GERD during pregnancy is an acid—dependent disease of the esophagus caused by damage to the mucous membrane when the contents of the stomach are thrown, which has arisen or worsened under the influence of gestational factors. It is manifested by heartburn, acid belching, dysphagia, less often — nausea, vomiting, dysphagia, epigastric pain, cough, dysphonia, hypersalivation in sleep, taste perversions, depressed mood. It is diagnosed using alkaline and omeprazole tests, esophagoscopy, pH-metry, manometry. Alginates, antacids, selective histamine blockers, proton pump inhibitors, and prokinetics are used for treatment.
K21 Gastroesophageal reflux disease
GERD during pregnancy (gastroesophageal reflux disease, gastroesophageal reflux) is one of the most common diseases of the gastrointestinal tract, contributing to the occurrence of such a common symptom as heartburn of pregnant women. According to the observations of specialists in the field of obstetrics and gynecology, from 30 to 95% of patients experience heartburn during pregnancy, which some experts even consider a natural manifestation of pregnancy. In 21-80% of patients suffering from GERD, the disease debuted precisely due to gestation.
Women who have given birth many times are more susceptible to the disease. The urgency of timely detection of gastroesophageal reflux is due to a significant deterioration in the quality of life of a pregnant woman and the need to prescribe pharmacotherapy to almost half of the patients.
Gastroesophageal reflux of acidic gastric contents develops with weakening of the cardiac sphincter, impaired motility of the esophagus and stomach, increased gastric secretion, decreased protective properties of the esophageal mucosa. The occurrence of GERD is facilitated by congenital and acquired hernias of the esophageal orifice of the diaphragm with a displacement to the posterior mediastinum of the abdominal esophagus, part or all of the stomach, smoking, nutritional errors, obesity.
A certain role is played by the intake of nitrates, antidepressants, progestins, anticholinergic drugs, calcium channel blockers and other drugs that cause transient relaxation of the esophageal sphincter. As a separate prerequisite for the development of gastroesophageal reflux disease, specialists in the field of modern gastroenterology consider pregnancy. The high incidence of GERD during pregnancy is associated with the action of factors such as:
- Increased progesterone levels. Under the influence of progestins, the lower esophageal sphincter relaxes, the tone of which is restored only in the postpartum period. Due to a decrease in the tone of smooth muscle fibers and a decrease in the sensitivity of intestinal receptors to histamine and serotonin, physiological hyperprogesteronemia slows down the motility of the gastrointestinal tract, worsens gastric emptying. As a result, reflux occurs more often.
- Increased intra-abdominal pressure. During pregnancy, the mutual arrangement of the internal organs of the abdominal cavity is violated, which is associated with the development of the fetus and the growth of the uterus. With the displacement of the stomach to the diaphragm, evacuation stagnation of its contents is formed faster and the risk of formation of a diaphragmatic hernia increases. The factor of increased intra-abdominal pressure is most significant when carrying a multiple pregnancy and a large fetus.
The mechanism of GERD development during pregnancy is based on the casting of aggressive stomach contents into the lower esophagus. Gastroesophageal reflux usually occurs with a decrease in the pressure of the cardiac sphincter less than 2 mm Hg. or an increase in intragastric pressure more than 5 mm Hg. Both of these factors are detected in pregnant women. Refluktat containing hydrochloric acid, pepsin, and in some cases bile acids, has an irritating effect on the epithelium of the esophagus, causes a local inflammatory reaction, and in some patients provokes the onset of erosive processes.
When systematizing the forms of GERD during pregnancy, the same criteria are taken into account as outside the gestational period — the nature of the course of the disease and the condition of the esophageal mucosa. This approach allows us to develop optimal medical tactics aimed at eliminating clinical symptoms and the morphological basis of their occurrence without the risk of negative effects on the fetus. Depending on the time of existence of the disorder, acute gastroesophageal reflux disease is distinguished, lasting up to 3 months, and a chronic process that exists for 3 months or more. Taking into account the features of damage to the esophageal mucosa, such forms of GERD are distinguished as:
- Gastroesophageal reflux without esophagitis. In the non-erosive variant of the disorder, detected in 55-70% of patients, there are no endoscopic signs of epithelial damage. Although the probability of complications in this case is lower, the quality of life of the patient worsens in the same way as in the presence of erosions.
- Reflux-esophagitis. In 30-45% of pregnant women with GERD, visible signs of esophagitis caused by the aggressive action of stomach contents are determined during endoscopy. With the erosive form of gastroesophageal reflux, acute and long-term consequences of the disease are more often observed.
When predicting the outcome of GERD during pregnancy, the severity of the endoscopically positive variant of the disease according to the Los Angeles classification is also taken into account. Reflux-esophagitis of A and B degrees is most favorable during pregnancy, in which defects spread to 1-2 folds of the mucosa, and their sizes, respectively, are up to or more than 5 mm. With C degree of GERD, less than 75% of the circumference of the esophagus is affected, and with D — 75% or more, which significantly increases the likelihood of a complicated course.
75% of patients with gastroesophageal reflux complain of heartburn, which gradually increases as childbirth approaches. Discomfort and burning behind the sternum often occur after eating spicy, fatty, fried foods, overeating, physical exertion, lying down and bending. Heartburn attacks can be repeated several times a day and last from minutes to several hours. Pregnant women suffering from GERD may belch sour or bitter, a feeling of a lump in the throat, chest pain when swallowing with irradiation to the precardial region, neck, lower jaw, interscapular space.
Sometimes nausea and vomiting are noted in the II-III trimesters, it is extremely rare that swallowing first solid and then liquid food is difficult. Extraesophageal manifestations of reflux disease during pregnancy are a feeling of bursting in the epigastrium, rapid satiety, repeated coughing and choking attacks, hoarse voice, sore throat, increased salivation in sleep, burning cheeks and tongue, taste perversion, bad breath. Often pregnant women have a dreary-depressed mood. In rare cases, GERD is asymptomatic.
Usually gastroesophageal reflux does not contribute to the occurrence of any obstetric complications, however, with extensive erosive lesion of the esophagus, more pronounced anemia during pregnancy may develop. In two—thirds of GERD patients during pregnancy worsens: in 10-11% of cases, relapse occurs in the 1st trimester, aggravated by early toxicosis, in 33-34% — in the 2nd trimester and more than half of pregnant women – in the 3rd.
Rare specific complications that occur against the background of physiological immunodeficiency during pregnancy are acute esophagitis caused by candida and herpetic infections. There is a risk of ulceration of the mucosa with the development of esophageal bleeding. The long-term consequences of reflux disease are narrowing (strictures) of the esophagus, dysplasia and metaplasia of the epithelium (Barrett’s esophagus) and esophageal adenocarcinoma.
During pregnancy, the diagnosis of GERD is usually established on the basis of typical clinical symptoms with the daily occurrence of heartburn. An obstetrician-gynecologist and a gastroenterologist are involved in the diagnosis. Instrumental methods traditionally used in the diagnosis of the disease are used only in pregnant women because of the possible provocation of premature birth and the aggravation of other complications (nephropathy, early toxicosis, preeclampsia, eclampsia). Recommended for diagnostic purposes:
- The “alkaline” test. The intake of absorbed antacids quickly relieves an attack of heartburn. The positive effect of alkaline preparations is associated with the neutralization of hydrochloric acid coming from the stomach into the esophagus. In the presence of extraesophageal manifestations, the study is supplemented with an omeprazole test aimed at eliminating symptoms by inhibiting gastric secretion.
- Endoscopy of the esophagus. Esophagoscopy is performed if extensive erosion, ulceration, esophageal bleeding, strictures are suspected, and allows to exclude neoplasia. During endoscopic examination, GERD is manifested by swelling and slight vulnerability of the esophageal mucosa, it is possible to identify areas of damaged epithelium. In some cases, it is possible to visualize the discharge of gastric juice.
- Intraesophageal pH-metry. The method is effective in non-erosive forms of gastroesophageal reflux. Electrometric determination of the acidity of the contents of the esophagus is carried out using a flexible intraesophageal probe attached to an acidogastrometer. pH-metry allows you to identify episodes of reflux of gastric juice and determine the conditions of their occurrence.
- Manometry. The registration of pressure in different parts of the gastrointestinal tract using special catheters with strain gauges verifies the weakening of the cardiac sphincter and impaired motor skills. The manometric study also provides an objective assessment of the elasticity, tone, contractile activity of the esophageal wall, drawing up a profile of pressure in the esophagus.
If necessary, the examination is supplemented with gastrocardiomonitoring, gastrointestinal impedancometry, and bilimetry. X-ray examinations of the esophagus during pregnancy are not carried out. GERD is differentiated with functional dyspepsia, gastric and duodenal ulcers, acute infectious esophagitis, benign tumors and esophageal cancer. If extraesophageal symptoms are detected, differential diagnosis with angina pectoris, bronchial asthma may be required.
Therapeutic tactics are aimed at the rapid elimination of clinical symptoms, restoration of the esophageal mucosa, prevention of complications and relapses. In 25% of cases, the condition can be improved by non-drug methods. Pregnant women with mild GERD are recommended to give up smoking, adjust their diet and diet with frequent fractional meals in small portions, reduce the amount of high-protein and low-lipid products, with the exception of citrus juices, chocolate, caffeine-containing beverages, spices, mint, alcohol.
Caution is necessary when using funds that temporarily reduce the tone of the cardia. Effective sleep with a raised headboard, chewing gum with calcium carbonate. The identification of pronounced clinical symptoms requires the appointment of special drug therapy. During pregnancy, some of the drugs used in standard treatment regimens for gastroesophageal reflux are used with caution due to possible effects on the fetus or the occurrence of obstetric complications. Patients with severe GERD are shown:
- Non-absorbable antacids and alginates. They are considered 1st-line drugs for the treatment of gastrointestinal reflux disease in pregnant women. Due to the neutralization of hydrochloric acid, a decrease in the digesting abilities of pepsin, the adsorption of lysolecitin, bile acids, improved evacuation of stomach contents, stimulation of prostaglandin secretion, antacids reduce the damaging effect of reflux. Alginates have a protective effect on the esophageal mucosa.
- Histamine H2 receptor blockers. They are used when GERD antacid therapy is ineffective. The antisecretory activity of selective histamine blockers is due to the effect on the receptors of the parietal cells of the stomach. Due to the suppression of secretion, the acidity and volume of gastric contents decrease, which helps to reduce its aggressiveness and pressure on the cardiac sphincter. The effect of H2-histamine blockers on the fetus has not been sufficiently studied, which limits their use.
- Proton pump inhibitors. High efficiency and rapid achievement of therapeutic results in the appointment of PPIs are based on blocking the secretion of hydrochloric acid at the level of secretory tubules of parietal cells. The limited use of pump inhibitors is due to a decrease in the bactericidal properties of gastric juice, which, against the background of natural suppression of immunity, contributes to the development of food infections and impaired absorption of calcium necessary for the normal course of gestation.
As additional means, prokinetics that improve gastrointestinal motility and herbal enveloping preparations can be used. During gestation, surgical treatment of severe and complicated forms of GERD is not carried out. Pregnancy is recommended to be completed by natural childbirth in a physiological period. Caesarean section is performed when obstetric indications are detected.
Prognosis and prevention
When adequate treatment is prescribed, the damaged esophageal mucosa usually fully recovers after 4-12 weeks, with non-erosive variants of the disease, improvement occurs within 4-10 days. Prevention of gastroesophageal reflux involves normalization of diet and lifestyle: rejection of bad habits, sufficient rest and sleep, control of weight gain with a tendency to obesity, exclusion of products that irritate the esophageal mucosa or stimulate hypersecretion of the stomach, taking medications that can disrupt the motility of the gastrointestinal tract, only as prescribed and under the supervision of a doctor. To prevent a recurrence of GERD, a pregnant woman is recommended to take 1-3 days of alginates and antacids “on demand” when symptoms appear.