A 28-year-old primigravid woman at 24 weeks gestation comes to the office due to heartburn and nausea. Over the last several weeks she has also had retrosternal and epigastric pain after eating. Although the patient uses 2 pillows to sleep and avoids spicy food, she awakens several nights a week due to heartburn and regurgitation. The symptoms started a month ago and have been minimally responsive to over-the-counter antacids.
The patient has a history of heartburn prior to pregnancy, which she managed with dietary changes and over-the-counter antacids. Her father died from esophageal cancer at age 60. The patient does not use tobacco, alcohol, or illicit drugs. She takes a multivitamin daily.
Which of the following is the most appropriate management for this patient?

Question

A 28-year-old primigravid woman at 24 weeks gestation comes to the office due to heartburn and nausea.  Over the last several weeks she has also had retrosternal and epigastric pain after eating.  Although the patient uses 2 pillows to sleep and avoids spicy food, she awakens several nights a week due to heartburn and regurgitation.  The symptoms started a month ago and have been minimally responsive to over-the-counter antacids.
The patient has a history of heartburn prior to pregnancy, which she managed with dietary changes and over-the-counter antacids.  Her father died from esophageal cancer at age 60.  The patient does not use tobacco, alcohol, or illicit drugs.  She takes a multivitamin daily.
Which of the following is the most appropriate management for this patient?

Quizplus · Accepted Answer

11ec193a_989f_587e_853d_5f90345f65ed_MD0002_00 During pregnancy, physiologic changes (eg, decreased lower esophageal sphincter tone due to estrogen/progesterone) commonly cause gastroesophageal reflux disease (GERD) symptoms to develop or become exacerbated. Because treatment may pose problems given drug safety concerns, a step-up approach is used. Initial management of GERD is with lifestyle and dietary modifications such as elevating the head during sleep, avoiding acidic foods (eg, citrus, coffee), avoiding eating <3 hours prior to bedtime, and avoiding alcohol and tobacco. GERD symptoms that are unresponsive to lifestyle modifications are treated with antacids (eg, calcium carbonate, magnesium-containing compounds); Alka-Seltzer and similar aspirin-containing drugs should be avoided due to concerns of adverse fetal effects. Symptoms that persist are treated with sucralfate and, if still unresponsive (as in this patient), with acid-reducing agents such as histamine-2 receptor antagonists (eg, ranitidine, famotidine). Proton pump inhibitors are probably safe, although data are more limited. GERD typically improves or resolves in the postpartum period, but recurrence in subsequent pregnancies is likely. (Choice A) This patient's symptoms have not responded to an over-the-counter antacid; therefore, additional acid-neutralizing therapy is unlikely to be effective. In addition, antacids are used for intermittent, mild GERD that occurs less than once a week. (Choice C) Esophageal manometry is indicated to evaluate for other etiologies (eg, achalasia) in patients diagnosed with GERD whose symptoms have not responded to proton pump inhibitors and whose esophagogastroduodenoscopy is normal. (Choice D) Esophagogastroduodenoscopy is indicated in pregnant patients with GERD who have a GERD-related complication (eg, hemorrhage). (Choice E) This patient's symptoms have not responded to lifestyle modification and antacids, and are unlikely to respond to further lifestyle modifications (eg, low-fat diet). Metoclopramide may be considered for GERD that is unresponsive to acid-reducing agents, particularly if the GERD is associated with motility disorders. Educational objective: Gastroesophageal reflux disease is common during pregnancy. Initial treatment includes lifestyle modification and antacids; more severe cases are treated with histamine-2 receptor antagonists or proton pump inhibitors. __________ References: Gastroesophageal reflux disease in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/17889808)

A 28-Year-Old Primigravid Woman at 24 Weeks Gestation Comes to the Office