Indigestion and acid reflux in pregnancy

Indigestion in pregnancy is commonly due to acid reflux. Acid reflux occurs when acid from the stomach leaks up into the gullet (oesophagus). This may cause heartburn - usually felt as a burning pain which rises from the upper stomach behind the breastbone - and other symptoms. Attention to diet and lifestyle may help to ease symptoms. Antacids are commonly used. A medicine which prevents your stomach from making acid may be prescribed if symptoms remain troublesome.

What is indigestion?

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

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

Understanding the oesophagus and stomach

Acid reflux inflammation

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

Stomach cells also make 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 occurs when some acid leaks up (refluxes) into the gullet (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 tightness (tone) of the sphincter is reduced during pregnancy.

• The size of the baby in the tummy (abdomen) causes an increased pressure on the stomach.

One or both of the above increase the chance that acid will reflux into the oesophagus. The indigestion usually settles on its own after the birth of your baby when your hormones change back to their non-pregnant state and the baby is no longer increasing pressure on your stomach.

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

What are the symptoms of acid reflux and indigestion in 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 sensation which rises from the upper tummy (abdomen) or lower chest up towards the neck. (It is a confusing term as it has nothing to do with the heart!)

• Waterbrash. This is a sudden flow of sour-tasting saliva in your mouth.

• Upper abdominal pain or discomfort.

• Pain in the centre of the chest behind the breastbone (sternum).

• Feeling sick (nausea) and being sick (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 happen more often, or are more severe, in the last three months of pregnancy. As soon as the baby is born, indigestion due to pregnancy usually disappears quickly.

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

Do I need any investigations?

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

Lifestyle changes that may help with indigestion symptoms

The following are commonly advised. There has been little research to prove how well these lifestyle changes help to ease acid leaking back up (reflux) and indigestion 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 to what extent specific foods contribute to the problem.

Let common sense be your guide. If it seems that a food is causing symptoms, 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 and fatty foods.

• Fruit juices.

• Hot drinks.

• Coffee.

• Alcoholic drinks. (Current advice is that you avoid all alcohol in pregnancy anyway.)

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 the separate leaflet called Pregnancy and Smoking.

Have good posture

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

Bedtime

If symptoms return on 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 cm (with sturdy blocks or bricks under the bed's legs), this will help gravity to keep acid from refluxing into the gullet (oesophagus).

Consider any medicines that you are taking

Some medicines may make symptoms worse. Women are rarely prescribed these medicines during pregnancy. However, it's worth checking with your pharmacist or your doctor if you think medication you are on could be making your symptoms worse.

Is there any medication for indigestion in pregnancy?

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

Antacids and alginates

Antacids are alkaline liquids or tablets that neutralise the acid. A dose usually gives rapid relief. You can use antacids when you need them for mild or infrequent bouts of indigestion. 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: this is because they may be harmful to your developing baby.

You can buy many different brands of antacids, and some are available on prescription. A doctor or pharmacist can advise. Some points about antacids are:

• They can interfere with the absorption of iron tablets. Therefore, they should be taken at a different time of day from any iron supplements you are taking. 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 an antacid 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 gullet (oesophagus) from stomach acid. They form a protective raft when they come into contact with stomach acid, blocking the acid from entering the oesophagus. Some alginates are specifically licensed for use in pregnancy. Again, your pharmacist can advise.

Acid-suppressing medicines

Omeprazole is an acid-suppressing medicine that is licensed for use in pregnancy to treat indigestion that is still troublesome despite any lifestyle changes and antacids. Omeprazole needs to be taken regularly to be effective.

Note: Other medicines that are commonly used for heartburn, indigestion, 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.