Pregnancy is a remarkable and life-changing event. A woman’s body is transformed into one of the most efficient life-sustaining machines on earth. However, this transformation is not without difficulty for some women. It brings a whole range of physiological and emotional challenges, including pregnancy heartburn or acid reflux. This occurs in approximately 70% of women, commonly between weeks 27 and 40 of pregnancy. While this may pass after delivery, it can severely impact the quality of life during pregnancy. This essay aims to explore the causes, symptoms, and treatment options for managing heartburn and acid reflux in pregnant women.
1. Introduction
Pregnancy heartburn is a burning sensation felt in the chest or throat caused by the backflow of acidic stomach contents into the esophagus, which is triggered by the pregnancy hormones and the growing uterus. As the pregnancy progresses, the enlarging uterus pushes the stomach into the diaphragm. This puts immense pressure on the stomach, causing it to distend and overflow the acidic stomach contents into the esophagus. At the same time, the hormones relaxin and progesterone are secreted to relax the smooth muscles. However, these hormones also relax the lower esophageal sphincter, the one-way valve separating the esophagus and stomach. This allows the acidic contents to reflux back into the esophagus, causing heartburn and acid reflux.
1.1. Significance of Addressing Acid Reflux in Pregnancy
Pregnancy brings numerous physiological changes, including increased levels of sex hormones, with estrogen and progesterone increasing abruptly throughout the first trimester. Various physical alterations occur, including an enlarging uterus, increased body weight, and a thoracoabdominal shift. Gastroesophageal reflux (GER) is a common problem during pregnancy, experienced by 40–85% of women [1]. Abnormal esophageal motility, elevated intragastric pressure, and relaxation of the lower esophageal sphincter contribute to the development of GER. Pregnancy changes gastroesophageal reflux disease (GERD) symptomatology, with increased heartburn incidence but a decline in the rate of dysphagia and esophageal spasms after pregnancy commencement. The majority of women experience heartburn and acid reflux during pregnancy, which may interfere with the therapeutic effects of antiemetics, leading to greater severity of nausea and vomiting of pregnancy (NVP).
Women experiencing refractory NVP with heartburn or acid reflux are often treated with antireflux therapies. There are concerns associated with medication use during pregnancy, especially during the first trimester—when drug exposure may lead to congenital malformations, growth restriction, and functional developmental disorders. The first goal of this study was to quantify whether acid-reducing pharmacotherapy is effective in decreasing the severity of NVP in women experiencing heartburn or acid reflux. Because acid-reducing agents typically do not treat the underlying pathophysiological condition, the effect of heartburn or reflux treatment was also assessed separately to determine its impact on NVP severity. Secondly, the cumulative effect of multiple antiemetics was assessed to determine if increased antiemetic medication alters the severity of NVP.
2. Understanding Acid Reflux
Among the countless bodily changes accompanying pregnancy, one that is commonly discussed is heartburn or gastroesophageal reflux disease (GERD). Symptoms associated with GERD are heartburn, acid reflux, regurgitation, eructation, flatulence, stomach bloating, indigestion, and sensation of a lump in the throat, which may even affect quality of sleep. Besides normal physiological changes, some lifestyle changes may also be shown to have a beneficial effect on gastroesophageal reflux symptoms [1].
Heartburn and/or acid reflux are common medical disorders. The incidence of gastroesophageal reflux disorders in pregnancy estimates range between 40% and 85%. In one study, 24 out of 36 women was able to answer heartburn questions correctly, while 30 out of 36 women was able to answer acid reflux questions correctly. Some studies suggest that acid reflux in pregnant women is under-reported and under-treated. These symptoms can occur any time during pregnancy possibly due to hormone-induced decrease in lower esophageal sphincter tone, reduced gross intestinal motility, change in gastric emptying and intragastric pressure, temporary esophageal mobility, and esophageal cutaneous afferent hypersensitivity.
2.1. Causes and Symptoms
Acid reflux, also referred to as gastroesophageal reflux or gastroesophageal reflux disease (GERD), occurs when acid from the stomach rises into the esophagus, causing a burning sensation in the chest or throat. In severe cases, the stomach acid can enter the airways, leading to a cough or asthma attack. Symptoms of acid reflux can include sore throat, absence of voice, the sensation of a lump in the throat (lump in the throat), coughing, wheezing, or other respiratory problems [1]. If a persistent cough is the only symptom, silent reflux or laryngopharyngeal (LPR) reflux should be investigated. Chronic incidence of acid reflux can lead to the development of Barrett’s esophagus, which can change into esophageal cancer [2].
Pregnant women have a higher risk of developing GERD. During pregnancy, hormonal changes may delay gastric emptying time. In addition, the size of the uterus can lead to increased intra-abdominal pressure. Both of these factors can have an influence on the development of symptoms as they limit the emptying of the stomach and increase reflux. A study found that 40% to 85% of women experienced GERD during pregnancy, with half of them having persistent symptoms throughout the entire pregnancy. It was most frequently reported the last days of the first trimester, increased continuously during pregnancy to 4 to 12 weeks post-partum, and usually resolved directly after delivery.
3. Challenges in Managing Acid Reflux During Pregnancy
As discussed previously, acid reflux is one of the most common gastrointestinal disorders affecting the quality of life and productivity of patients. Special considerations are entertained for patient management during pregnancy. Moreover, during pregnancy, along with the anatomical, physiological, and psychological changes that happen in various body systems, drugs should be evaluated based on the potential teratogenic risks along with their pharmacokinetic profiles [2].
There are challenges not only for the physicians but also for the chemists and industry professionals to design formulations that can be dosed in the pregnant state. Preclinical or significant experimental in vivo evidence to predict human exposure, safety, and effectiveness for the novel entities is often limited. The reason is the ethical and practical limitations associated with conducting experiments in pregnant women. All-encompassing claims for safety are often difficult to make in the case of approved drugs because most drugs have been tested or consumed by pregnant women only coincidentally. Similarly, clinical studies to evaluate the pharmacokinetics and pharmacodynamics in the pregnant state are scarce [3].
3.1. Safety Concerns with Common Medications
Acid reflux, also known as GERD, is a common condition during pregnancy. Extra pressure from the growing uterus can cause food and stomach acid to back up into the esophagus. That’s why many pregnant women experience heartburn or acid indigestion. More than half of all pregnant women will experience these symptoms. While dietary and lifestyle modifications are generally recommended for treatment during pregnancy, some medicines are considered safe to use as well.
You may be concerned about whether it’s safe to take medications to treat heartburn or acid indigestion during pregnancy. Many over-the-counter (OTC) medicines have been studied extensively in pregnant women and have been found to be generally safe when used as directed. H2 receptor antagonists (H2RAs) such as ranitidine (Zantac), famotidine (Pepcid), or cimetidine (Tagamet) are also considered safe options to use if an antacid does not provide relief. Proton pump inhibitors (PPIs) such as omeprazole (Prilosec) and pantoprazole (Protonix) are prescription medications that reduce the amount of acid produced by the stomach. PPIs should be avoided during the first trimester of pregnancy if possible due to an increase in the risk for congenital birth defects [4].
4. Non-pharmacological Approaches to Alleviate Acid Reflux
The buildup of gastric acid in esophagus is called acid reflux, a condition associated with heartburn, sour taste, sore throat, cough, hoarseness and/or difficulty swallowing. Recently, the prevalence of acid reflux has increased in the general population and pregnant women [1]. This increase may be contributed by lifestyle modifications, dietary factors or the increased use of non-steroidal anti-inflammatory drugs (NSAIDs). Acid reflux usually treated with drug interventions involving antacids with anti-secretory agents. The incidence of side effects with routine administration of drugs is a matter of concern. There is limited scope for the use of drugs during pregnancy since several drugs can potentially pass through the placenta and affect the development of foetus. Hence, need was felt to evaluate non-drug approaches that can be employed by the target population (pregnant women) to ameliorate acid reflux. However, with the absence of investigation on non-drug approaches for this particular population and its strong association with poor quality of life (QOL) issues, a project was initiated to study systematically the efficacy of various non-drug approaches for ameliorating acid reflux in general and the pregnant population in particular. Non-pharmacological approaches include selected complementary and alternative medicine (CAM) practices, specifically diet and lifestyle modifications, yoga, herbal tea, and homeopathy. Non-drug interventions provide a potential strategy for controlling acid reflux.
4.1. Dietary Modifications
Lifestyle and dietary modifications are the first-line management of mild to moderate gastro-esophageal reflux disease (GERD) in pregnant women [2]. There are many dietary modifications, many of which are based on tradition or anecdotal evidence [5]. Modifications regarding choice of food, food preparation style, frequency and timing of intake, position during eating and after eating have been suggested in the literature. In general, the recommendations on dietary modifications should include consuming smaller sized meals, more frequently during the day, avoiding spicy foods, orange juice, grapefruit juices, fatty or fried foods, or carbonated beverage. Smoker women should be suggested to stop smoking, as smoking has been shown to increase the risk of reflux episodes. It is also suggested to decrease the workload after eating and avoid reclining posture. Additionally, it could be worth waiting for 2-3 hours after having dinner before lying down.
4.2. Lifestyle Changes
Lifestyle changes could help pregnant women to cope with acid reflux. Addressing some aspects of daily life could significantly help in relieving the symptoms of the disease. Patients and their partners/mothers may feel less overwhelmed if they see the holistic approach taken toward managing the disease. Also, it could be ongoing support to the pregnant woman, which could in turn help the women cope with this condition more successfully [6].
5. Conclusion
Managing acid reflux during pregnancy is an essential aspect of maternal well-being. Keeping the digestive system healthy, especially the esophagus and stomach, is vital for comfort and health. This guide offers ideas and recommendations to help pregnant women relieve acid reflux symptoms safely. Knowing how heartburn happens is important. Pregnancy increases the risk of heartburn due to hormonal changes and the growth of the fetus taking up space in the belly. Foods such as spicy and greasy stuff can cause heartburn. Non-food factors like not eating for a long time or lying down too quickly also aggravate it. Typical acid reflux symptoms include a burning feeling behind the breastbone, vomiting, regurgitating food, and dry cough. To relieve acid reflux symptoms, adjusting food intake is recommended. This includes having little meals, avoiding spicy, fatty, and sour foods, ending meals at least 2-3 hours before sleeping, and eating fruits like bananas and melons. Drinking enough water and avoiding carbonated drinks and alcohol is also suggested.
In addition, changing certain habits can help with acid reflux during pregnancy. This includes sitting or sleeping in a straight position, wearing loose clothes, elevating the head at night, and not lying down for at least 2 hours after meals. Some herbal remedies like chewing on ginger, peppermint, and cinnamon, drinking ginger tea, and using honey, chamomile, or licorice tea can help. However, pregnant women should be careful when using herbal remedies and consult a doctor first. If these methods don’t work, women can consider using antacids, H2 antagonists, or proton pump inhibitors after discussing with a doctor.
Pregnancy is a significant period for women, bringing many changes to both physical, mental, and social aspects. Among those concerns, acid reflux has been a common discomfort in pregnant women that should be noticed and treated properly. Discomfort and symptoms of acid reflux that are not taken care of well can lead to many further health problems for both the pregnant mother and the fetus.
5.1. Importance of Addressing Acid Reflux in Pregnancy
During pregnancy, an array of physiological and hormonal adaptations in a woman’s body occurs to nurture the developing fetus. Unfortunately, most of these adaptations tend to favor gastro-esophageal reflux disease (GERD) development, exacerbation, or persistence [2]. GERD is one of the most common gastrointestinal (GI) disorders faced by a majority of pregnant women. With its debilitating and yet avoidable symptoms, acid reflux significantly impairs the quality of life (QoL) of a woman during her pregnancy. Moreover, the potential harmful effects on both mother and fetus illustrate the importance of this topic.
Acid reflux, commonly termed as GERD, is the retrograde flow of gastric content into the esophagus, which may or may not be associated with GERD symptoms. Such symptoms can be chronic or recurrent, and thus, impact the day-to-day life of an individual [7]. With the progress of time, uneasiness and comfortlessness of a woman suspected to be advancing into pregnancy lead to a premonition of conception, highlighted by the latence of menstruation. According to World Health Organization (WHO) estimates, around 140 million babies are to be born each year. Thus, it’s no surprise that scientific setups in practically all countries have provided for the study and management of disorders affecting pregnant women.
Nevertheless, there are very few GI disorders that are truly specific to pregnancy, which primarily involve the esophagus or stomach. GERD symptoms, epigastric pain, nausea, and excessive vomiting are frequent in pregnancy, posing before the clinician, obstacles of medical, diagnostic, and therapeutic concern. Women-well before conception, have acquired-changing lifestyles and eating habits: late-night snacks, fast foods, and casualized chomping. The tendency to reflux/regurgitate episodically is due to a compromise in esophageal motility. Health care providers should devise new strategies for early identification and proper management of broad-spectrum disorders like GERD affecting mothers and fetus both, in order to unburden them from life-threatening complications.
References:
[1] S. Kaur Gill, C. Maltepe, K. Mastali, and G. Koren, “The Effect of Acid-Reducing Pharmacotherapy on the Severity of Nausea and Vomiting of Pregnancy,” 2009. ncbi.nlm.nih.gov
[2] C. Frias Gomes, M. Sousa, I. Lourenço, D. Martins et al., “Gastrointestinal diseases during pregnancy: what does the gastroenterologist need to know?,” 2018. ncbi.nlm.nih.gov
[3] M. Levitus, S. A. Shainker, and M. Colvin, “COVID-19 in the Critically Ill Pregnant Patient,” 2022. ncbi.nlm.nih.gov
[4] M. M H J van Gelder, P. Beekers, Y. R J van Rijt-Weetink, J. van Drongelen et al., “Associations Between Late-Onset Preeclampsia and the Use of Calcium-Based Antacids and Proton Pump Inhibitors During Pregnancy: A Prospective Cohort Study,” 2022. ncbi.nlm.nih.gov
[5] J. Kristiina Reijonen, K. Maaria Hannele Tihtonen, T. Hannele Luukkaala, and J. Tapio Uotila, “Association of dietary fiber, liquid intake and lifestyle characteristics with gastrointestinal symptoms and pregnancy outcome,” 2022. ncbi.nlm.nih.gov
[6] A. Pali S. Hungin, C. Scarpignato, L. Keefer, M. Corsetti et al., “Review article: rethinking the “ladder” approach to reflux‐like symptom management in the era of PPI “resistance” ‐ a multidisciplinary perspective,” 2022. ncbi.nlm.nih.gov
[7] A. P Vyawahare, A. Gaidhane, and B. Wandile, “Asthma in Pregnancy: A Critical Review of Impact, Management, and Outcomes,” 2023. ncbi.nlm.nih.gov