Prevalence and risk factors for gastroesophageal reflux in pregnancy

The Saudi Gastroenterology Association consensus on the clinical care pathway for the diagnosis and treatment of GERD

ABSTRACT

Gastroesophageal reflux disease (GERD) is one of the most common problems encountered in outpatient general medicine and gastroenterology clinics. GERD may present with classic esophageal symptoms, extraesophageal symptoms, or mixed symptoms. The diagnosis and treatment of GERD are challenging due to the variety of symptoms and multifactorial pathophysiology. Since there is no consensus on the diagnosis and treatment of GERD in Saudi Arabia, the Saudi Gastroenterology Association established an expert group to formulate a consensus on the clinical care pathway for the diagnosis and treatment of GERD to update health-care providers in Saudi Arabia. The expert group reviewed the literature including recently published international guidelines, clinical trials, and expert opinion and conducted virtual and in-person meetings. A total of 22 statements on the definition, diagnosis, and treatment of GERD were formulated, and three algorithms for the clinical care of GERD were developed with a detailed description for each step. The expert group endorsed the new definition of GERD, the practical principles of interpretation of the diagnostic GERD evaluation, and the practical guidance for GERD treatment including medical, surgical, and endoscopic therapy. The expert group recommends further studies to investigate local data on the diagnosis and treatment of GERD.

Prevalence and characteristics of gastroesophageal reflux disease in pregnant women

INTRODUCTION AND AIMS

The prevalence of gastroesophageal reflux disease (GERD) has been reported to be increasing in recent years. However, there have been few reports on the prevalence of GERD during pregnancy in the Asian population. The aim of our study was to evaluate the prevalence and characteristics of GERD in Vietnamese pregnant women.

MATERIALS AND METHODS

This cross-sectional study was conducted at the antenatal clinic of the Nhan Dan Gia Dinh Hospital, Ho Chi Minh, Vietnam. Four hundred females, at various stages of pregnancy, were enrolled. GERD was diagnosed if there was troublesome heartburn and/or acid regurgitation, at least once a week, during the current pregnancy.

RESULTS

The overall prevalence of GERD in pregnancy was 38.5% (154/400). The prevalence of GERD in the third trimester was significantly higher than that in the second trimester (46.8% vs. 30.7%, P=0.008) and tended to be higher than its prevalence in the first trimester (46.8% vs. 35.4%, P=0.051). In the pregnant women with GERD, the frequency of regurgitation was significantly higher than that of heartburn (92.9% vs. 30.5%, P<0.001). Those typical symptoms were more prevalent in the daytime, compared with nighttime.

CONCLUSION

Our study showed that GERD was prevalent during pregnancy in Vietnam. In the pregnant women with GERD, regurgitation was much more common than heartburn, and those typical reflux symptoms occurred more frequently in the daytime, compared with nighttime.

Proton Pump Inhibitors Use and Risk of Preeclampsia: A Meta-Analysis

Evidence from preclinical studies suggests a preventive effect of proton pump inhibitors (PPIs) in preeclampsia. Recently, several epidemiological studies have described a conflicting association between the use of PPIs during pregnancy and preeclampsia risk. This study aimed to evaluate the association between PPI use and the risk of preeclampsia. We searched databases, including MEDLINE, Embase, Scopus, Web of Science Core Collection, Emcare, CINAHL, and the relevant grey literature from inception until 13 September 2021. Studies reporting the preeclampsia risk with the use of PPIs were eligible for inclusion. Literature screening, data extraction, and the risk of bias assessment were performed independently by two investigators. Random-effect meta-analysis was performed to generate relative risks (RR) and 95% confidence intervals (CI). The risk of preeclampsia and preterm preeclampsia among women receiving PPIs during pregnancy were the primary outcomes of interest. This meta-analysis comprised three studies involving 4,877,565 pregnant women, of whom 119,017 were PPI users. The included studies were judged to have a low risk of bias. The risk of preeclampsia among pregnant women who received PPIs anytime during pregnancy was significantly increased (RR 1.27 (95% CI: 1.23–1.31)), although the increase was trivial in absolute terms (2 per 1000). The subgroup analysis revealed that the risk was increased in each of the three trimesters. The risk of preterm preeclampsia among pregnant women receiving PPIs anytime during pregnancy was not significantly increased (RR 1.04 (95% CI: 0.70–1.55)). The certainty evaluated by GRADE in these estimates was low. PPI use may be associated with a trivial increase in the risk of preeclampsia in pregnant women. There is no evidence supporting that PPI use decreases the risk of preeclampsia or preterm preeclampsia.

Pregnancy and the Singing Voice: A Survey of What Singers Report

Pregnancy has profound effects on a variety of body systems by way of hormonal and physical changes. Many of these changes directly affect body systems involved in singing. Assumptions exist about what can happen to a person's voice during pregnancy, but these assumptions are based on theoretical predictions leaving little knowledge of the lived experiences of voice changes during pregnancy. An anonymous mixed-method survey was given to 321 professional singers to gain insights on the lived experiences of pregnant singers. This investigation explored what people were told about the effects of pregnancy on the voice in comparison to what they actually experienced. Results show that about half of the respondents' experience matched what they were told for respiration. For phonation and vocal quality less than 25% respondent's experience matched what they were told. In addition, most of the information respondents received came from friends, colleagues, and teachers compared to medical professionals suggesting a need for more interdisciplinary education to best prepare vocalists who are contemplating becoming pregnant.

Review of recent evidence on the management of heartburn in pregnant and breastfeeding women

Gastroesophageal reflux disease (GERD) is one the most common medical complaints in pregnant women. Some women continue to experience GERD symptoms after delivery. Effective management of GERD symptoms is important to improve productivity and quality of life. Management of heartburn in pregnant and breastfeeding women involves lifestyle modifications, dietary modifications, non-pharmaceutical remedies and pharmaceutical drugs. For most patients, lifestyle/dietary modifications are helpful in reducing GERD symptoms. For patients who require a more intense intervention, various types of pharmaceutical drugs are available. However, the suitability of each treatment for use during pregnancy and lactation must be taken into consideration. This article explores the reported efficacy and safety of these treatment options in pregnant and breastfeeding women. Recommended treatment algorithm in pregnant and breastfeeding women have been developed.

Parturient with Acute Abdomen

Management of a parturient with an acute abdomen presents unique challenges. We aim to review the common obstetric and nonobstetric causes for acute abdomen in pregnancy, approach to diagnosis, the role of imaging, and management including the scope and timing of operative intervention.

Short Meal-to-Bed Time Is a Predominant Risk Factor of Gastroesophageal Reflux Disease in Pregnancy

BACKGROUND

Short meal-to-bed time (MTBT) has been reported to relate to gastroesophageal reflux disease (GERD), but evidence is lacking in pregnant women. We aimed to assess the characteristics of GERD and the association between MTBT and GERD during pregnancy.

PATIENTS AND METHODS

A cross-sectional study was carried out on 400 pregnant women aged 18 years and older visiting the antenatal clinic of Gia-Dinh People's Hospital, Vietnam. GERD was defined as having troublesome heartburn and/or regurgitation at least once a week. Reflux-related insomnia was defined as having difficulties in initiating or maintaining sleep through the night. MTBT was defined as "short" if it was ≤2 hours in more than two thirds of days in a week.

RESULTS

There were 154 (38.5%) patients with GERD and 20 (13.0%) patients with reflux-related insomnia. In multivariate analysis, there were 3 factors significantly associated with GERD: third trimester [odds ratio (OR)=1.66; 95% confidence interval (CI): 1.03-2.69], previous history of typical reflux symptoms (OR=9.05; 95% CI: 5.29-15.50), and short MTBT (OR=12.73; 95% CI: 2.92-55.45). The frequency of reflux symptoms progressively increased across subgroups of patients with no short MTBT, either daytime or nighttime short MTBT, and with both daytime and nighttime short MTBT. Nighttime MTBT was also a significant risk factor for reflux-related insomnia (OR=4.60; 95% CI: 1.64-12.92).

CONCLUSIONS

We reported for the first time that short MTBT was a predominant risk factor of GERD in pregnancy. This dieting habit was significantly associated with reflux symptom frequency and reflux-related insomnia.

Vegetarian diets during pregnancy: effects on the mother's health. A systematic review

While interest in vegetarian nutrition has been steadily increasing, some aspects have not yet been consistently investigated. One topic requiring evidence-based confirmation is the adoption of a vegetarian diet during pregnancy and lactation. Maternal diet is not only correlated with the fetus's and infant's health, but appears relevant for that of the mother as well. Not only is an adequate delivery of nutrients to the fetus and infant mandatory, but the increased physiological needs of the maternal body require an adequate supply of nutrients and can represent harmful stress events that may lead to well-defined pathological conditions. In this review, we aim to systematically investigate state-of-the-art of vegetarian diets during pregnancy and lactation, focusing on maternal nutritional status and pregnancy outcomes. Data are scarce, often inconsistent and not homogeneous for many of the topics we considered, mainly because only a few studies have been performed in developed countries, whereas other studies have derived from developing countries, where vegetarianism can be a proxy indicator of malnutrition. For this reason, we did not find sufficient data to provide evidence-based information and recommendations. To date, the available literature does not clearly support a negative impact on the mother's health and pregnancy outcomes, but, analogously with the findings in the vegetarian adult population, an improvement in the quality of studies might facilitate finding more information on the possible positive impact of well-planned vegetarian diets during pregnancy and lactation. More epidemiological and interventional studies are warranted, in order to address the question as to whether vegetarian nutrition represents an advantage for the mother or poses nutritional issues that need further attention.

Is Estrogen a Curse or a Blessing in Disguise? Role of Estrogen in Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD), a condition wherein there is reflux of stomach contents into the esophagus, causing heartburn and regurgitation with a sour and bitter taste in the mouth. It may or may not lead to mucosal injury. GERD symptoms can be troublesome and negatively impact the quality of life. Estrogen, the sex hormone in females, may play a role in the gender differences observed in GERD symptoms. This review article analyzes estrogen's mechanism in the causation of GERD symptoms and its complications. A better understanding of pathophysiology will help us guide early detection, treatment, and prevention of repeated reflux complications. We did a comprehensive PubMed database search and analyzed differences in GERD symptoms experienced by males and females and the role of estrogen in erosive and non-erosive GERD. GERD symptoms in association with hormonal replacement therapy (HRT) and pregnancy, the lower esophageal sphincter (LES) relaxant effects, and estrogens' protective effect on the esophagus from mucosal injury due to repeated reflux are discussed. Estrogen can cause GERD as an adverse effect and, at the same time, can be used to protect the mucosa from GERD induced injury and its complications like metaplasia and cancer. The mechanism is complex and requires further studies and trials. We recommend future researchers to look for possible estrogen use to treat erosive GERD and complication prevention.

Prevalence of benzodiazepines and benzodiazepine-related drugs exposure before, during and after pregnancy: A systematic review and meta-analysis

BACKGROUND

Maternal use of benzodiazepines during pregnancy is common and has increased over the last decades. In this systematic review and meta-analysis, we studied the literature to estimate the worldwide use of benzodiazepines before, during and after pregnancy, which could help to estimate benzodiazepine exposure and to prioritize and guide future investigations.

METHODS

We systematically searched Embase, Medline Ovid, Web of Science and Cochrane Central up until July 2019 for studies reporting on benzodiazepine use before (12 months), during and after pregnancy (12 months). Random effects meta-analysis was conducted to calculate pooled prevalence estimates, as well as stratified according to substantive variables.

RESULTS

We identified 32 studies reporting on 28 countries, together reporting on 7,343,571 pregnancies. The worldwide prevalence of benzodiazepine use/prescriptions during pregnancy was 1.9% (95%CI 1.6%-2.2%; I² 97.48%). Highest prevalence was found in the third trimester (3.1%; 95%CI 1.8%-4.5%; I² 99.83%). Lorazepam was the most frequently used/prescribed benzodiazepine (1.5%; 95%CI 0.5%-2.5%; I² 99.87%). Highest prevalence was found in Eastern Europe (14.0%; 95%CI 12.1%-15.9%; I² 0.00%).

LIMITATIONS

All analyses revealed considerable heterogeneity.

CONCLUSIONS

Our meta-analysis confirmed that benzodiazepine use before, during and after pregnancy is prevalent. The relatively common use of benzodiazepines with possible risks for both mother and (unborn) child is worrying and calls for prescription guidelines for women, starting in the preconception period. Given the substantial proportion of children exposed to benzodiazepines in utero, future research should continue to study the short- and long-term safety of maternal benzodiazepine use during pregnancy and to explore non-pharmacological alternative treatments.

Validity and Reliability of the Antepartum Gastrointestinal Symptom Assessment Instrument

OBJECTIVE

To examine the psychometric properties of the nine-item Antepartum Gastrointestinal Symptom Assessment (AP-GI-SA) instrument.

DESIGN

Single-group prospective design.

SETTING

Urban prenatal clinic serving a diverse population.

PARTICIPANTS

Convenience sample of 45 pregnant women.

METHODS

Participants completed the AP-GI-SA before a scheduled prenatal care appointment. We used Bayesian structural equation modeling to evaluate the construct validity of the scale and assessed known-groups validity. We assessed reliability through maximal reliability coefficient estimate and measured internal consistency with Cronbach's alpha coefficient.

RESULTS

Participants completed the instrument in 2 minutes or less. Construct validity was supported by confirmatory factor analysis (posterior predictive p value = 0.49, gamma-hat = 0.970, and root mean square error of approximation = 0.065), which indicated that the single-factor model is a plausible data-generative model for GI symptoms. The maximal reliability coefficient of 0.75 and Cronbach's alpha coefficient of 0.67 supported reliability. Average AP-GI-SA scores were the highest for women in the third trimester. Of all nine GI symptoms, heartburn in the third trimester received the highest score.

CONCLUSION

Our findings provide preliminary support for the validity and reliability of the AP-GI-SA. The instrument may be used as a measure in intervention studies where GI symptoms of pregnancy are an outcome. The AP-GI-SA could also be useful in clinical settings to quickly evaluate GI symptoms.

Indian consensus on gastroesophageal reflux disease in adults: A position statement of the Indian Society of Gastroenterology

The Indian Society of Gastroenterology developed this evidence-based practice guideline for management of gastroesophageal reflux disease (GERD) in adults. A modified Delphi process was used to develop this consensus containing 58 statements, which were generated by electronic voting iteration as well as face-to-face meeting and review of the supporting literature primarily from India. These statements include 10 on epidemiology, 8 on clinical presentation, 10 on investigations, 23 on treatment (including medical, endoscopic, and surgical modalities), and 7 on complications of GERD. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The prevalence of GERD in India ranges from 7.6% to 30%, being  < 10% in most population studies, and higher in cohort studies. The dietary factors associated with GERD include use of spices and non-vegetarian food. Helicobacter pylori is thought to have a negative relation with GERD; H. pylori negative patients have higher grade of symptoms of GERD and esophagitis. Less than 10% of GERD patients in India have erosive esophagitis. In patients with occasional or mild symptoms, antacids and histamine H₂ receptor blockers (H2RAs) may be used, and proton pump inhibitors (PPI) should be used in patients with frequent or severe symptoms. Prokinetics have limited proven role in management of GERD.

Estradiol mediates relaxation of porcine lower esophageal sphincter

Most pregnant women have symptoms of gastroesophageal reflux disease (GERD) during pregnancy. Postmenopausal hormone replacement therapy is associated with GERD. The effects of estradiol on lower esophageal sphincter (LES) motility and GERD are not clearly known. The purpose of this study is to investigate the effects of estradiol on the motility of the porcine LES. Relaxations of clasp and sling strips of porcine LES caused by estradiol were measured using isometric transducers. We investigated the mechanism of estradiol-induced relaxation of the porcine LES using tetraethylammonium, apamine, iberiotoxin, glibenclamide, KT5720, KT5823, NG-nitro-l-arginine, tetrodotoxin, and ω-conotoxin GVIA. Reverse transcription polymerase chain reaction (PCR) analysis and immunohistochemistry (IHC) were performed to determine the existence of the G protein-coupled estrogen receptor (GPER) in the porcine LES. In endothelin-1-precontracted porcine LES strips, estradiol caused marked relaxations in a concentration-dependent manner. The mechanism of estradiol-induced relaxation on the porcine LES was associated with the potassium channel. Reverse transcription PCR analysis and IHC revealed that GPER was expressed in the sling and clasp fibers of the porcine LES. This finding suggests that GPER mediates the relaxation of the porcine LES. Estradiol may play a role in LES motility.

Heritability and genetic correlation between GERD symptoms severity, metabolic syndrome, and inflammation markers in families living in Mexico City

Objective

The aim of this study was to estimate the heritability (h²) and genetic correlation (ρG) between GERD symptoms severity, metabolic syndrome components, and inflammation markers in Mexican families.

Methods

Cross-sectional study which included 32 extended families resident in Mexico City. GERD symptoms severity was assessed by the ReQuest in Practice questionnaire. Heritability and genetic correlation were determined using the Sequential Oligogenic Linkage Analysis Routines software.

Results

585 subjects were included, the mean age was 42 (±16.7) years, 57% were women. The heritability of the severity of some GERD symptoms was h² = 0.27, 0.27, 0.37, and 0.34 (p-value <1.0x10^-5) for acidity complaints, lower abdominal complaints, sleep disturbances, and total ReQuest score, respectively. Heritability of metabolic syndrome components ranged from 0.40 for fasting plasma glucose to 0.61 for body mass index and diabetes mellitus. The heritability for fibrinogen and C-reactive protein was 0.64 and 0.38, respectively. Statistically significant genetic correlations were found between acidity complaints and fasting plasma glucose (ρG = 0.40); sleep disturbances and fasting plasma glucose (ρG = 0.36); acidity complaints and diabetes mellitus (ρG = 0.49) and between total ReQuest score and fasting plasma glucose (ρG = 0.43). The rest of metabolic syndrome components did not correlate with GERD symptoms.

Conclusion

Genetic factors substantially explain the phenotypic variance of the severity of some GERD symptoms, metabolic syndrome components and inflammation markers. Observed genetic correlations suggest that these phenotypes share common genes. These findings suggest conducting further investigation, as the determination of a linkage analysis in order to identify regions of susceptibility for developing of GERD and metabolic syndrome.

Health-related quality of life of pregnant women with heartburn and regurgitation

BACKGROUND

Heartburn and regurgitation frequently occur in the third trimester of pregnancy, but their impact on quality of life has not been thoroughly investigated.

OBJECTIVE

To measure health-related quality of life of third-trimester pregnant women with heartburn and regurgitation. Methods Data on obstetric history, heartburn and regurgitation frequency and intensity, history of heartburn and regurgitation and health-related quality of life were collected of 82 third-trimester pregnant women.

RESULTS

Sixty-two (76%) women had heartburn, and 58 (71%), regurgitation; 20 were asymptomatic. Mean gestational age was 33.8±3.7 weeks; 35 (43%) women had a family history of heartburn and/or regurgitation, and 57 (70%) were asymptomatic before pregnancy. The following quality of life concepts were significantly reduced: physical problems and social functioning for heartburn; physical problems and emotional functioning for regurgitation. There was agreement between heartburn in present and previous pregnancies.

CONCLUSION

Heartburn and/or regurgitation affected health-related quality of life of third trimester pregnant women.

Novel clues for ultrasonographic diagnosis of reflux in pregnant women: a pilot study

The aim of the present study was to define some novel radiological clues that may aid in the ultrasonographic diagnosis of gastroesophageal reflux in pregnant women. A total of 84 pregnant women, consisting of 42 reflux patients and 42 controls were included in the study. Reflux and control groups were compared in terms of age and our novel ultrasonographic landmarks related to oesophageal structure. While the two groups did not differ in terms of age, they were significantly different from each other with respect to: single layer, single wall oesophageal thickness; double layer, double wall oesophageal thickness; oesophageal hiatal diameter; perioesophageal fat pad thickness; hypoechogenic single wall muscularis mucosa and lamina propria thickness. Owing to our newly defined radiological clues, ultrasonography may have a 'greater than expected' role in the diagnosis of gastroesophageal reflux in pregnant women. However, further studies must be performed to document the actual diagnostic potential of these radiological tips.

A prospective longitudinal cohort study: evolution of GERD symptoms during the course of pregnancy

Background

Symptoms of gastro-esophageal reflux disease (GERD) in pregnancy are reported with a prevalence of 30–80%. The aim of this study was to assess the prevalence and severity of GERD symptoms during the course of pregnancy. Furthermore current practice in medical care for GERD during pregnancy was assessed.

Methods

We performed a prospective longitudinal cohort study on 510 pregnant women (mean age 28.12, SD 5.3). Investigations for reflux symptoms where based on the use of validated reflux-disease questionnaire (RDQ). Additional information was collected about the therapy. A group of non-pregnant women (mean age 24.56, SD 5.7) was included as controls. Frequency and severity of reflux symptoms were recorded in each trimester of pregnancy.

Results

The prevalence of GERD symptoms in pregnant women increased from the first trimester with 26.1 to 36.1% in the second trimester and to 51.2% in the third trimester of pregnancy. The prevalence of GERD symptoms in the control group was 9.3%.

Pregnant women received medication for their GERD symptoms in 12.8% during the first, 9.1% during the second and 15.7% during the third trimester. Medications used >90% antacids, 0% PPI.

Conclusion

GERD symptoms occur more often in pregnant women than in non-pregnant and the frequency rises in the course of pregnancy. Medical therapy is used in a minority of cases and often with no adequate symptom relief.

The safety of fetal exposure to proton-pump inhibitors during pregnancy

BACKGROUND

Proton-pump inhibitors (PPIs) are often needed in pregnancy due to the high rates of acid reflux. Previous studies did not include medical pregnancy terminations data, which may cause a bias toward the null hypothesis. We assessed the fetal safety of PPIs following exposure during gestation including data from medical pregnancy terminations.

METHODS

A unified computerized database was created by linking a computerized database of medications dispensed from 1998 to 2009 to all women registered in "Clalit" HMO, southern district of Israel, with computerized databases containing maternal and infant hospitalization records from the district hospital. Rates of congenital malformations in PPIs exposed and unexposed pregnancies, as well as other adverse fetal effects were compared. Medical pregnancy termination data were included in the analysis.

RESULTS

A total of 114,960 (75%) infants were born during the study period to women registered at "Clalit," 110,783 of them were singleton pregnancies; 1,239 women had medical pregnancy terminations, of which 468 were performed due to fetal malformations. A total of 1,186 infants and abortuses had been exposed to PPIs during the first trimester of pregnancy. Exposure to PPIs was not associated with an increased risk of congenital malformations (adjusted OR 1.06; 95% CI = 0.84-1.33). Similarly, exposure to PPIs during the third trimester of pregnancy was not associated with increased risk of perinatal mortality, premature delivery, low birth weight, or low Apgar scores.

CONCLUSIONS

Intrauterine exposure to PPIs was not associated with increased risk for congenital malformations, perinatal mortality, or morbidity. These results are strengthened with the inclusion of data from medical pregnancy terminations.