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Pregnancy Care Guidelines

56 Reflux (heartburn)

Reflux (heartburn) is a common symptom in pregnancy. Most women can relieve mild symptoms by modifying their diet and lifestyle. Women with persistent or more severe symptoms may also require advice about specific treatments.

56.1 Background

Reflux (heartburn) is very common antenatally. While it is considered a normal part of a healthy pregnancy, symptoms may be frequent and distressing to women.

Reflux is generally a symptom of gastro-oesophageal reflux disorder (GORD), where some gastric contents are regurgitated into the oesophagus, causing discomfort and a burning sensation behind the sternum and/or throat. Acid regurgitation may also reach the pharynx, resulting in a bitter or sour taste in the mouth. While the exact causes of the increase in reflux during pregnancy are not clear, it is thought that hormonal effects on antireflux barriers in the lower oesophagus and on gastric function may play a part (Ali & Egan 2007; Majithia & Johnson 2012). When symptoms persist, further investigation may identify other causes (eg bariatric surgery, stomach cancer and Helicobacter pylori infection (Tiong et al 2006; Cherian et al 2008) and treatment after the birth may be needed.

56.1.1 Incidence during pregnancy

Reflux is estimated to occur in 30–50% of pregnancies, with the incidence up to 80% in some groups (Richter 2003; Ali & Egan 2007). Symptoms tend to become both more severe and frequent as pregnancy progresses.

Older women and those having second or subsequent pregnancies are more likely to experience heartburn (Dowswell & Neilson 2008). There is also evidence suggesting that pre-pregnancy heartburn and weight gain during pregnancy increase the risk of heartburn during pregnancy (Rey et al 2007).

56.2 Discussing reflux 

Reflux is not associated with adverse pregnancy outcomes and therefore treatment aims to relieve symptoms for women. There is limited evidence on the effectiveness and safety of current interventions. Generally, the first approach is advice on diet and lifestyle, either to reduce acid production or avoid reflux associated with postural change (Richter 2005)

56.2.1 Lifestyle approaches 

Narrative reviews recommend lifestyle modifications for mild symptoms (Tytgat et al 2003; Ali & Egan 2007)

  • abstaining from alcohol, tobacco and medications that may increase symptoms (eg anticholinergics, calcium channel antagonists) 
  • having smaller more frequent meals 
  • avoiding lying down within 2–3 hours of eating 
  • elevating the head of bed by 10–15 cm.

Recommendation

  • Consensus-based
  • LII

Offer women experiencing mild symptoms of heartburn advice on lifestyle modifications and avoiding foods that cause symptoms on repeated occasions.

Approved by NHMRC in June 2014; expires June 2019

56.2.2 Treatments

A range of medications affecting different physiological processes (eg antacids, histamine-2 [H2] receptor antagonists, proton pump inhibitors) may be used to relieve persistent or severe symptoms (Dowswell & Neilson 2008).

RCT evidence on the safety of reflux medications during pregnancy is limited (Richter 2005). Available evidence from lower level studies suggests that the use of antacids, proton pump inhibitors and H2 blockers for reflux during pregnancy presents no known significant safety concern for either the mother or baby:

  • antacids are considered safe in pregnancy and may be preferred by women as they give immediate relief; calcium-based formulations are preferable to those that contain aluminium (Tytgat et al 2003)
  • the use of proton pump inhibitors during pregnancy is not associated with an increased risk for major congenital birth defects, spontaneous miscarriage, preterm birth, perinatal mortality or morbidity (Diav- Citrin et al 2005; Gill et al 2009a; Gill et al 2009b; Pasternak & Hviid 2010; Majithia & Johnson 2012; Matok et al 2012)
  • the use of H2 blockers in pregnancy is not associated with any increase in risk of spontaneous miscarriage, preterm birth or small-for-gestational-age baby (Gill et al 2009b).

One small RCT (n=36) (da Silva et al 2009) found that the use of acupuncture in pregnancy may reduce reflux symptoms.

Recommendation

  • Grade C
  • 57

Give women who have persistent reflux information about treatments.

Approved by NHMRC in June 2014; expires June 2019

56.3 Practice summary: reflux

When

A woman is experiencing reflux.

Who

  • Midwife
  • GP
  • obstetrician
  • Aboriginal and Torres Strait Islander Health Practitioner
  • Aboriginal and Torres Strait Islander Health Worker
  • multicultural health worker
  • accredited dietitian.

What

  • Provide advice
    Advise women that the causes of reflux vary between individuals and avoiding the food and drinks that cause them reflux may reduce symptoms. Sleeping on the left side, raising the head of the bed, and not lying down after eating may also help. Reassure women that symptoms usually subside after pregnancy, but may recur in a subsequent pregnancy.
  • Discuss treatments
    Discuss any remedies the woman may be using to treat reflux. Advise women that if symptoms persist or become more severe, medication can be considered.
  • Take a holistic approach
    Assist women to identify food and drinks that may cause reflux and to find culturally appropriate alternatives. Consider costs if prescribing medication to treat reflux.

56.4 Resources

  • Remote Primary Health Care Manuals (2017). Common discomforts of pregnancy. In: Women’s Business Manual (6th edition). Alice Springs, NT: Centre for Remote Health.

References

  • Ali RA & Egan LJ (2007) Gastroesophageal reflux disease in pregnancy. Best Pract Res Clin Gastroenterol 21(5): 793–806.
  • Cherian S, Forbes D, Sanfilippo F et al (2008) The epidemiology of Helicobacter pylori infection in African refugee children resettled in Australia. Med J Aust 189(8): 438–41.
  • da Silva JB, Nakamura MU, Cordeiro JA et al (2009) Acupuncture for dyspepsia in pregnancy: a prospective, randomised, controlled study. Acupunct Med 27(2): 50–53.
  • Diav-Citrin O, Arnon J, Shechtman S et al (2005) The safety of proton pump inhibitors in pregnancy: a multicentre prospective controlled study. Aliment Pharmacol Ther 21(3): 269–75.
  • Dowswell T & Neilson JP (2008) Interventions for heartburn in pregnancy. Cochrane Database Syst Rev(4): CD007065.
  • Gill SK, O’Brien L, Einarson TR et al (2009a) The safety of proton pump inhibitors (PPIs) in pregnancy: a meta-analysis. Am J Gastroenterol 104(6): 1541–45.
  • Gill SK, O’Brien L, Koren G (2009b) The safety of histamine 2 (H2) blockers in pregnancy: a meta-analysis. Dig Dis Sci 54(9): 1835–38.
  • Majithia R & Johnson DA (2012) Are proton pump inhibitors safe during pregnancy and lactation? Evidence to date. Drugs 72(2): 171–79.
  • Matok I, Levy A, Wiznitzer A et al (2012) The safety of fetal exposure to proton-pump inhibitors during pregnancy. Dig Dis Sci 57(3): 699–705.
  • Pasternak B & Hviid A (2010) Use of proton-pump inhibitors in early pregnancy and the risk of birth defects. N Engl J Med 363(22): 2114–23.
  • Rey E, Rodriguez-Artalejo F, Herraiz MA et al (2007) Gastroesophageal reflux symptoms during and after pregnancy: a longitudinal study. Am J Gastroenterol 102(11): 2395–400.
  • Richter JE (2003) Gastroesophageal reflux disease during pregnancy. Gastroenterol Clin North Am 32(1): 235–61.
  • Richter JE (2005) Review article: the management of heartburn in pregnancy. Aliment Pharmacol Ther 22(9): 749–57.
  • Tiong AC, Patel MS, Gardiner J et al (2006) Health issues in newly arrived African refugees attending general practice clinics in Melbourne. Med J Aust 185(11-12): 602–6.
  • Tytgat GN, Heading RC, Muller-Lissner S et al (2003) Contemporary understanding and management of reflux and constipation in the general population and pregnancy: a consensus meeting. Aliment Pharmacol Ther 18(3): 291–301.
Last updated: 
20 November 2018