Heartburn During Pregnancy
"Doctor Jay! What can I do? I'm burning up!"
Linda was 7 months pregnant and the heartburn was overwhelming. To her, it seemed constant. She couldn't lie down at night. The discomfort of her bulging belly was nothing in comparison.
Linda has a lot of company. Heartburn (a symptom of gastro-esophageal reflux disease or GERD) occurs in one-quarter to one-half of all pregnant women. It usually begins in the first or second trimester of pregnancy and continues throughout the remainder of the pregnancy. Fortunately, the heartburn is usually mild and intermittent, but frequently enough, it is troublesome or severe. Complications of GERD (esophageal bleeding, trouble swallowing, loss of weight, etc.) are uncommon. In non-pregnant circumstances, heartburn is easily and successfully treated since there are several types of medication that are highly effective in relieving heartburn. The problem is that we do not know how safe these medications are for the developing fetus, and no one is going to test them in pregnant women to find out! About the best we can do is test them in pregnant animals at doses much higher than would ever be used in humans.
The cause of GERD during pregnancy is a bit more complicated than in the non-pregnant state. The basic cause--reflux of acid from the stomach into the esophagus--is the same. Similar to the situation with GERD in the non-pregnant state, the lower esophageal sphincter (the muscle at the lower end of the esophagus that normally prevents acid from refluxing) is weak in pregnancy. This probably is an effect of the high levels of estrogens and especially progesterones that are part of pregnancy. This weakness resolves after delivery. It is not known whether unexplained, transient relaxations of the sphincter, a common cause of reflux in the non-pregnant state, also occur in pregnancy. It also is not known if the contraction (motility) of the esophagus above the sphincter--a common contributor to GERD in the non-pregnant state--is impaired in pregnancy and is responsible for delaying the clearance of acid from the esophagus back into the stomach. What makes pregnancy different is the distortion of the organs in the abdomen and the increased abdominal pressure caused by the growing fetus. These changes clearly promote the reflux of acid.
The management of GERD during pregnancy involves many of the same principles as management in the non-pregnant state. Specifically, the so-called "lifestyle" changes should be meticulously followed. The two feet of the head of the bed should be raised on 6 to 8 inch blocks. Alternatively--and perhaps more conveniently--a 6 to 8 inch wedge-shaped foam rubber pad should be used to elevate the upper body. It is important that the foam be firm enough to truly elevate the upper body. The wedge should also extend all the way to the waist so that the entire chest is elevated. Lying on the left side at night may decrease acid reflux just as it does in non-pregnant patients with GERD. (In this position, it is physically more difficult for acid to reflux into the esophagus.) Occasionally, it may be necessary to sleep in a recliner chair at a 45-degree or greater angle. Any specific foods that aggravate heartburn should be avoided (e.g., coffee, cola, tea, alcohol, chocolate, fat, citrus juices, etc.) Frequent, small meals should be eaten rather than three large meals, and the last meal of the day should be early in the evening. After meals, pregnant women with heartburn should not lie down. After the evening meal, no further liquids should be consumed. (The more empty the stomach at bedtime, the less likely there will be reflux of acid.) Smoking, of course, should be discontinued for several reasons, including the fact that it aggravates reflux. Chewing gum also may be helpful. Chewing gum stimulates saliva which contains bicarbonate. The saliva and bicarbonate are swallowed,and the bicarbonate neutralizes the acid that has refluxed into the esophagus.
If lifestyle changes are not adequate, treatments with substances that are minimally absorbed into the body (and, therefore, not a potential threat to the fetus) should be started. Such treatments include antacids (e.g., Maalox, Mylanta), alginic acid/antacid combination (Gaviscon), and sucralfate (Carafate). The most reasonable starting regimen is antacids alone, one hour after meals and at bedtime. It may be necessary to alternate magnesium and aluminum-containing antacids to avoid diarrhea or constipation . If antacids are not effective alone, then the antacids should be continued and alginic acid/antacid added. The antacids and alginic acid/antacid should be taken after meals and at bedtime, more frequently if necessary.
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