Interventions for heartburn in pregnancy

Association of dietary fiber, liquid intake and lifestyle characteristics with gastrointestinal symptoms and pregnancy outcome

Objectives

Heartburn and constipation are common gastrointestinal symptoms during pregnancy. High fiber and liquid intake have beneficial effects on these symptoms in non- pregnant population. Our aim was to evaluate the association of dietary fiber, fluid intake and lifestyle characteristics with constipation, heartburn, and pregnancy outcome.

Study design

Two hundred pregnant women were enrolled in this prospective cohort study during the 1st trimester of pregnancy. Participants completed a self- administered questionnaire concerning bowel symptoms, dietary fiber, liquid intake, and lifestyle characteristics before pregnancy, during pregnancy and post-partum. After exclusions 173 pregnant women participated the study and 173, 173, 136, 109 and 91 completed pre-pregnancy, and 1st, 2nd, and 3rd trimester, and post-partum questionnaires, respectively. Data on deliveries and perinatal outcome (n = 173) were collected from hospital records. In trajectory analysis, the women were clustered in groups based on the intake of fiber and liquids. Generalized linear mixed models and logistic regression analyses were used to find associations of fiber and fluid intake with constipation, heartburn and pregnancy outcome.

Results and conclusions

Heartburn increased significantly during pregnancy and the highest prevalence (33%) was during the third trimester. A combination of low fiber and low fluid intake increased the risk of constipation during pregnancy (OR 5.9, 95% CI 2.00-17.4). Low fiber intake increased the risk of combined adverse outcome (cesarean section, premature delivery and/or small for gestational age; OR 3.4, 95% CI 1.2-9.6). Sufficient fiber and liquid intake may be protective against pregnancy-associated constipation and may be associated with improved pregnancy outcome.

Efficacy of alginate-based reflux suppressant and magnesium-aluminium antacid gel for treatment of heartburn in pregnancy: a randomized double-blind controlled trial

The aim of this study was to compare the therapeutic efficacy of alginate-based reflux suppressant and magnesium-aluminium antacid gel for treatment of heartburn in pregnancy. A double-blinded, randomized, controlled trial was conducted. One hundred pregnant women at less than 36 weeks gestation with heartburn at least twice per week were randomized to either alginate-based reflux suppressant or to magnesium-aluminium antacid gel. Details of heartburn were recorded before beginning the treatment and the second week of study. Primary outcome measure was the improvement of heartburn frequency after treatment and secondary outcome were the improvement of heartburn intensity, quality of life, maternal satisfaction, maternal side effects, pregnancy and neonatal outcomes. There was no difference between treatment and control groups in improvement of heartburn frequency (80% vs 88%, p = 0.275), 50% reduction of frequency of heartburn (56% vs 52%, p = 0.688), improvement of heartburn intensity (92% vs 92%, p = 1.000) and 50% reduction of heartburn intensity (68% vs 80% cases, p = 0.075). There were also no significant differences in quality of life, maternal satisfaction, maternal side effects, pregnancy and neonatal outcomes. Alginate-based reflux suppressant was not different from magnesium-aluminium antacid gel in the treatment of heartburn in pregnancy.

Health care utilisation of women who experience pregnancy-related reflux, nausea and/or vomiting

OBJECTIVE

Nausea, vomiting and reflux are common conditions experienced by women during pregnancy. The objective of this project was to examine women's use of health services for these conditions.

METHODS

The study sample was obtained via the Australian Longitudinal Study on Women's Health. A total of 2445 women who were pregnant or who had recently given birth in 2009 were invited to complete a sub-survey in 2010 about pregnancy and health service utilisation. A response rate of 79.2% was obtained.

RESULTS

During their pregnancy, 604 (32.9%) respondents experienced nausea, with 255 (42.2%) of these women seeking help from a health care practitioner. A total of 201 women (11%) reported repeated vomiting, and 637 women (34.7%) reported reflux, of which 78.6% and 59.2% sought help, respectively. There were no significant differences in the mental and physical health measures between women with nausea, vomiting and/or reflux who sought help and women who did not. Having private health insurance with obstetric cover was associated with seeking help for reflux; this was the only demographic measure significantly associated with seeking help for any condition.

CONCLUSION

Research is required to understand why many women do not seek professional help for common gastrointestinal conditions during pregnancy.

Interventions for heartburn in pregnancy

BACKGROUND

Heartburn is one of the most common gastrointestinal symptoms in pregnant women. It can occur in all trimesters of pregnancy. The symptoms of heartburn in pregnancy may be frequent, severe and distressing, but serious complications are rare. Many interventions have been used for the treatment of heartburn in pregnancy. These interventions include advice on diet, lifestyle modification and medications. However, there has been no evidence-based recommendation for the treatment of heartburn in pregnancy.

OBJECTIVES

To assess the effects of interventions for relieving heartburn in pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2015), ClinicalTrials.gov (2 March 2015), Asian & Oceanic Congress of Obstetrics & Gynaecology (AOCOG) conference proceedings (20-23 October 2013, Centara Grand & Bangkok Convention Centre, Bangkok, Thailand), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTS of interventions for heartburn in pregnancy compared with another intervention, or placebo, or no intervention. Cluster-RCTs would have been eligible for inclusion but none were identified. We excluded studies available as abstracts only and those using a cross-over design.Interventions could include advice on diet, lifestyle modification and medications (such as antacids, sucralfate, histamine 2-receptor antagonists, promotility drugs and proton pump inhibitors (PPIs)).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We included nine RCTs involving 725 women. However, five trials did not contribute data. Four trials involving 358 women contributed data. Trials were generally at mixed risk of bias.We only identified data for three comparisons: pharmaceutical treatment versus placebo or no treatment; acupuncture versus no treatment and pharmacological intervention versus advice on dietary and lifestyle changes. Pharmaceutical treatment compared with placebo or no treatmentTwo trials evaluated any pharmaceutical treatment compared with placebo or no treatment. One trial examined a treatment rarely used nowadays (intramuscular prostigmine 0.5 mg versus placebo). One trial evaluated the effect of magnesium and aluminium hydroxide plus simethicone liquid and tablet compared with placebo. For the primary outcome of this review (relief of heartburn), women who received pharmaceutical treatment reported complete heartburn relief more often than women receiving no treatment or placebo (risk ratio (RR) 1.85, 95% confidence interval (CI) 1.36 to 2.50 in two RCTs of 256 women, I(2) = 0%, moderate-quality evidence). Data on partial relief of heartburn were heterogenous and showed no clear difference (average RR 1.35, 95% CI 0.38 to 4.76 in two RCTs of 256 women, very low-quality evidence). In terms of secondary outcomes, there was no clear difference in the rate of side effects between the pharmaceutical treatment group and the placebo/no treatment group (RR 0.63, 95% CI 0.21 to 1.89 in two RCTs of 256 women, very low-quality evidence). Pharmacological intervention versus advice on dietary and lifestyle choicesOne study compared 1 g of sucralfate with advice on dietary and lifestyle choices in treating heartburn. More women in the sucralfate group experienced complete relief of heartburn compared to women who received advice on diet and lifestyle choices (RR 2.41, 95% CI 1.42 to 4.07; participants = 65; studies = one). The only secondary outcome of interest addressed by this trial was side effects. The evidence was not clear on intervention side effects rate between the two groups (RR 1.74, 95% CI 0.07 to 41.21; participants = 66; studies = one). There was only one instance of side effects in the pharmacological group. Acupuncture compared with no treatmentOne trial evaluated acupuncture compared with no treatment but did not report data relating to this review's primary outcome (relief of heartburn). In terms of secondary outcomes, there was no difference in the rate of side effects between women who had acupuncture and women who had no treatment (RR 2.43, 95% CI 0.11 to 55.89 in one RCT of 36 women). With regard to quality of life, women who had acupuncture reported improved ability to sleep (RR 2.80, 95% CI 1.14 to 6.86) and eat (RR 2.40, 95% CI 1.11 to 5.18 in one RCT of 36 women).The following secondary outcomes were not reported upon in any of the trials included in the review: miscarriage, preterm labour, maternal satisfaction, fetal anomalies, intrauterine growth restriction, low birthweight.

AUTHORS' CONCLUSIONS

There are no large-scale RCTs to assess heartburn relief in pregnancy. This review of nine small studies (which involved data from only four small studies) indicates that there are limited data suggesting that heartburn in pregnancy could be completely relieved by pharmaceutical treatment. Three outcomes were assessed and assigned a quality rating using the GRADE methods. Evidence from two trials for the outcome of complete relief of heartburn was assessed as of moderate quality. Evidence for the outcomes of partial heartburn relief and side effects was graded to be of very low quality. Downgrading decisions were based in part on the small size of the trials and on heterogenous and imprecise results.There are insufficient data to assess acupuncture versus no treatment and no data to assess other comparisons (miscarriage, preterm labour, maternal satisfaction, fetal anomalies, intrauterine growth restriction, low birthweight).Further RCTs are needed to fully evaluate the effectiveness of interventions for heartburn in pregnancy. Future research should also address other medications such as histamine 2-receptor antagonists, promotility drugs, proton pump inhibitors, and a raft-forming alginate reflux suppressant in treatment of heartburn in pregnancy. More research is needed on acupuncture and other complimentary therapies as treatments for heartburn in pregnancy. Future research should also evaluate any adverse outcomes, maternal satisfaction with treatment and measure pregnant women's quality of life in relation to the intervention.

Heartburn in pregnancy

INTRODUCTION

Heartburn is a common complaint during pregnancy; the incidence is reported to be between 17% and 45%.

METHODS AND OUTCOMES

We conducted a systematic overview and aimed to answer the following clinical question: What are the effects of interventions to prevent or treat heartburn in pregnancy? We searched Medline, Embase, The Cochrane Library, and other important databases up to December 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review).

RESULTS

At this update, searching of electronic databases retrieved 80 studies. After deduplication and removal of conference abstracts, 59 records were screened for inclusion in the review. Appraisal of titles and abstracts led to the exclusion of 58 studies and the further review of one full publication. The full article evaluated did not meet our reporting criteria, and thus no new evidence was added at this update. We performed a GRADE evaluation for two PICO combinations.

CONCLUSIONS

In this systematic overview, we categorised the efficacy for six interventions, based on information about the effectiveness and safety of acid-suppressing drugs, antacids with or without alginates, raising the head of the bed, reducing caffeine intake, reducing intake of fatty foods, and reducing the size and frequency of meals.

Minor ailments in pregnancy are not a minor concern for pregnant women: a morbidity assessment survey in rural Sri Lanka

BACKGROUND

Although maternal mortality has become a major focus on global public health agenda, maternal morbidity is a neglected area of research. The purpose of this paper is to present the burden of acute maternal illness during pregnancy.

METHODS

A cross sectional study was carried out in Anuradhapura district, Sri Lanka. Pregnant women residing in the Anuradhapura district with a gestational age more than 24 weeks through 36 weeks were recruited to the study using a two-stage cluster sampling technique. All pregnant women who consented participated in a detailed interview using a structured questionnaire. Self reported episodes of acute illness during pregnancy were the main outcome measures. Secondary outcomes were utilization of medical services and frequency of hospitalizations.

RESULTS

Nausea and vomiting during pregnancy (NVP) was experienced by 325 (69.7%) of the 466 pregnant women studied. Other common symptoms were backache (152, 32.6%), dizziness (112, 24.0%) and heartburn/regurgitation (107, 23.0%). Of the 421 pregnant women who reported ill health conditions 260 (61.8%) women sought medical treatment for these illnesses. Total number of episodes that needed treatment seeking were 373. Hospitalizations were reported by 83 (17.8%) pregnant women and the total number of hospitalizations was 109. The leading cause of hospitalization was NVP which accounted for 43.1% of total admissions and 49.1% of total days spent in hospitals.

CONCLUSIONS

Minor maternal ill health conditions affecting day-to-day life have a major burden on pregnancy period. Evidence based management guidelines and health promotion strategies are needed to control and prevent these conditions, in order to provide comprehensive, good quality maternal health care.

Heartburn and regurgitation in pregnancy: the effect of fat ingestion

BACKGROUND

Reflux symptoms are common in pregnancy, but their association with fat ingestion is unclear.

AIM

To investigate an association of dietary fats with heartburn and regurgitation in pregnancy.

METHODS

This is a prospective study in which 89 pregnant women (gestational age 34 +/- 4 weeks) attending a low-risk prenatal outpatient clinic were asked to provide information on the frequency they experienced heartburn and regurgitation. Fat ingestion was estimated by means of a 24-h diet record. Symptomatic patients were compared with those with no reflux symptoms (n = 20).

RESULTS

Heartburn once a week or more often occurred in 56 of the 89 patients (63%). The ingested amount of polyunsaturated fatty acids was higher in patients with heartburn (11.2 +/- 6.4 vs. 7.7 +/- 3.5 mg; P = 0.022) than in controls after adjusting for age, gain weight during pregnancy, ingestion of caffeine and vitamin C, and total energetic intake. The ingestion of monounsaturated fatty acids was higher in patients with heartburn, but with a borderline statistical significance (16.1 +/- 11 vs. 11.8 +/- 6.5 mg; P = 0.061). No association was observed between the consumption of fats and regurgitation.

CONCLUSIONS

This study suggests that heartburn in the third trimester of pregnancy is associated with the ingestion of polyunsaturated fatty acids.