Heartburn during pregnancy

Heartburn symptoms are one of the most commonly reported complaints among pregnant women.

Heartburn usually starts during the first trimester and tends to worsen during the second and third trimesters.

Studies have shown elevated levels of the hormone progesterone accompanied by increased intra-abdominal pressures from the enlarging uterus, may lower esophageal sphincter (LES) pressure in pregnant women contributing to heartburn symptoms, according to research highlighted in the newly updated “Pregnancy in Gastrointestinal Disorders” monograph by the American College of Gastroenterology (ACG).

From the monograph, physician experts from ACG have compiled important health tips on managing heartburn symptoms, and importantly, identifying which heartburn medications are safe for use in pregnant women and those, which should be avoided.

Strategies to Ease Heartburn Symptoms during Pregnancy
According to the ACG, pregnant women can treat and relieve their heartburn symptoms through lifestyle and dietary changes. The following tips can help reduce heartburn discomfort:

1. Avoid eating late at night or before retiring to bed. Common heartburn triggers include greasy or spicy food, chocolate, peppermint, tomato sauces, caffeine, carbonated drinks, and citrus fruits.
2. Wear loose-fitting clothes. Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.
3. Eat smaller meals. Overfilling the stomach can result in acid reflux and heartburn.
4. Don't lie down after eating. Wait at least 3 hours after eating before going to bed. When you lie down, it's easier for stomach contents (including acid) to back up into the esophagus, particularly when you go to bed with a full stomach.
5. Raise the head of the bed 4 to 6 inches. This can help reduce acid reflux by decreasing the amount of gastric contents that reach the lower esophagus.
6. Avoid tobacco and alcohol. Abstinence from alcohol and smoking can help reduce reflux symptoms and avoid fetal exposure to potentially harmful substances.

The Do's and Don'ts of Using Heartburn Drugs during Pregnancy
Pregnant women with mild reflux usually do well with simple lifestyle changes. If lifestyle and dietary changes are not enough, you should consult your doctor before taking any medication to relieve heartburn symptoms.

According to ACG President Amy E. Foxx-Orenstein, DO, FACG, “Heartburn medications to treat acid reflux during pregnancy should be balanced to alleviate the mother's symptoms of heartburn, while protecting the developing fetus.”

Based on a review of published scientific clinical studies (in animals and humans) on the safety of heartburn medications during pregnancy, researchers conclude there are certain drugs that are considered safe for use in pregnancy and those which should be avoided.

Antacids are one of the most common over-the-counter medications to treat heartburn. As with any drug, antacids should be used cautiously during pregnancy.

Antacids

1. Antacids containing aluminum, calcium, or magnesium are considered safe and effective in treating the heartburn of pregnancy.
2. Magnesium-containing antacids should be avoided during the last trimester of pregnancy because it could interfere with uterine contractions during labor.
3. Avoid antacids containing sodium bicarbonate. Sodium bicarbonate could cause metabolic alkalosis and increase the potential of fluid overload in both the fetus and mother.

Histamine-type II (H-2) Receptor Antagonists
While limited data exists in humans on the safety of histamine-type II (H-2) receptor antagonists, ranitidine (Zantac®) is the only H-2 antagonist, which has been studied specifically during pregnancy.

In a double-blind, placebo controlled, triple crossover study, ranitidine (Zantac®) taken once or twice daily in pregnant heartburn patients not responding to antacids and lifestyle modification, was found to be more effective than placebo in reducing the symptoms of heartburn and acid regurgitation. No adverse effects on the fetus were reported. (Larson JD, et al., “Double-blind placebo-controlled study of ranitidine for gastroesophageal reflux symptoms during pregnancy.” Obstet Gynecol 1997; 90:83-7.)

A study on the safety of cimetidine (Tagamet®) and ranitidine (Zantac®) suggests that pregnant women taking these drugs from the first trimester through their entire pregnancy have delivered normal babies. (Richter JE., “Gastroesophageal reflux disease during pregnancy. Gastroenterol Clin N Am 2003; 32:235-61.)

Proton Pump Inhibitors
Proton pump inhibitors should be reserved for pregnant patients with more severe heartburn symptoms and those not responding to antacids and lifestyle and dietary changes. Lansoprazole (Prevacid®) is the preferred PPI because of case reports of safety in pregnant women. Limited data exists about human safety during pregnancy with the newer PPIs.

Full text of the monograph, including a complete list of heartburn medications that are considered safe to use during pregnancy can be found on the ACG website at http://www.acg.gi.org/physicians/pdfs/PregnancyMonograph.pdf