Acid Reflux in Pregnancy

Acid reflux is a common condition in the West and there is a suggestion that it is increasing. Obesity is increasing in the West and since obesity can cause or worsen acid reflux, the increase in acid reflux is likely to be related to a combination of our diet, lifestyle and obesity. There is, however, a group that develops acid reflux as a part of life’s natural process. Pregnant women develop GERD symptoms as a result of pregnancy.

It is estimated that as much as 80% of pregnant women have GERD symptoms and the symptoms vary from mild to very severe. It is rarely serious in this group and, of course, it is limited to the length of the pregnancy.

Nausea and vomiting is common in the first trimester and is mainly due to the rising level of the female hormone, estrogen and progesterone circulating in the blood stream. Acid reflux symptoms are more common in the third trimester.

In the third trimester, the uterus is large and has pushed up into the upper abdomen distorting the configuration of the organs in the abdomen. The stomach is pushed up against the diaphragm. This can affect the competence of the Lower Esophageal Sphincter (LES) and cause acid reflux. It can also force part of the stomach up through the diaphragmatic hiatus. This is a hiatus hernia. A hiatus hernia can result in acid reflux.

In addition weight gain during pregnancy (especially in the apple shape) will settle around the waist. This weight will press on the abdomen and increase the intra-abdominal pressure. This pressure on the LES may force food up into the esophagus.

During pregnancy estrogen and progesterone levels need to be high to maintain the pregnancy. These two female hormones are produced by the ovaries until the placenta takes over. These hormones relax smooth muscles of the uterus and are necessary to allow the uterus to stretch to accommodate the developing pregnancy.

Unfortunately this muscle relaxation is not confined to the uterus. The muscles of the GI tract are affected. In the large bowel reduced strength of peristaltic contraction leads to slow transit time and likely constipation. In the esophagus it reduces the tone of the LES allowing reflux and slows down peristalsis along the esophagus. The food swallowed is cleared slower and the LES is lax. A double whammy.

Patients who have had GERD symptoms before falling pregnant tend to have severe GERD in pregnancy. Sometimes in pregnancy GERD can be so severe that hospitalisation is necessary. Also vomiting can be so severe that weight loss follows. In pregnancy regular weight gain is expected. Weight loss suggests a referral to a gastro-enterologist especially if the weight is below the pre-pregnancy benchmark.

Severe GERD can lead to mal-nutrition. This can be harmful to the mother and may put the foetus at risk at a time of vital development and growth.

Ginger is a good safe treatment of GERD in pregnancy and you only need a small amount. It can stimulate saliva production. Saliva is a natural antacid. Ginger helps relieve nausea and vomiting and it is a carminative (relieve gas). Lifestyle change is important. If still smoking and drinking alcohol, then it is time to stop. Elevating the head of the bed is beneficial and lying on the left side is best because in this position the stomach is lower than the esophagus.

Avoid or reduce your intake of fats, coffee, tea, chocolate, certain citrus fruits, certain spices, tomatoes and garlic. When exercising, avoid bouncing up and down and exercises that involve bending forwards. Stick to exercises that keep you upright. Stretching exercises and power or brisk walking are unlikely to aggravate GERD symptoms.

Antacids are safe in pregnancy because they do not cross the placenta into the baby’s circulation. However, antacids containing sodium (sodium bicarbonate) can cause fluid retention. Aluminium containing antacids can make constipation of pregnancy worse. Magnesium can slow down labour. These drugs are in Category A. The categories were laid down by the FDA in 1979 and are related to safety profile and potential harm to the foetus. Category A is safe in pregnancy.

The H2-receptor antagonists and proton pump inhibitors are in Category B except omeprazole which is in Category C. These drugs cross the placenta but trials results are not adequate to consider them safe during pregnancy. So far no trial has shown any harm to the foetus.