Heartburn
During Pregnancy.
Introduction.

Patients who experience a burning discomfort in the chest after eating may be experiencing heartburn.  Understanding more about what heartburn is, why it occurs and what can be done to alleviate these symptoms will help patients to enjoy their pregnancy more fully.

Do I have heartburn?

Heartburn or acid indigestion usually presents with symptoms of a burning discomfort in the chest, located underneath the sternum or breast bone.  It is most often worse after eating meals, bending over or lying down.  As a result, most pregnant patients seem to initially complain of heartburn at night after going to bed.  In severe cases where reflux of gastric acid occurs, patients may complain of symptoms of chronic cough or hoarseness.  Heartburn and gastric acid reflux are often collectively referred to as gastroesophageal reflux disease or simply “GERD”.

What causes heartburn during pregnancy?

During pregnancy, patients are more predisposed to heartburn for two reasons.  First, the pregnancy hormones that keep the uterus relaxed also tend to relax other muscles. The lower esophageal muscular sphincter that keeps food and stomach acid in the stomach relaxes during pregnancy.  This makes it more likely that stomach contents may backwash into the lower esophagus causing discomfort.  Second, the enlarging pregnant uterus pushes the intestines upward as it grows resulting in more pressure on the stomach.  This results in an increased frequency of GERD symptoms, especially during the third trimester.


Foods and beverages to avoid.

Fatty foods such as french fries, macaroni and cheese, and doughnuts as well as spicy foods such as curries and some mexican foods are more frequently associated with GERD symptoms.  Likewise, acidic juices such as lemon, orange or cranberry juices are also known to exacerbate the symptoms of GERD.  Last, caffeinated drinks and alcoholic beverages, which are discouraged during pregnancy, will also make a patient’s heartburn worse and should be avoided.

What can a patient do to address heartburn?

In addition to avoiding certain foods, there are several things that patients can do to help minimize heartburn symptoms.  First, avoid eating or drinking fluids within two to three hours of bedtime.  Retiring to bed on an empty stomach will minimize reflux symptoms.  Second, consider sleeping at a slightly inclined angle, using pillows to help elevate the head and torso.  This will help to keep stomach contents where they need to be.  Lastly, if these suggestions are not adequate, consider using an over-the-counter antacid such as chewable calcium carbonate tablets (Tums) to help reduce the amount of gastric acid in the stomach.  This will also provide an additional source of calcium for a baby’s growing bones.


What to do when nothing seems to work?

When conservative interventions have been tried and do not seem to help adequately alleviate a patient’s symptoms, prescription medications may be indicated.  There are two commonly used classes of heartburn medication. 

H2 Blockers.  H2 blockers are perhaps the most widely used choice of medication for GERD during pregnancy when lifestyle and dietary changes have not worked. These drugs work by temporarily blocking the production of acid from the cells in the stomach. Although older and less effective than the new Proton Pump Inhibitor category of heartburn medication, they are often used during pregnancy due to their lower cost and extensive safety record.  All H2 blockers are available over-the-counter, but in lower doses than the prescription strength your doctor can order.  Examples of H2 blockers include cimetidine (Tagamet), ranitidine (Zantac), and famotidine (Pepcid).

Proton Pump Inhibitors.  Proton pump inhibitors (PPIs) are the strongest inhibitors of stomach acid currently commercially available to patients.  They permanently impair the acid producing mechanism of the cells of the stomach making it an effective choice in treating the symptoms of GERD.  These medications are typically more expensive than H2 blocker medications.  Examples of PPIs include omeprazole (Prilosec), famotidine (Prevacid) and pantoprazole (Protonix).

After a patient visits with her doctor about the frequency and severity of her GERD symptoms, a patient’s physician can decide which medication would best help address her GERD symptoms.  The medication chosen will vary depending on the patient’s gestational age and severity of complaints, while taking into account other medical concerns the patient may have or medication they may already be taking.


When should I be concerned?

Although symptoms of heartburn or gastric reflex are common in pregnancy, they are rarely a serious medical concern and most often will resolve after delivery.  However, on occasion, patients may develop additional symptoms that may suggest a more serious medical problem.  If patients develop any of the symptoms listed in the table below, they should notify their physician.


Conclusion.

We hope that this brief explanation of heartburn and common interventions to alleviate the symptoms of GERD will help patients to feel more comfortable during their pregnancy and be informed as to when medical intervention by their doctor is recommended.