Heartburn During Pregnancy
Medical Author: Jay W. Marks, M.D.
"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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