Dyspepsia in Pregnancy

What is dyspepsia?

Dyspepsia is a term which includes a group of symptoms (detailed below) that come from a problem in your upper gut. The gut or 'gastrointestinal tract' is the tube that starts at the mouth, and ends at the anus. The upper gut includes the oesophagus, stomach, and duodenum. Various conditions cause dyspepsia.

Dyspepsia occurs at some point in around half of all pregnant women. Dyspepsia in pregnancy is usually due to reflux of acid from the stomach into the oesophagus.

Understanding the oesophagus and stomach

When we eat, food passes down the oesophagus (gullet) into the stomach. Cells in the lining of the stomach make acid and other chemicals which help to digest food.

Stomach cells also make a mucus which protects them from damage caused by the acid. The cells lining the oesophagus are different and have little protection from acid.

There is a circular band of muscle (a 'sphincter') at the junction between the oesophagus and stomach. This relaxes to allow food down, but normally tightens up and stops food and acid leaking back up (refluxing) into the oesophagus. In effect, the sphincter acts like a valve.

What causes acid reflux during pregnancy?

Acid reflux is when some acid leaks up (refluxes) into the oesophagus. The lining of the oesophagus can cope with a certain amount of acid. However, if more than the usual amount of acid refluxes, it may cause some inflammation on the lining of the oesophagus which can cause symptoms.

The sphincter at the bottom of the oesophagus normally prevents acid reflux. It is thought that when you are pregnant:

• The increased level of certain hormones that occurs has a relaxing effect on the sphincter muscle. That is, the tone (tightness) of the sphincter is reduced during pregnancy.
• The size of the baby in the abdomen causes an increased pressure on the stomach.

One or both of the above increases the chance that acid will reflux into the oesophagus. The dyspepsia usually goes away after the birth of your baby when your hormones change back to their non-pregnant state and when the baby is no longer causing increased pressure on your stomach.

You are more likely to develop dyspepsia in pregnancy if you have previously suffered from gastro-oesophageal reflux before you were pregnant.

What are the symptoms of acid reflux and dyspepsia of pregnancy?

Symptoms can vary from mild (in most cases) to severe. They can include one or more of the following:

• Heartburn. This is a burning feeling which rises from the upper abdomen or lower chest up towards the neck. (It is a confusing term as it has nothing to do with the heart!)
• Upper abdominal pain or discomfort.
• Pain in the centre of the chest behind the sternum (breastbone).
• Feeling sick and vomiting.
• Bloating.
• Quickly feeling 'full' after eating.

Symptoms tend to occur in 'bouts' which come and go, rather than being present all the time. They may begin at any time during pregnancy, but are usually more frequent or severe in the last third of pregnancy. As soon as the baby is born, dyspepsia due to pregnancy quickly goes.

Note: various other problems both associated with pregnancy, and unrelated to pregnancy, are sometimes confused with dyspepsia. For example, pain in the right or left of the upper abdomen is not usually due to dyspepsia. Excessive vomiting is not usually due to dyspepsia. If symptoms change, or are not typical, or become severe, or are recurring, then you should see your doctor.

Do I need any investigations?

Dyspepsia in pregnancy is usually recognised by your typical symptoms. Investigations are generally not needed.

'Lifestyle' changes that may help with symptoms

The following are commonly advised. There has been little research to prove how well these 'lifestyle' changes help to ease reflux and dyspepsia in pregnancy. However, they are certainly worth a try:

Consider avoiding certain foods, drinks and large meals

Some foods and drinks may make reflux worse in some people. (It is thought that some foods may relax the sphincter and allow more acid to reflux.) It is difficult to be certain how much foods contribute. Let common sense be your guide. If it seems that a food is causing symptoms, then try avoiding it for a while to see if symptoms improve. Foods and drinks that have been suspected of making symptoms worse in some people include: peppermint, tomatoes, chocolate, fatty and spicy foods, fruit juices, hot drinks, coffee, and alcoholic drinks. Also, avoid large meals if they bring on symptoms. Some women find that eating smaller meals more frequently is helpful.

Stop smoking if you are a smoker

The chemicals from cigarettes relax the sphincter muscle and make acid reflux more likely. Symptoms may ease if you are a smoker and stop smoking. In any case, it is strongly advised that pregnant women should not smoke for other reasons as well. See separate leaflet called 'Smoking - and Pregnancy' for more detail.

Have a good posture

Lying down or bending forward a lot during the day encourages reflux. Sitting hunched may put extra pressure on the stomach which may make any reflux worse.

Bedtime

If symptoms recur most nights, it may help to go to bed with an empty, dry stomach. To do this, don't eat in the last three hours before bedtime, and don't drink in the last two hours before bedtime. If you raise the head of the bed by 10-15 cms (with books under the bed's legs), this will help gravity to keep acid from refluxing into the oesophagus.

Consider any medicines that you are taking

Some medicines may make symptoms worse. (Most pregnant women will not be taking these medicines, but they are mentioned here for completeness.) They may irritate the oesophagus, or relax the sphincter muscle and make acid reflux more likely. The most common culprits are anti-inflammatory painkillers (such as ibuprofen or aspirin), sedative drugs, some antidepressants and calcium channel blockers such as nifedipine. Tell a doctor if you suspect that a prescribed medicine is making symptoms worse.

Is there any medication for dyspepsia of pregnancy?

For many women (especially if they have mild symptoms), making some lifestyle changes as above is enough to ease dyspepsia. However, if lifestyle changes do not help, medication may be needed to treat dyspepsia in pregnancy.

Antacids and alginates

Antacids are alkali liquids or tablets that neutralise the acid. A dose usually gives quick relief. You can use antacids 'as required' for mild or infrequent bouts of dyspepsia. Antacids containing aluminium or magnesium can be taken on an 'as required' basis. Those containing calcium should only be used occasionally or for a short period. Antacids that contain sodium bicarbonate or magnesium trisilicate should be avoided as they may be harmful to your developing baby.

There are many brands of antacids that you can buy. You can also get some on prescription. A doctor or pharmacist can advise. Some points about antacids are:

• Most antacids are considered to be safe to take in pregnancy.
• They can interfere with the absorption of iron tablets. Therefore, they should be taken at a different time of day if you are taking iron supplements. If possible, you should take your antacid at least two hours before or after you take your iron supplement.
• It is probably best to use one with a low sodium content if you have high blood pressure or pre-eclampsia (a complication of pregnancy).

Alginates are often combined with antacids. Alginates help to protect the oesophagus from stomach acid. They form a protective 'raft' when they come into contact with stomach acid and block the acid from entering the oesophagus. Some alginates are specifically licensed for use in pregnancy.

Acid-suppressing medicines

If symptoms are still troublesome despite any lifestyle changes and antacids, your doctor may prescribe a medicine called ranitidine. This medicine works by reducing the amount of acid that the stomach makes. It usually eases the symptoms of dyspepsia quite well. Note: ranitidine is not licensed for use in pregnancy by the manufacturers but it has been used in pregnancy for many years with no reports of harm to the developing baby. It is generally considered safe to take. Ranitidine needs to be taken regularly (and not just when you have dyspepsia symptoms) to be effective.

Omeprazole is another acid-suppressing drug that is licensed for use in pregnancy to treat dyspepsia. Omeprazole also needs to be taken regularly to be effective.

Note: it is only ranitidine and omeprazole that should be used if you are pregnant. Other medicines that are commonly used for heartburn, dyspepsia, acid reflux etc, should not be used. For example, cimetidine, esomeprazole, lansoprazole and pantoprazole. It is not known whether these other medicines are safe to take during pregnancy.

References

• Dyspepsia - pregnancy-associated, Clinical Knowledge Summaries (May 2008)
• Antenatal care: routine care for the healthy pregnant woman, NICE Clinical Guideline (March 2008)