Heartburn management in pregnant, lactating women begins with lifestyle changes

Heartburn during pregnancy and lactation should be managed with lifestyle modifications, and physicians must discuss with the patient risks and benefits of medications in cases where disease severity increases, according to a recent review.

Pregnant women with heartburn present the same symptoms as those in the general adult population. Typical symptoms include heartburn (pyrosis) and regurgitation, as well as nausea, vomiting, indigestion and epigastric pain, among others. These symptoms appear late in the first trimester or second trimester.

Symptoms alone can form the basis of an initial diagnosis of reflux in pregnancy, similarly to the general adult population, so there is no need for alternate diagnostic tools. [Best Pract Res Clin Gastroenterol 2007;21:793-806]

Modifications in lifestyle are deemed the safest and first-choice therapy for treating reflux in pregnancy. These changes involve eating smaller portions during meals, refraining from eating late at night, elevating the head of the bed, and avoiding postural changes and dietary triggers that may exacerbate symptoms. Such measures can usually relieve mild symptoms.

Pharmacologic therapy should be considered in patients with persistent symptoms, although in a “step-up” strategy, with progressive intensification of treatment. Antacids, alginates and sucralfate are the first‐line therapy of choice. If symptoms persist, any of the histamine-2 receptor antagonists (H₂Ras) can be used, with the exception of nizatidine (due to foetal teratogenicity or harm in animal studies). Proton pump inhibitors (PPIs) are reserved for patients with intractable symptoms or complicated gastro-oesophageal reflux disease. All PPIs are FDA category B drugs, except for omeprazole, which is a category C drug.

According to researchers, only a few of relevant drugs are contraindicated for use in pregnancy or while breastfeeding. But it should be noted that not all drug agents have been extensively evaluated in pregnant women or during the breastfeeding period.

For the present review, the researchers conducted a comprehensive search using multiple online databases.