburn in pregnancy
Reflux of acid from the stomach into the esophagus causes heartburn in pregnant women, just like in non-pregnant patients. Certain factors, however, make this more prevalent in pregnancy. First of all, the change in the levels of estrogen and progesterone during pregnancy work on the lower esophageal sphincter muscle between the stomach and esophagus, weakening it, and thereby increasing the chance of reflux. Secondly, the increased abdominal pressure caused by the growing fetus promotes the reflux of acid, much like the pressure caused by being obese.
As to the treatment of heartburn in pregnancy, first, lifestyle modifications are recommended. That would include:
- elevating the head of the bed
- lying on one's left side at night
- avoiding caffeine, chocolate and peppermints
- eating frequent, small meals.
- chewing gum (may be helpful as saliva production can neutralize acid).
If lifestyle modifications fail, medical therapy may be necessary. While she should check with her obstetrician, the first line of treatment would usually include medications that are not absorbed into the bloodstream, such as antacids (Mylanta, Maalox, Gaviscon).
If the antacids don't work, and especially if the symptoms are so severe that she is not appropriately gaining weight, your doctor may recommend H2 blockers (such as Zantac, Tagamet or Pepcid). But these drugs are absorbed into the bloodstream, and therefore, they can get into the blood of the fetus. Animal studies have shown no effect on the fetuses of pregnant animals, but haven't been any human studies. You should check with your obstetrician to see if he feels an H2 blocker would be a safe drug for your wife. Lastly, proton pump inhibitors such as Nexium, Prevacid and Aciphex should be used only in severe cases that don't respond to H2 blockers. While animal studies have shown safety, these drugs are newer and therefore have less long-term data available than the H2 blockers. With all drugs, concern is greatest in the first trimester, when major abnormalities can occur in the developing fetus. The concern lessens as pregnancy proceeds and the most critical development of the fetus has already taken place.
As with any disease in pregnant women, the treatment of heartburn can be challenging, so you must check with your physician as to what the best treatment for your wife would be.
Q: Is endoscopy safe in pregnancy?
A: Recent guidelines were published by the American Society for Gastrointestinal Endoscopy discussing the safety of endoscopy in pregnant and lactating women. The conclusion was, that while the safety and the efficacy of GI endoscopy in pregnant patients is not well studied, invasive procedures are justified when it is clear that not using them could expose the fetus and/or the mother to harm. In situations where therapeutic intervention is necessary, endoscopy offers a relatively safe alternative to radiologic or surgical intervention.
That being said, it would not be wise to perform an endoscopy during pregnancy to simply evaluate acid reflux or heartburn. The primary indications for endoscopy in pregnancy are significant or continued GI bleeding, severe or refractory nausea and vomiting or abdominal pain, and difficult or painful swallowing. General principles guiding endoscopy in pregnancy are to always have a strong indication, especially in high-risk pregnancies; to defer endoscopy to the second trimester whenever possible; to use the lowest effective dose of sedative medications and to use FDA category A or B drugs if possible.
[Note: Category A drugs have undergone "adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities," according to the FDA. Category B drugs: "animal studies have revealed no evidence of harm to the fetus, however, there are no adequate and well-controlled studies in pregnant women OR animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus.]
Published On: November 28, 2007