An Educational Resource For Heartburn And Acid Reflux

Introduction

The experience of pregnancy and childbirth has long been described as miraculous. A pregnant woman’s body grows and changes, preparing for the pending birth. There are some common gastrointestinal problems commonly associated with pregnancy and the period directly after the birth, or the post-partum period. These problems, although part of the miracle of birth, can make you feel less than miraculous. This article will explore some common problems that occur during pregnancy, and offer some solutions. It will also explore some more serious gastrointestinal problems that can occur as a result of pregnancy.
 

Constipation During Pregnancy and After the Birth

My patient's husband called me on a Saturday afternoon from his wife Kathy’s hospital room.  He was the proud father of baby twin boys.  But Kathy was extremely uncomfortable. Ever since the babies were born, she could not move her bowels.

Constipation means different things to different people. Some people feel as though they have to strain during a bowel movement, or they are bloated, or passing pebble-like stools. In the world of medicine, constipation is defined as fewer than three bowel movements per week.

Constipation is a very common problem in pregnancy and in the days after delivering a baby, or the post-partum period. If a mother has an episiotomy (repair of torn rectal tissue), having a bowel movement can be very painful, and she may unconsciously hold on to her stool. Also, after a cesarean section delivery, the bowel can be temporarily paralyzed. This is called an ileus. There are some very simple things one can do to help alleviate constipation during pregnancy and in the post-partum period.

What Can I do About Constipation?

Exercise
Early in pregnancy exercise is very helpful to prevent constipation. Even walking will help to loosen your bowels, and will help you feel less bloated.

Fluids
During pregnancy, the amount of water that is absorbed from your intestine into your blood increases. You will need to drink even more water than usual to keep your intestine and your baby healthy. Drinking at least ten, 8-ounce glasses of water will be essential for you and for the baby. If you are pregnant during the summer and it is hot or humid, you may need even more water. Drinking more water during pregnancy will help to prevent constipation.

The right calcium and vitamin supplements
Calcium supplements and vitamin pills, essential for your baby’s development, can cause bloating and constipation. The following are some suggestions for calcium and vitamin supplements that are less constipating.

Calcium
The best calcium supplements are those that can dissolve in the pH of vinegar (also called acetic acid). Easily digested calcium supplements, which cause less constipation, include TUMS and Calcitrate. Usually I recommend TUMS because they supply calcium and they help to alleviate heartburn and bloating. Each TUMS contains 200 mg of elemental calcium. Taking five or six a day, in addition to a well-balanced diet, provides an excellent source of calcium. Be careful to avoid antacids that contain aluminum, which can be very constipating.

Vitamins
A "prenatal" vitamin, which is specially designed for  pregnant women, is the best digested. My patients prefer Stuart Natal Plus or Materna. The generic is also acceptable. These vitamins are bio-available, which means they are well absorbed from the gut and will cause less nausea and bloating. They have the extra iron, folate and B vitamins that you need when you are pregnant. Don't forget, if possible you should start your folate 1 mg supplements 6 months before you become pregnant!

Stool softeners
In some cases, a stool softener is needed to relieve constipation. Obstetricians often recommend that patients use Docusate. Docusate works as a surfactant to decrease the wall tension between the stool and the colon. It is not habit forming and acts mainly to keep the stool soft for easy, natural passage. It is well tolerated, it comes in 100 mg capsules, and Docusate can be taken 1-3 times every night.

Alternating hot and cold
Drinking cold fluids or eating ice chips, then drinking warm fluids, like decaffeinated tea, helps to stimulate and tone the bowel, and also helps to pass gas.

Incentive spirometer
If you are on bed rest during your pregnancy, an incentive spirometer (a device into which you inhale deeply, either raising balls or creating bubbles depending on the model) will be essential to keep your bowels moving and to keep your lungs clear. The incentive spirometer cannot be over-used. Every ten minutes is perfect.

Constipation remedies to beware of
I do not recommend senna, the herbal remedy for constipation. This substance, although advertised as natural, causes cramping and secretion of electrolytes and water from the colon. This is called a secretory diarrhea, which at best is unpleasant and at worst causes an electrolyte imbalance in the blood. Some patients drink prune juice for constipation, but I do not recommend this either since its active ingredient is phenolphthalein, which can also cause a secretory diarrhea as well as bowel dependence.

Nursing
After the baby is born, nursing can actually help to alleviate constipation. Stimulation resulting from the baby’s sucking causes the uterus to contract, and helps to move the bowels.

Enema
An enema is an effective way to empty the colon. It is, however, a rather invasive measure, and may be uncomfortable for women who have had cesarean deliveries, or episiotomies.

If you have any constipation or abdominal discomfort during or after your pregnancy, you should consult with your doctor. Sometimes a medical condition such as a thyroid problem (hypothyroidism) may develop during pregnancy and cause constipation.
 

For Kathy, all that was needed was reassurance, some time, and a little instruction on how to nurse the babies. Once she was able to relax, have a glass of tea, and nurse her babies, her bowels moved and she was much more comfortable.
 

Heartburn During Pregnancy

Another problem that can begin early in pregnancy is heartburn, or reflux. It is in part a result of hormonal changes during pregnancy.  Women’s progesterone level increases during pregnancy, which loosens the normal sphincter between the stomach and the esophagus (the gastroesophageal junction). When this sphincter loosens, the acidic contents of the stomach move up into the esophagus and cause burning pain, or pyrosis.  The higher level of progesterone also slows the emptying of the stomach, called a paralyzed stomach or gastroparesis.

What Can I Do About Heartburn?

Watch what you eat
To help prevent nausea and reflux, it is best to avoid fat, chocolate, and fried foods.  Also, you may have to watch your intake of foods like cabbage, broccoli and lettuce, which are all high in raffinose, a kind of sugar. Although very healthy, these vegetables produce gas in the stomach that may be uncomfortable during pregnancy so you should eat them only in moderate amounts.

Antacids
TUMS, which also serve as a calcium supplement, will help to prevent heartburn as well. If you suck them, the esophagus will contract and acid will be cleared quickly.

Caffeine/alcohol and nicotine
Many of the lifestyle modifications that help to prevent heartburn should be automatic during pregnancy. It is best to avoid smoking, caffeine and alcohol. You should not use any medicine, even if it is over the counter, unless your doctor specifically approves it.
 

Nausea and Vomiting During Pregnancy

One Monday morning I was called to see a patient who was vomiting and felt nauseated. Sharon had learned she was pregnant 2 weeks earlier.

Early Nausea is Normal
Nausea and vomiting occur in up to half of all pregnant women beginning two weeks after the missed period, and may be related to hormonal changes during pregnancy. We call the first thirteen weeks of pregnancy the first trimester, since a normal pregnancy in women is about forty weeks long. Generally, the nausea and vomiting will end by the twelfth week of pregnancy, so by the second trimester you should feel much better.

What Can I Do About Nausea?
Eating small, frequent, low-fat meals will help with the nausea. Many women like watermelon, cantaloupe, berries, peaches, and nectarines when they are pregnant. Also, sipping liquids between meals, rather than with meals, will cause less stomach distention and less nausea. Avoid carbonation. ‘Gas in the glass’ will go right to your intestine.

Mild nausea is normal, but if you have severe symptoms you should consult with your doctor right away.

Sharon's blood pressure, physical examination, and blood tests were all normal. I instructed Sharon carefully about dietary and lifestyle modifications, and we talked about the role of antacids and prenatal vitamins in her pregnancy. Sharon was able to eat and drink adequate amounts of food and fluid and within a few weeks she was feeling much better.

Abnormal Nausea During Pregnancy

While nausea and vomiting is common in pregnancy, there is a less common condition called hyperemesis gravidarum, which can occur at any time during pregnancy. This condition is characterized by severe vomiting, which can lead to dehydration and electrolyte abnormalities in the blood. True hyperemesis gravidarum is a serious problem and requires intravenous fluid and possibly intravenous feeding.

Some indications of hyperemesis gravidarum are:
 

• Low levels of sodium, chloride, or potassium in the blood.
• In severe cases, the heart rate may go up to 100 or even 120 with a decrease in blood pressure.
• Blood tests in a patient who is dehydrated may show an elevation in
• BUN and creatinine, which are proteins that reflect kidney function.

Nausea late in pregnancy
It is important to know that the onset of vomiting later in pregnancy may indicate a true emergency. In pregnancy, the bowel can become twisted (volvulus), or obstructed. These are rare but serious conditions which may require surgery, so it is very important that you contact your doctor if you start vomiting after the first trimester.
 

Serious Gastrointestinal Conditions to Watch For in Pregnancy

There are some inflammatory conditions that can develop in pregnancy, which are important to be aware of as well. They include acute cholecystitis, pancreatitis, and appendicitis.

Acute Cholecystitis
The gallbladder tends to be dilated and sluggish during pregnancy, so gallstones, or ‘sludge’, can form in the gallbladder. Sometimes this results in an obstructed gallbladder, which is called acute cholecystitis and may require surgery. Symptoms that accompany this condition include dull pain in your right upper abdomen, fever, chills, nausea, and vomiting.

Pancreatitis
In some patients, a gallstone can get caught in the main bile duct and cause gallstone pancreatitis. This means that a stone leaving the gallbladder blocks the opening to the pancreas and causes the enzymes that normally digest food in the intestine to attack the pancreas itself. This causes inflammation of the pancreas, or pancreatitis. Symptoms may include a constant, dull pain in the mid-abdomen or back, nausea, and vomiting.

Treatment: A camera with an instrument channel called an ERCP scope can be used to take the stone out, without major surgery. The ERCP scope is inserted into the mouth, down into the stomach, and into the duodenum where the bile duct enters the intestine. A balloon-tipped catheter is then advanced into the bile duct and by inflating the balloon and pulling it through the duct the stone can be removed. We know from studies that this can be done safely during pregnancy if necessary.
 

Appendicitis
Another serious problem that can occur during pregnancy is appendicitis. The appendix, a pouch of intestine located in the right lower abdomen, can become inflamed and infected. During pregnancy the appendix moves into the upper right abdomen. Sometimes the symptoms of appendicitis are not very clear. You may be mildly nauseous and feverish, and you may not feel like eating. It is important that your doctor hear of these symptoms right away because if appendicitis is diagnosed early, the baby and mother will both be safe. Treatment is surgical removal of the appendix.
 

Liver Problems During Pregnancy

Last summer, my patient Laura came to my office. She was excited to be nearing the end of her pregnancy but she was very itchy. I could see that the whites of her eyes were turning yellow. With a blood test, I found that her bilirubin level was high, but otherwise her liver function was very good. What was wrong?

In medicine we say that when a patient gets a consult for abnormal liver function tests and that patient is pregnant, don't walk, RUN!! There can be serious problems with the liver during pregnancy. In my patient's case, she had what we call cholestasis of pregnancy, which simply means, the bilirubin  was accumulating in her blood, but her liver function was normal.

There is, however, a liver condition called fatty liver of pregnancy, which constitutes a medical emergency and must be treated right away. If you are pregnant and you feel itchy or notice a yellow color in your eyes or skin, you must consult your doctor immediately.
 

Laura responded very well to a powder called cholestyramine, which helps to bind bile salts. She had a healthy boy and came to see me with the beautiful child a few weeks later. She was no longer itching and her skin was pink and normal. She felt very well but asked me what she could do for constipation.

Well, after reading this article, what would you say if your patient asked you?