Gastrointestinal Disorders During Pregnancy: Common Symptoms And Safe Treatments
Monika Andrijauskaitė
Introduction
Digestive tract (DT) disorders are among the most common complaints experienced by women during pregnancy. These disorders may be associated with increased progesterone concentrations in the blood (e.g., nausea, vomiting, gastroesophageal reflux disease (GERD)) and/or elevated prostaglandin levels (e.g., diarrhea) (1). Some DT disorders are specific to pregnancy. Most do not require treatment, but in some cases pregnant women develop chronic DT-related diseases that require special care and treatment. In order to determine the most appropriate management and treatment strategies for pregnant women with DT disorders, it is important to understand the frequency and causes of these conditions (2, 3). This article discusses the most common DT-related symptoms and diseases that develop during pregnancy.
Nausea And Vomiting
Nausea and/or vomiting are common DT disorders that occur in early pregnancy, usually resolving spontaneously without requiring special treatment. Nausea is reported by 50–90% of pregnant women, while vomiting occurs in 25–55% of cases (4, 5). Young age, obesity, first pregnancy, and smoking are considered risk factors for nausea during pregnancy.
During the first trimester, usually around 6–8 weeks of gestation, up to 91% of women experience nausea. A mild form of this condition is commonly referred to as morning sickness. Although the pathophysiology of nausea during pregnancy is not fully understood, it is associated with hormonal fluctuations, DT motility disorders, and psychosocial factors.
If nausea and/or vomiting persist into the second or third trimester, other possible causes should be considered. In pregnant women, nausea and vomiting may be caused by urinary tract infection, gastroenteritis, peptic ulcer disease, pancreatitis, gallbladder or bile duct disorders, hepatitis, appendicitis, adrenal insufficiency, or increased intracranial pressure. In later pregnancy, these symptoms may also be associated with hydramnios or preeclampsia.
The choice of treatment depends on symptom severity. Mild nausea may be relieved by dietary modifications, such as eating smaller and more frequent meals, reducing fat intake, and increasing carbohydrate consumption. Pregnant women are also advised to avoid factors that may trigger nausea, including coffee, iron supplements, heat, humidity, and poorly ventilated rooms.
If these measures are ineffective, ginger products such as ginger candies or ginger tea may be used (6). Pyridoxine (vitamin B6) has also been shown to alleviate nausea and is considered safe during pregnancy. The recommended dose is 10–25 mg every 6–8 hours, not exceeding 200 mg/day (7).
If symptoms persist, a combination of pyridoxine and doxylamine may be used to suppress nausea and vomiting during pregnancy. A dose of 20 mg pyridoxine combined with 20 mg doxylamine is recommended before bedtime, with dose adjustments if necessary (8). Currently, doxylamine is not registered in the Register of Medicinal Products of the Republic of Lithuania.
For severe nausea and vomiting, metoclopramide 10 mg may be administered every 6–8 hours (9). Large cohort studies have shown that metoclopramide use during the first trimester does not increase the risk of major congenital malformations, miscarriage, or preterm birth (10, 11).
GERD
GERD affects approximately 40–85% of pregnant women (12). Many studies have shown that GERD symptoms increase and worsen during later pregnancy, but usually become milder or disappear completely after childbirth (13).
During pregnancy, the enlarging uterus increases intra-abdominal pressure and displaces the lower esophageal sphincter (LES), which may promote LES relaxation. Many authors consider this the main mechanism contributing to GERD during pregnancy (14, 15).
The most common symptoms of GERD are heartburn and acid reflux. Burning chest pain, dysphagia, a sensation of a lump in the throat, and excessive salivation occur less frequently but are also characteristic symptoms of GERD (16, 17). GERD is usually diagnosed based on clinical symptoms.
The primary treatment for GERD during pregnancy consists of lifestyle and dietary modifications, such as elevating the head of the bed during sleep and avoiding foods that promote reflux. Medication is recommended when these measures are ineffective.
Treatment usually begins with antacids. However, antacids containing sodium bicarbonate or magnesium trisilicate should be avoided during pregnancy (18). Sucralfate may subsequently be administered at a dose of 1 g three times daily (19). If symptoms persist, H2 histamine receptor blockers may be used, such as ranitidine at a dose of 75–150 mg twice daily (20).
Proton pump inhibitors may also be prescribed during pregnancy, with omeprazole, lansoprazole, and pantoprazole generally preferred (21, 22).
Abdominal Bloating And Constipation
Pregnant women frequently complain of bloating and constipation. These symptoms affect approximately 16–39% of women from early pregnancy until 6–12 weeks postpartum.
Bloating and constipation during pregnancy are associated with hormonal changes that impair intestinal motility. Increased progesterone concentrations slow the activity of intestinal smooth muscle. This effect may also be influenced by reduced levels of the hormone motilin in the blood. In addition, the enlarged uterus may compress pelvic organs and slow intestinal transit.
To relieve constipation during pregnancy, priority is given to increasing dietary fiber and fluid intake or using concentrated dietary fiber supplements, as these substances are not absorbed in the intestine.
In more severe cases, lactulose or bisacodyl may be prescribed. Castor oil stimulates uterine contractions and should therefore be avoided during pregnancy.
Diarrhea
Diarrhea is defined as three or more loose bowel movements per day. During pregnancy, diarrhea affects approximately 34% of women. The most common causes include infections caused by Salmonella, Shigella, Campylobacter, Escherichia coli, parasites, or viruses. Other possible causes include food poisoning, medication-induced diarrhea, and irritable bowel syndrome.
If diarrhea persists for more than 48 hours, is accompanied by profuse watery stools, rectal bleeding, or noticeable weight loss, the underlying cause should be investigated. Recommended diagnostic tests may include viral antigen testing, stool culture and microscopy, and complete blood count evaluation.
The primary goal of treatment is restoration of fluid and electrolyte balance through oral or intravenous rehydration therapy. Pharmacological treatment may begin with bismuth subsalicylate. Loperamide, an antidiarrheal agent, is also considered safe during pregnancy. However, antispasmodic and anticholinergic medications are generally not recommended for pregnant women.
Gallbladder Stones
During pregnancy, gallbladder motility slows due to the effects of progesterone, while increased estrogen levels promote cholesterol synthesis and gallstone formation. According to the literature, gallbladder sludge is found in up to 31% of pregnant women, while gallstones are diagnosed in up to 2% of expectant mothers. Cholecystectomy is one of the most common non-obstetric surgical procedures performed during pregnancy, second only to appendectomy.
Diagnosing gallbladder stones during pregnancy may be more difficult because the enlarged uterus can alter the location and character of pain. In addition, relaxation of the abdominal wall may make signs of peritonitis less pronounced.
Pain is typically localized in the right upper abdominal quadrant or epigastric region. Other symptoms may include nausea, vomiting, intolerance to fatty foods, bloating, fever, or jaundice.
When symptoms of gallbladder stones occur during pregnancy, conservative treatment is usually recommended initially, including pain management, intravenous fluid therapy, dietary modifications, and antibiotic treatment if indicated.
Severe pain may be treated with intravenous opioids, while mild pain may be managed with acetaminophen. Nonsteroidal anti-inflammatory drugs should generally be avoided during pregnancy, especially after 32 weeks of gestation.
If conservative management is ineffective or episodes recur, surgical treatment should be considered. Cholecystectomy is usually safest during the second trimester or at the beginning of the third trimester.
Summary
- Nausea, vomiting, GERD, and other gastrointestinal disorders are common during pregnancy. This article briefly reviews the main causes of these conditions and current treatment recommendations.
- Nausea and vomiting during pregnancy are associated with hormonal fluctuations, altered gastrointestinal motility, and psychosocial factors. Symptom management may include dietary modifications, avoidance of nausea triggers, ginger-containing products, vitamin B6 supplementation, and metoclopramide.
- GERD most commonly presents with heartburn and acid reflux. Recommended treatment during pregnancy includes lifestyle and dietary modifications, antacids, sucralfate, H2 histamine receptor blockers, and proton pump inhibitors.
- Management of constipation during pregnancy primarily focuses on increasing dietary fiber and fluid intake. If symptoms persist, lactulose or bisacodyl may be prescribed.
- In cases of frequent watery stools occurring three or more times daily, rehydration therapy is recommended. Bismuth subsalicylate and loperamide may be used to control diarrhea during pregnancy.
- Hormonal changes during pregnancy increase the risk of gallstone formation. When symptoms of cholecystitis develop, conservative treatment with acetaminophen, intravenous opioids, intravenous rehydration, dietary modifications, and, if necessary, antibiotic therapy is recommended.
