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Gastroesophageal reflux disease in pregnancy

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Gastroesophageal reflux disease during pregnancy is common. Altered structure and function of the normal physiological barriers to reflux of gastric contents into the oesophagus explain the high incidence of this problem in pregnant women. For the majority of patients, life-style modifications are helpful, but are not sufficient to control symptoms and medication is required. The optimum management of reflux in pregnant patients requires special attention and expertise, since the safety of the mother, foetus and neonate remain the primary focus. Gastroenterologists and obstetricians should work together to optimise treatment. Typically, one utilises a step-up program that starts with life-style modifications and antacids. If those methods fail, histamine-2 receptor antagonists and proton pump inhibitors are tried. Rarely, promotility agents are used. Initiation of these medications must be undertaken after a careful discussion of risks and benefits with patients. In patients without a prior history of reflux, symptoms usually abate after delivery.

Introduction

Gastrointestinal symptoms are one of the most frequent medical complaints during pregnancy. Some women have gastrointestinal disorders that are unique to pregnancy and other pregnant women present with chronic gastrointestinal disorders that require special consideration during pregnancy. Pregnancy alters visceral anatomy, and affects the normal motility of the oesophagus, stomach and intestines. Gastroesophageal reflux disease (GORD), commonly experienced as heartburn, is reported by 40%–85% women during pregnancy.1, 2 GORD occurs when the passage of gastric contents into the oesophagus causes symptoms or damages the mucosa. In addition to gastric acid, bile acids and digestive enzymes such as pepsin also disrupt mucosal integrity or provoke oesophageal dysmotility.

The variation in the incidence of GORD reported in pregnancy is probably due to the lack of consensus over the definition of the disease.3 To review the global epidemiology of GORD in pregnancy is currently problematic as there is no internationally applied definition, although the need for this has been recognised.4 Some studies have looked at the association of heartburn and ethnicity in pregnant women. One study5 noted a higher incidence of heartburn in Caucasians when compared with Nigerians (79% vs 9% respectively). Bainbridge et al6 found no difference in the incidence of heartburn in pregnancy between Caucasian Europeans and Asians. Marrero et al7 studied 607 women during various stages of pregnancy via questionnaire, and found there was an increased risk of heartburn with increasing gestational age, presence of pre-partum heartburn and parity, but not race. First symptoms of heartburn were reported to occur in the first trimester in 50% cases, in the second trimester in 20%–40% and in the last term of pregnancy in 10%.8 The purpose of this chapter is to review the clinical features, pathophysiology, evaluation and management of GORD in pregnant patients.

Section snippets

Clinical features

The clinical spectrum of GORD in pregnancy is similar to that in non-pregnant state. The predominant symptoms are heartburn and regurgitation. Other common symptoms include nausea, vomiting, epigastric pain, waterbrash and anorexia (Table 1). Precipitating factors that aggravate the symptoms include ingestion of fatty or spicy food, eating soon before bedtime, and the ingestion of certain foods like chocolate, mints, caffeinated beverages and medications that decrease lower oesophageal

Pathophysiology of gord in pregnancy

The pathophysiology of GORD in pregnancy is probably multifactorial, involving both mechanical and hormonal factors. The suggested predominant factor is a decrease in the LOS pressure due to a progressive rise in circulating oestrogen and progesterone.9 Many studies have shown that LOS pressure decreases during the course of pregnancy. Van Thiel et al10, 11 demonstrated that resting LOS pressure is lower than normal during all three trimesters of pregnancy, reaching a nadir at 36 weeks

Evaluation of gord in the pregnant patient

Clinical presentation of GORD in pregnancy is similar to that observed in the general population. The initial diagnosis of GORD can reliably be made on symptoms alone. A careful history should be obtained, focusing on current complaints and or any prior history of dyspeptic or reflux-type symptoms. Invasive investigations such as manometry and pH probes are rarely needed, although these can be safely performed during pregnancy.23 Barium studies should be avoided because of radiation exposure to

Management of gord in pregnancy

The optimum management of GORD in pregnant women requires special attention and expertise, since the effects of medications on the foetus and neonate must be considered carefully. Gastroenterologists and obstetricians should participate in the shared care of pregnant patients with GORD, since this condition can profoundly impair the quality of life of pregnant women. Initial management of GORD in pregnant patients usually consists of conservative measures such as life-style modifications and

Antacids

Antacids are commonly used for the treatment of GORD and appear to be safe in pregnancy. Antacids are used by 30–50% of women for the relief of heartburn and other acid reflux symptoms during pregnancy.28 Despite the widespread use of antacids, there are limited data available concerning their effects on the foetus and no controlled trials of efficacy in pregnancy. Teratogenic effect of magnesium, aluminium or calcium-containing antacids are not observed in animal studies.29 However, 15–30% of

The role of endoscopy in evaluating gord in pregnancy

Upper gastrointestinal endoscopy is recommended during pregnancy for the diagnosis of suspected GORD only when symptoms are severe and refractory to intensive medical therapy or in the setting of GORD associated complications such as haemorrhage (Figure 1). The procedure can be safely performed without harm to the mother or foetus by careful monitoring of blood pressure and oxygen saturations.57, 58 The choice of sedation, for example midazolam and diazepam (category D), fentanyl (category C)

Summary

Gastroesophageal reflux disease with resultant heartburn is common during pregnancy. The aetiology is multi-factorial but a predominant factor contributing to a decrease in LOS pressure is elevation of female sex hormones, in particular progesterone. The disease presents a special challenge for the clinician mainly because of the potential adverse effect of various pharmacological agents on the foetus. Most cases are managed by obstetricians, and serious reflux complications during pregnancy

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