GERD and Dyspepsia in Pregnancy: Management Choices and Risks

Dyspepsia or pyrosis complicates up to 80% of pregnancies; gastroesophageal reflux disease (GERD) is almost as common.¹ The causes include decreased motility of the GI during gestation and an increase in intra-abdominal pressure by the enlarging uterus, which in some patients, may even cause the cardial valve to herniate above the diaphragm.¹

Management of this condition includes:

• Small, frequent meals
• Avoidance of lying down flat
• Avoidance of tobacco, alcohol and caffeine
• Herbal measures such as mint tea or mint oil dipped toothpicks may be helpful
• Nonprescription medications (eg, Maalox, Milk of Magnesia, Gaviscon)
• Prescription drugs

The prescription drugs that can be used include:

• Antacids (eg, sucralfate)
• Agents that promote gastric emptying (eg, metoclopramide)
• H1 inhibitors (eg, cimetidine, ranitidine)
• Proton pump inhibitors (eg, esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole)

All of these drugs have been classified by the FDA as Category B except for omeprazole which is assigned to Category C.²

In the Digestive Disease Week meeting held in New Orleans from May 1st to 5th 2010, a report by Andrew D. Rhim, Janet R. Hardy et al. showed an increased risk of cardiovascular anomalies in babies born to women treated during pregnancy with proton pump inhibitors (PPIs). Omeprazole carried the highest risk among the PPIs evaluated. There was no increased risk of defects in other organ systems.

This was a nested case control analysis, which may overstate the risks. The results showed an adjusted odds ratio of 2.14 or, in other words, a risk of cardiac anomalies that is twice that of the controls. Because PPI use was not associated with an increase in risk of defects in other organ systems, it makes it less likely that the association is due to confounding factors.³

Based on this, and older data, it appears that PPIs should probably not be considered the first line therapy for dyspepsia and GERD in pregnant women.

From the standpoint of safety to the fetus, GERD that does not respond to conservative lifestyle measures should be treated first with over-the-counter antacids.^₁ If prescription drugs are needed, sucralfate may be the first line because it is not absorbed, although its aluminum content may be of concern in mothers with renal insufficiency.¹

Proton pump inhibitors have been frequently used to this point due to high efficacy and perceived safety. It appears now, based on the above mentioned study that the old H1 inhibitors may be a preferable choice if antacid therapy fails.

All of the H1 inhibitors are Category B drugs, though concerns about the anti-androgenic effect of cimetidine (although no effect has been shown in pregnancy) may make ranitidine or famotidine more advisable. It should be noted that there is very limited data on famotidine.⁴

Another drug that may be considered is metoclopramide. Metoclopramide increases lower esophageal sphincter tone and enhances antral and small intestinal contractions, thus relieving the symptoms of GERD.⁵ It is a very old drug and has been proven to be effective and safe in pregnancy.¹ The major side effect, and the reason why this drug is not in more common use, is the rare occurrence of extrapyramidal effects (which can be managed with anticholinergics and antihistamines). The even rarer occurrence of tardive dyskinesia is not a concern because it only occurs after long term therapy which is not the case in this indication.⁵ This drug is also classified as Category B.⁶

Finally the PPIs may still be used, although it may be prudent to warn patients about the small but significant risk of cardiac anomalies in newborns. If used, esomeprazole, lansoprazole, pantoprazole, or rabeprazole may be preferable to omeprazole.

Pedro Miranda-Seijo, MD, FACOG, is a Clinical Instructor at the University of Colorado School of Medicine.

References
1. Gabbe: Obstetrics, Normal and Problem Pregnancies, 5th edition, p 1124
2. Briggs et al: Drugs in Pregnancy and Lactation, 8th ed. Xxiii
3. Digestive Disease Week, New Orleans May 1-5, abstract No 475b
4. Briggs et al: Drugs in Pregnancy and Lactation, 8th ed. p 706
5. Goodman & Gilman’s Pharmacological Basis of Therapeutics, 10th edition, pp 1025-1026
6. Briggs et al: Drugs in Pregnancy and Lactation, 8th ed. P1197