Dyspepsia in Pregnancy

Dyspepsia in pregnancy is commonly due to acid reflux. Acid reflux is when acid from the stomach leaks up into the gullet (oesophagus). This may cause heartburn and other symptoms. Attention to diet and lifestyle factor may help. Antacids are commonly used. A medicine which prevents your stomach from making acid may be prescribed if symptoms remain troublesome.

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 up to half of all pregnant women. The 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 from 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.

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.

What causes acid reflux during pregnancy?

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.

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 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, then you should see a doctor.

What can I do to help with symptoms?

The following are commonly advised. There has been little research to prove how well these 'lifestyle' changes help to ease reflux. 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, spicy foods, 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 too.)

Have a good posture
Lying down or bending forward a lot during the day encourages reflux. Sitting hunched or wearing tight belts 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.

Side-effect from medicines
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). Others include: diazepam, theophyline, nitrates, and calcium channel blockers such as nifedipine. Tell a doctor if you suspect that a prescribed medicine is making symptoms worse.
What are the treatments for dyspepsia of pregnancy?

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

    * 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, they should not be taken two hours before or after taking iron supplements.)
    * 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).

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. Ranitidine is considered safe to take during pregnancy.

(Note: medicines other than ranitidine that are commonly used for heartburn, dyspepsia, acid reflux, etc should not be used if you are pregnant. For example, cimetidine, or proton pump inhibitors. It is not known whether these other medicines are safe or not to take during pregnancy.)