Heartburn in Pregnancy - Is There Any Relief?
Heartburn in Pregnancy - Is There Any Relief?
Wendy L. Wright, MS, RN, ARNP, FNP, FAANP
Rosemary R. Berardi, Pharm.D., FCCP, FASHP, FAPHA
For women who are pregnant, heartburn is no laughing matter. It is a common and uncomfortable condition that will affect more than 50 percent of pregnant women at some point in a pregnancy1. When heartburn does occur in pregnancy, it is more likely to be felt in the later part, particularly in the second and third trimester.
During pregnancy, hormone levels change frequently, including progesterone. As the level of progesterone rises during the pregnancy, the lower esophageal sphincter, (the trap door between the stomach and the esophagus) is allowed to relax. This relaxation allows food and stomach contents that contain acid to reflux back into the esophagus, thus creating a feeling of heartburn or indigestion. In addition, the expanding uterus puts additional pressure on the stomach which can also create an environment which promotes heartburn. Together - these forces work against the pregnant woman to increase the likelihood of heartburn.
For many pregnant women, heartburn feels like a burning sensation or irritation in the chest and may also be associated with a sour or acidic taste in the mouth. Pregnancy itself is tough for many women and heartburn can only make things worse. Fortunately, effective relief is available.
Lifestyle modifications are a useful, first step in tackling pregnancy-related heartburn. The table below describes key changes pregnant women should make:
| Lifestyle Modification... | ...Rationale |
|
Eat small, frequent meals... |
...To avoid overloading your stomach and triggering heartburn |
Avoid triggers such as caffeine, carbonated beverages, chocolate, orange juice, acidic foods. Or, try using the low-acid options... |
... These trigger foods increase the acidity of the stomach and its contents. For low-acid recommendations, please click here |
|
Wear loose fitting pregnancy clothing... |
...To avoid additional pressure on the stomach and its contents |
Elevate the head of your bed by 4 - 6 inches by placing a brick or phone book under the supports beneath the head of the bed... |
...This will decrease likelihood of heartburn while lying down |
|
Avoid eating within 2 - 3 hours of bedtime... |
...As a full stomach when you lie down may increase the likelihood of heartburn |
Avoid smoking and drinking alcohol during pregnancy... |
...Not only will these decrease the risk of heartburn, they are also important recommendations for a healthy pregnancy |
|
Consider dairy products to relieve symptoms... |
...Milk may neutralize some of the gastric acidity. Calcium is also great for healthy bones |
|
Try chewing gum after meals (avoid mint/spearmint)... |
...Your saliva may help to neutralize the acidity of the stomach contents (mint and spearmint have been implicated as triggers of heartburn). |
Avoid foods which are high in fat content... |
...Fatty foods may increase the risk for heartburn |
Unfortunately, not all heartburn in pregnancy will be controlled with lifestyle modifications. There are additional safe options. As always, however, please consult your health care provider including your physician, physician assistant, nurse practitioner and pharmacist prior to trying any of these options:
Antacids act by neutralizing stomach acid and provide rapid relief of heartburn (within minutes). They are available over-the-counter (OTC) and are considered to be the most safe and well-studied medications for the treatment of heartburn during pregnancy. There are numerous antacid products available and the many different choices may make selecting an antacid confusing. Here are some general rules: antacids containing aluminum, calcium and magnesium are generally considered safe when used in recommended dosages. Some experts, however, recommend avoiding all magnesium products in the third trimester as magnesium can interfere with uterine contractions during labor2. Products which contain sodium bicarbonate, such as Alka-Seltzer Heartburn Relief ®, (see Selected Antacid Products Table) should be avoided throughout pregnancy as they may increase fluid retention.3
Calcium-containing antacids are often preferred during pregnancy, although taking too much calcium
may be a concern. The recommended calcium intake during pregnancy is about 1000-1300 milligrams of
calcium per day4. However, self-treatment with frequent an/or high dosages of a calcium-containing
antacid may result in exceeding the upper limit of 2500 milligrams of calcium per day, especially if you
include prenatal vitamins that contain calcium and dietary calcium intake.
Examples of antacids frequently used in pregnancy include Tums®, Maalox® and Mylanta®. However, antacid trade names can be problematic as there are numerous similarly named products available (see Selected Antacid Products Table) 5. For example, Maalox Total Stomach Relief® contains bismuth subsalicylate (which should be avoided during pregnancy) while Maalox Quick Dissolve Chewable Antacid Tablets® contains 600 milligrams of calcium carbonate! In addition, many of the newer antacid formulations, which once contained only magnesium and aluminum hydroxide, now have varying amounts of calcium added which should be accounted for in the total daily calcium intake. Below, please find the Selected Antacid Products Table of a few similarly named antacid and bismuth products. As always, you should consult your health care provider before taking any of the following:
| Trade Name | Primary Ingredients | Adult Dosage (maximum daily dosage) |
|
Alka-Mints Chewable Antacid® |
Calcium carbonate 850 milligrams |
Chew one to two tablets every two hours as needed. |
|
Alka Seltzer Heartburn Relief® |
Sodium bicarbonate 1940 milligrams; citric acid 1000milligrams |
Dissolve two tablets in four ounces of water |
|
Alka Seltzer Original® |
Sodium bicarbonate 1916 milligrams; citric acid 1000 milligrams; aspirin 325 milligrams |
Dissolve two tablets in four ounces of water every hour as needed. |
|
Alternagel Liquid® |
Each 5milliliter contains aluminum hydroxide 600 milligrams |
Take one to two teaspoons between meals and at bedtime. |
|
Gaviscon Extra Strength Liquid® |
Each 5 milliliter contains* aluminum hydroxide 254 milligrams; magnesium carbonate 237 milligrams |
Take two to four teaspoons 4 times a day, after meals and at bedtime. |
|
Gelusil Tablets® |
Aluminum hydroxide 200 milligrams; magnesium hydroxide 200 milligrams; simethicone 25 milligrams |
Chew two to four tablets; repeat hourly if symptoms return. |
|
Maalox Liquid Regular Strength Antacid / Antigas® |
Each 5 milliliter contains aluminum hydroxide 200 milligrams; magnesium hydroxide 200 milligrams; simethicone 20 milligrams |
Take two to four teaspoons four times a day. |
Maalox Quick Dissolve Regular Strength Antacid Tablets® |
Calcium carbonate 600 milligrams |
Chew one to two tablets as symptoms occur |
|
Maalox Total Stomach Relief Maximum Strength® |
Each 15 milliliter contains bismuth subsalicylate 500 milligrams |
Take two tablespoons half-hour to hour as required. |
|
Mylanta Gelcaps® |
Calcium carbonate 550 milligrams; magnesium hydroxide 125 milligrams |
Swallow two to four gelcaps as needed |
|
Mylanta Maximum Strength Liquid® |
Each 5 milliliter contains aluminum hydroxide 400milligrams; magnesium hydroxide 400 milligrams; simethicone 40 milligrams |
Take two to four teaspoons between meals and at bedtime. |
|
Mylanta Regular Strength Liquid® |
Each 5 milliliter contains aluminum hydroxide 200 milligrams; magnesium hydroxide 200 milligrams; simethicone 20 milligrams |
Take two to four teaspoons between meals and at bedtime. |
|
Mylanta Supreme Liquid® |
Each 5 milliliter contains calcium carbonate 400 milligrams; magnesium hydroxide 135 milligrams |
Take two to four teaspoons between meals and at bedtime. |
|
Mylanta Ultra Chewable Tabs® |
Calcium carbonate 700 milligrams; magnesium hydroxide 300 milligrams |
Chew two to four tablets between meals and at bedtime. |
|
Pepto-Bismol Original Liquid® |
Each 15 milliliter contains bismuth subsalicylate 262 milligrams |
Take two tablespoons every half-hour to hour as required |
|
Phillips Milk of Magnesia Original® |
Each 5 milliliter contains magnesium hydroxide 400 milligrams |
Take one to three teaspoons every four hours. |
|
Rolaids Antacid Tablets® |
Calcium carbonate 550 milligrams; magnesium hydroxide 110 milligrams |
Chew two to four tablets hourly as needed. |
|
Tums E-X Extra Strength® |
Calcium carbonate 750 milligrams |
Chew two to four tablets as needed. |
Tums Regular Strength Tablets® |
Calcium carbonate 500 milligrams |
Chew two to four tablets as needed. |
Antacids may be combined with alginic acid or simthicone. Alginic acid acts by forming a viscous layer that floats on the stomach contents and theoretically protects the esophageal lining from acid reflux. Although alginic acid is designated as an "inactive" ingredient by the Food and Drug Administration (FDA), products containing antacids and alginic acid (e.g., Gaviscon®) may be more effective than antacids alone for some individuals. Antacids may also contain simethicone to reduce discomfort related to intestinal gas5.
The H2-Receptor Antagonists (H2RAs) act by suppressing stomach acid. These agents have been shown to be safe and are FDA approved for use in pregnancy6. The H2RAs are available OTC and include cimetidine (Tagamet HB®), ranitidine (Zantac 75® and Zantac 150®), famotidine (Pepcid AC®, Pepcid AC Max®, and Pepcid Complete® which also contains an antacid) and nizatidine (Axid AR®). The H2RAs may be used when there is an inadequate response to antacids and lifestyle modifications.
Cimetidine (Tagamet HB) and ranitidine (Zantac 75 and Zantac 150), have been used and studied much more widely in women who are pregnant than famotidine (Pepcid AC and Pepcid AC Max and Pepcid Complete) and nizatidine (Axid AR) have been and do not appear to be associated with an increased risk of congenital malformations in humans3. However, some authorities (and clinicians) recommend that cimetidine (Tagamet HB) not be used during pregnancy because of possible feminization3. Although famotidine (Pepcid AC and Pepcid AC Max and Pepcid Complete) and nizatidine (Axid AR) appear safe during pregnancy, there are much less supportive safety data in humans3. There are conflicting animal data reported for nizatidine (Axid AR) and thus it is considered by some to be less safe than the other H2RAs during pregnancy.3
Proton Pump Inhibitors (PPIs) such as omeprazole (Prilosec®, Prilosec OTC®, lansoprazole (Prevacid®), pantoprazole (Protonix®), esomeprazole (Nexium®) and rabeprazole (Aciphex®) are powerful acid suppressants and should only be used during pregnancy in women with intractable symptoms who fail treatment with an H2RA or those with complicated reflux disease3. Because safety data in humans are limited, PPIs should be avoided, if possible, especially during the first trimester3.
Initially the FDA received reports of birth defects in pregnant women when omeprazole (Prilosec) was taken during the first trimester.3 However, other case reports and small studies have found no congenital abnormalities in infants even when omeprazole was taken during the first trimester.3 Although there is less human data on the safety of the other PPIs, recent data suggest that when omeprazole (Prilosec or Prilosec OTC), lansoprazole (Prevacid), and pantoprazole (Protonix) were taken during pregnancy, birth defects were comparable in women who were not taking a PPI7.
Sucralfate acts by coating the esophageal and stomach lining rather than suppressing acid production. Although it may not be as effective as medications that reduce stomach acid (H2RAs and PPIs), it remains a viable option given that it is poorly absorbed from the gastrointestinal tract3. Sucralfate is only available by prescription in the United States.
Heartburn in pregnancy is a common and frequently, very treatable condition. Lifestyle modifications are usually the only treatment needed by many individuals. When these changes are unsuccessful, consult your health care provider who can assist you in selecting a safe and effective heartburn medication for a healthy and happy pregnancy.
1 http://www.webmd.com/heartburn-gerd/heartburn-during-pregnancy
2 Tips to Ease the Heartburn of Pregnancy; Science Daily December 10, 2007
3 Richer JE. Review article: The management of heartburn in pregnancy. Aliment Pharmacol Ther 2005;22: 749-57.
4 National Institute of Health, Office of Dietary Supplements. Dietary supplement fact sheet: Calcium. Available at:
http://dietary-supplements.info.nih.gov/factsheets/calcium.asp. Accessed January 3, 2008.
5 Weber A, Berardi RR. Heartburn and Dyspepsia, in Handbook of Nonprescription Drugs, American Pharmaceutical Association, 15th Edition, 2006.
6 Briggs CC, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation: A Reverence Guide to
Fetal and Neonatal risk. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2009 (available now).
7 Diav-Citrin O, Arnon J, Scechtman S, et al. The Safety of Proton Pump Inhibitors in Pregnancy: a Multicentre Prospective Controlled Study. Aliment Pharmacol Ther. 2005;21:269-275.
