A 28-year-old woman at 32 weeks gestation is seen in the office for a routine prenatal visit. The patient has had burning, squeezing pain in the middle of her chest that lasts for minutes to hours at a time and usually occurs after meals. The pain is occasionally accompanied by small amounts of sour-tasting material in the back of her throat. The patient does not have any abdominal pain, emesis, or visible blood in the stool. Her pregnancy has been complicated by gestational diabetes mellitus, which has been well controlled with nutritional therapy and exercise. She does not use alcohol, tobacco, or illicit drugs. Vital signs are normal. Fundal height is 32 cm and fetal heart tones are normal. Which of the following is the most likely cause of the patient's symptoms?

Question

A 28-year-old woman at 32 weeks gestation is seen in the office for a routine prenatal visit.  The patient has had burning, squeezing pain in the middle of her chest that lasts for minutes to hours at a time and usually occurs after meals.  The pain is occasionally accompanied by small amounts of sour-tasting material in the back of her throat.  The patient does not have any abdominal pain, emesis, or visible blood in the stool.  Her pregnancy has been complicated by gestational diabetes mellitus, which has been well controlled with nutritional therapy and exercise.  She does not use alcohol, tobacco, or illicit drugs.  Vital signs are normal.  Fundal height is 32 cm and fetal heart tones are normal.  Which of the following is the most likely cause of the patient's symptoms?

Quizplus · Accepted Answer

Gastroesophageal reflux is characterized by the retrograde movement of acidic stomach contents through the lower esophageal sphincter (LES) into the esophagus. Manifestations are most common in the minutes or hours after eating and typically include burning, squeezing pain in the retrosternal area, and the regurgitation of acidic (sour-tasting) stomach contents into the mouth. Reflux occurs in most pregnant women and is common in all trimesters. The major underlying cause is elevated estrogen and progesterone levels, which relax the smooth muscle of the LES leading to decreased LES tone and reduced sensitivity to contractile stimuli (eg, high-protein meal). Later in pregnancy, reflux can also occur when the gravid uterus compresses the stomach and results in an altered LES angle or increased gastric pressure. (Choice B) Delayed gastric emptying is common in those with poorly controlled diabetes mellitus due to autonomic neuropathy. It usually presents with nausea, vomiting, early satiety, and a sensation of postprandial fullness. Patients who have short periods of diabetes mellitus (eg, gestational diabetes) are unlikely to develop the autonomic damage that leads to delayed gastric emptying. (Choice C) Diffuse esophageal spasm presents with difficulty swallowing solids and liquids and a sensation of food getting "stuck" in the esophagus. Pregnancy does not increase the risk of esophageal spasm. (Choice D) Helicobacter pylori infection can cause gastritis and peptic ulcer disease, which typically present with epigastric or abdominal pain 2-5 hours after eating (when acid is in the stomach with no food buffer). H pylori is not considered a predominant cause of reflux. (Choice E) Increased gastric acid production is seen in Zollinger-Ellison syndrome, which is caused by the secretion of gastrin from a pancreatic or duodenal neuroendocrine tumor. Patients usually have abdominal pain (from peptic ulcers) and diarrhea. Gastric acid levels are not increased in pregnancy. Educational objective: Pregnant women often develop gastroesophageal reflux disease (GERD) due to elevated levels of estrogen and progesterone, which relax the smooth muscle of the lower esophageal sphincter (LES). Later in pregnancy, GERD can also develop when the gravid uterus presses on the stomach and leads to an altered LES angle or increased gastric pressure. __________ References: Review article: the management of heartburn in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/16225482) Gastroenterology consultations in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/21323581)

A 28-Year-Old Woman at 32 Weeks Gestation Is Seen in the Office