Pregnancy and Gastroesophageal Reflux

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The passage of stomach contents into the esophagus is known as gastroesophageal reflux. This occurs commonly and is a normal physiologic process. It often occurs without causing any symptoms or damage to the lining of the esophagus. When reflux of stomach contents into the esophagus causes symptoms that impair normal function of daily life or causes damage to the esophagus, this is then known as gastroesophageal reflux disease (GERD).

Gastroesophageal reflux is very common in pregnancy and has been reported to occur during any trimester. It appears to become more more prevalent in later trimesters, however. Those who experience reflux with their first pregnancy are highly likely to experience it again with later pregnancies.

Why does it occur?

There are a variety of factors that have been found to cause acid reflux during pregnancy. The increased levels of female hormones during pregnancy affects the motility of the entire gut. When gut motility is slowed gastric contents build up and are at greater risk of backing up and passing into the esophagus.

Hormones also affect the tone of the sphincter muscle at the end of the esophagus where it meets the stomach, or lower esophageal sphincter (LES). When this muscle is relaxed, gastric contents can easily pass backwards into the esophagus. In all trimesters of pregnancy, the LES has been shown to have a lower pressure, or tone, that it normally would in a nonpregnant state. The sphincter tone returns to normal after giving birth in the postpartum period. Some research has shown that during pregnancy the LES also does not have the same inhibitory responses that it usually would in non-pregnant women, resulting in a decreased ability to keep the LES from relaxing inappropriately. Increasing intra-abdominal pressure from the growing baby in utero also places pressure against the LES during pregnancy. When the pressure from the abdomen is great enough to overcome the LES, stomach contents can reflux backwards into the esophagus.

Treatment

The initial approach to treating reflux in pregnancy is with dietary and lifestyle modifications. It is recommended to raise the head of the bed while sleeping and remain upright for at least two hours after meals to allow for food to pass with gravity through the gastrointestinal tract. Although specific dietary changes are not typically recommended, if particular foods are identified as triggers for reflux, it is suggested that those foods be temporarily eliminated from the diet. Triggers are person-specific, however, common tiggers include spicy foods, fatty foods, caffeine, chocolate, milk/dairy products, vinegar-based products, citrus fruits, and carbonated beverages. Avoiding large meals and eating more frequent, small meals may help in decreasing acid reflux events. Avoiding tight-fitting clothes may also help with reflux symptoms.

Medications

The first medications to try during pregnancy for acid reflux are antacids, such as tums. Antacids work on the spot to neutralize acid and relieve symptoms. Most antacids are safe in pregnancy, however, there are a few that contain ingredients that are not considered safe. It is important you speak with your doctor prior to starting any reflux medication on your own.

Sucralfate is the next medication of choice. This medication promotes healing of the stomach and esophagus lining and is safe to use. If these medications do not work, then try histamine receptor blockers, such as ranitidine or cimetidine. Histamine blockers block acid channels in the stomach, thereby reducing acid. Once all medications have been tried, and symptoms remain present, then proton-pump inhibitors (PPI's), such as omeprazole can be tried. PPI's have been shown to be probably safe in pregnancy, namely omeprazole, however, fewer studies have been conducted using PPI's as opposed to histamine blockers in pregnancy. Studies have shown lansoprazole and pantroprazole to be safe in pregnancy, as well.

Antacids, sucralfate, and histamine blockers are also safe to use when breastfeeding. However, PPI use during breastfeeding is not recommended due to the lack of studies showing their safety.

Delivery

Delivery of the newborn is the only cure for pregnancy-related acid reflux. After delivery, reflux symptoms typically gradually resolve to the normal baseline of that individual. Again, should pregnancy occur again later, it is likely that reflux will also recur.

Endoscopy

Upper endoscopy, or an esophagogastroduodenoscopy (EGD), is not indicated for most cases of pregnancy-related acid reflux. An EGD should only be performed if there is a very strong indication, such as bleeding. Ideally, endoscopy should be postponed until the second trimester when it is considered safe to administer sedation medication. In such situations, obstetrician/gynecology, anesthesiology, and gastroenterology staff should all be involved.

During pregnancy, if you are experiencing any gastrointestinal symptoms, you should discuss these with your obstetrician. Many symptoms are common changes with pregnancy, however, further evaluation or more advanced management may be necessary. Working together with your doctor will ensure a healthy and safe pregnancy.

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