Review article: the management of heartburn during pregnancy and lactation

Peptic ulcer disease

Annual prevalence estimates of peptic ulcer disease range between 0·12% and 1·5%. Peptic ulcer disease is usually attributable to Helicobacter pylori infection, intake of some medications (such as aspirin and non-steroidal anti-inflammatory medications), or being critically ill (stress-related), or it can be idiopathic. The clinical presentation is usually uncomplicated, with peptic ulcer disease management based on eradicating H pylori if present, the use of acid-suppressing medications-most often proton pump inhibitors (PPIs)-or addressing complications, such as with early endoscopy and high-dose PPIs for peptic ulcer bleeding. Special considerations apply to patients on antiplatelet and antithrombotic agents. H pylori treatment has evolved, with the choice of regimen dictated by local antibiotic resistance patterns. Indications for primary and secondary prophylaxis vary across societies; most suggest PPIs for patients at highest risk of developing a peptic ulcer, its complications, or its recurrence. Additional research areas include the use of potassium-competitive acid blockers and H pylori vaccination; the optimal approach for patients at risk of stress ulcer bleeding requires more robust determinations of optimal patient selection and treatment selection, if any. Appropriate continuation of PPI use outweighs most possible side-effects if given for approved indications, while de-prescribing should be trialled when a definitive indication is no longer present.

Topic Modeling Analysis of Chinese Medicine Literature on Gastroesophageal Reflux Disease: Insights into Potential Treatment

OBJECTIVE

To analyze Chinese medicine (CM) prescriptions for gastroesophageal reflux disease (GERD), we model topics on GERD-related classical CM literature, providing insights into the potential treatment.

METHODS

Clinical guidelines were used to identify symptom terms for GERD, and CM literature from the database "Imedbooks" was retrieved for related prescriptions and their corresponding sources, indications, and other information. BERTopic was applied to identify the main topics and visualize the data.

RESULTS

A total of 36,207 entries are queried and 1,938 valid entries were acquired after manually filtering. Eight topics were identified by BERTopic, including digestion function abate, stomach flu, respiratory-related symptoms, gastric dysfunction, regurgitation and gastrointestinal dysfunction in pediatric patients, vomiting, stroke and alcohol accumulation are associated with the risk of GERD, vomiting and its causes, regurgitation, epigastric pain, and symptoms of heartburn.

CONCLUSIONS

Topic modeling provides an unbiased analysis of classical CM literature on GERD in a time-efficient and scale-efficient manner. Based on this analysis, we present a range of treatment options for relieving symptoms, including herbal remedies and non-pharmacological interventions such as acupuncture and dietary therapy.

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.

Advancing breastfeeding promotion: leveraging integrative natural galactagogues and unveiling their potential roles-Insights from a 19-year Taiwan nationwide registry to address lactation insufficiency in postpartum women

Background

Lactation insufficiency is a prevalent challenge for nursing mothers globally. There is a growing interest in the use of herbal galactagogues for enhancing lactation, but their therapeutic efficacy and underlying mechanisms need thorough investigation. This study aims to investigate the efficacy and mechanisms of action of herbal galactagogues in addressing lactation insufficiency by utilizing real-world data and employing a network analysis approach.

Methods

Our retrospective study used Taiwan's Longitudinal Health Insurance Database 2000 (LHID2000) to identify 490 patients diagnosed with lactation insufficiency from 2000 to 2018. We analyzed demographic characteristics, co-existing diseases, and prescription patterns for both users and non-users of Chinese herbal products (CHP). Additionally, we utilized a network analysis approach to explore potential compounds and targets in the most frequently used CHP, the Wang Bu Liu Xing and Lu Lu Tong herb pair (WLHP) combination.

Results

Out of 490 patients, 81% were CHP users. There were no significant differences in demographic characteristics between CHP users and non-users, but we observed a notable divergence in the prevalence of co-existing diseases. A detailed examination of CHP prescriptions revealed the predominance of WLHP, prompting further investigation. Comprehensive analysis identified 29 major compounds in WLHP, which were associated with 215 unique targets. Intersection analysis revealed 101 overlapping targets between WLHP and lactation, suggesting their potential as therapeutic targets for lactation insufficiency treatment. Topological analysis of the protein-protein interaction (PPI) network identified 13 hub genes potentially crucial for the therapeutic effect of WLHP. Functional enrichment analysis showed that these targets were involved in critical lactation regulation pathways, including the PI3K-Akt signaling pathway, prolactin signaling pathway, estrogen signaling pathway, and AMPK signaling pathway.

Discussion

This study emphasizes the potential of CHP, specifically the WLHP combination, in managing lactation insufficiency. The multi-compound, multi-target approach of WLHP and its interaction with key biological processes and signaling pathways offer valuable insights into the underlying mechanisms of its therapeutic effects. These findings warrant further experimental validation and can guide future research and clinical applications of CHP in lactation insufficiency treatment.

News in pharmacology for the main medical pathologies of gestation

Obstetric diseases represent a highly complex medical challenge, especially regarding its clinical approach. The use of pharmacological agents during pregnancy is one of the main therapeutic alternatives in this group of patients; however, there is a general lack of knowledge about its use, efficacy, and possible adverse effects that may occur in routine clinical practice, even among medical professionals themselves. The high percentage of pregnant women who undergo drugs at some point during pregnancy, together with the developments that have occurred in recent years in the field of pharmacology, show the need for a detailed analysis that shows the existing current knowledge and helps in the clinical decision making. In this sense, the aim of this work is to conduct a review of the available scientific literature on the novelties in pharmacology for the main medical pathologies of pregnancy. Thus, the role of this field in analgesia, antibiotic therapy, digestive, respiratory, urological, psychiatric and neurological pathologies will be detailed, evaluating the indications, precautions and considerations that must be taken into account for its use.

Otolaryngology and the Pregnant Patient

Importance

Pregnancy may result in physiologic and pathologic changes in the head and neck. Otolaryngologists may need to intervene medically or surgically with pregnant patients. Careful consideration of risks to both the gravid patient and the developing fetus is vital.

Observations

Patients may present with otolaryngologic complaints exacerbated by or simply occurring during their pregnancy. Symptoms of hearing loss, vertigo, rhinitis or rhinosinusitis, epistaxis, obstructive sleep apnea, sialorrhea, voice changes, reflux, subglottic stenosis, and benign and malignant tumors of the head and neck may prompt evaluation. While conservative measures are often best, there are medications that are safe for use during pregnancy. When required, surgery for the gravid patient requires a multidisciplinary approach.

Conclusions and Relevance

Otolaryngologic manifestations in pregnant patients may be managed safely with conservative treatment, medication, and surgery when necessary. Treatment should include consideration of both the pregnant patient and the developing fetus.

Review article: Functional dyspepsia and pregnancy-Effects and management in a special population

BACKGROUND

Around 10% of Americans meet the Rome IV criteria for functional dyspepsia (FD), with a significantly higher rate in women. FD also has a higher prevalence in women below the age of 50, suggesting that women who are affected are likely to be of reproductive age. Unfortunately, there is a lack of research or evidence-based guidelines on managing FD in pregnancy.

AIMS AND METHODS

To address this issue, we aimed to perform a systematic review of the interactions between FD and pregnancy and managing pre-existing FD in the peripartum and post-partum phases using current lifestyle, pharmacological, non-pharmacological and alternative medicine interventions.

RESULTS

Due to the lack of Rome IV FD-specific data in pregnancy, we instead performed a narrative review on how existing FD interventions could be extrapolated to the pregnant population. Where possible we use the highest level of available evidence or official guidelines to answer these questions, which often involves synthesising treatment and safety evidence of these interventions in other diseases during pregnancy. Finally, we highlight current substantial knowledge gaps requiring further research for the safe management of a pregnant patient with pre-existing FD.

CONCLUSIONS

Overall, despite the paucity of knowledge of treating FD during pregnancy, providers can mitigate this uncertainty by planning ahead with the patient. Patients should ideally minimise treatment until after breastfeeding. However, interdisciplinary resources are available to ensure that minimal-risk interventions are maximised, while interventions with more risks, if necessary, are justifiable by both the patient and the care team. Future investigations should continue to elicit the mechanistic relationship between FD and pregnancy while cautiously expanding prospective research on promising and safe therapies in pregnant patients with pre-existing FD.

Clinical advances: pregnancy in gastroenterologic and hepatic conditions

The fields of gastroenterology and hepatology, along with endoscopic practice, have seen significant changes and innovations to practice in just the past few years. These practice changes are not limited to gastroenterology, but maternal fetal medicine and the care of the pregnant person have become increasingly more sophisticated as well. Gastroenterologists are frequently called on to provide consultative input and/or perform endoscopy during pregnancy. To be able to provide the best possible care to these patients, gastroenterologists need to be aware of (and familiar with) the various nuances and caveats related to the care of pregnant patients who either have underlying gastrointestinal (GI) conditions or present with GI and liver disorders. Here, we offer a clinical update with references more recent than 2018, along with a few words about SARS-CoV-2 infection and its relevance to pregnancy.

Choking together with aspiration of gastric contents: rare form of maternal death

Background

The common causes of early postpartum maternal deaths are cardiomyopathies, obstetric hemorrhage, hypertensive disorders, and sepsis. However, a maternal death from choking together with aspiration of gastric contents is a rare occurrence to be diagnosed at the autopsy examination.

Case presentation

A 27-year-old previously healthy lady developed breathlessness 48 h after delivery, while on supine position, 1 h after meals, and pronounced death on admission. Autopsy was insignificant except for large amount of gastric contents in the air ways. Microscopic examination revealed bronchioles filled with eosinophilic materials and a significant number of neutrophil infiltrations at the margin. Alveoli were free from edema fluid and inflammatory cells. Some alveoli were expanded with broken septae. Cause of death was airway obstruction due to choking together with aspiration of gastric contents.

Conclusions

Aspiration of gastric contents can cause sudden unexpected death at postpartum, and it is recommended to educate immediate and early postpartum mothers regarding the risk of aspiration.

Associations Between Late-Onset Preeclampsia and the Use of Calcium-Based Antacids and Proton Pump Inhibitors During Pregnancy: A Prospective Cohort Study

Purpose

Preeclampsia is a leading cause of maternal morbidity and mortality. Calcium-based antacids and proton pump inhibitors (PPIs) are commonly used during pregnancy to treat symptoms of gastroesophageal reflux disease. Both have been hypothesized to reduce the risk of preeclampsia. We determined associations of calcium-based antacid and PPI use during pregnancy with late-onset preeclampsia (≥34 weeks of gestation), taking into account dosage and timing of use.

Patients and Methods

We included 9058 pregnant women participating in the PRIDE Study (2012–2019) or The Dutch Pregnancy Drug Register (2014–2019), two prospective cohorts in The Netherlands. Data were collected through web-based questionnaires and obstetric records. We estimated risk ratios (RRs) for late-onset preeclampsia for any use and trajectories of calcium-based antacid and PPI use before gestational day 238, and hazard ratios (HRs) for time-varying exposures after gestational day 237.

Results

Late-onset preeclampsia was diagnosed in 2.6% of pregnancies. Any use of calcium-based antacids (RR 1.2 [95% CI 0.9–1.6]) or PPIs (RR 1.4 [95% CI 0.8–2.4]) before gestational day 238 was not associated with late-onset preeclampsia. Use of low-dose calcium-based antacids in gestational weeks 0–16 (<1 g/day; RR 1.8 [95% CI 1.1–2.9]) and any use of PPIs in gestational weeks 17–33 (RR 1.6 [95% CI 1.0–2.8]) seemed to increase risks of late-onset preeclampsia. We did not observe associations between late-onset preeclampsia and use of calcium-based antacids (HR 1.0 [95% CI 0.6–1.5]) and PPIs (HR 1.4 [95% CI 0.7–2.9]) after gestational day 237.

Conclusion

In this prospective cohort study, use of calcium-based antacids and PPIs during pregnancy was not found to reduce the risk of late-onset preeclampsia.

Severe hyponatraemia peripartum associated with omeprazole therapy

Hyponatraemia is the most commonly encountered electrolyte abnormality in pregnancy and may be associated with adverse maternal and neonatal outcomes. Rapid onset, severe hyponatraemia has been reported with proton-pump inhibitor therapy in non-pregnant individuals. Gastro-oesophageal reflux is very common during pregnancy, and proton-pump inhibitors are available without a prescription in many countries. A case of severe maternal hyponatraemia in the setting of recent omeprazole therapy is presented. Health professionals should be aware of this complication given the availability of proton-pump inhibitors without prescription and high rates of gestational gastro-oesophageal reflux.

Three trajectories of gestational weight gain identified in an Australian twin study

OBJECTIVES

Gestational weight gain (GWG) has been associated with maternal and child health outcomes, but knowledge of appropriate GWG for twin gestations is limited.

STUDY DESIGN

The Peri/Postnatal Epigenetic Twins Study is a prospective twin cohort study of 250 women and their twin children in Melbourne, Australia. We modeled trajectories of GWG using group-based growth modeling and compared these trajectories to GWG categories (within, above, or below current GWG recommendations for twin pregnancy). We fitted robust linear and Poisson regression models to assess associations of maternal pre-pregnancy and gestational exposures with risk of gaining weight outside the recommendations.

RESULTS

Of the 250 women enrolled in the PETS, GWG measures were available for 172 women. Forty-seven percent of women had GWG within the current recommendations. We identified three GWG trajectories - 23.6% of women had low GWG throughout pregnancy, 34.5% had average GWG throughout pregnancy, and 42.0% had average initial GWG, followed by high GWG from trimester two until delivery. Gestational diabetes mellitus (GDM) was associated with increased risk of inadequate GWG (RR: 2.40, 95%CI: 1.53, 3.75). Pre-pregnancy obesity (RR: 1.88, 95%CI: 1.09, 3.26) and hypertensive disorders of pregnancy (RR: 2.64, 95%CI: 1.20, 5.81) were associated with increased risk of excessive GWG.

CONCLUSIONS

More than half of the women in the PETS did not meet the current GWG recommendations. Women with GDM or hypertensive disorders were more likely to gain weight outside these guidelines. More research is needed to establish comprehensive guidelines for twin pregnancies.

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.

Antacids revisited: review on contemporary facts and relevance for self-management

Heartburn and acid regurgitation are the typical symptoms of gastroesophageal reflux. Despite the availability of several treatment options, antacids remain the mainstay treatment for gastroesophageal reflux-related symptoms based on their efficacy, safety, and over-the-counter availability. Antacids are generally recommended for adults and children at least 12 years old, and the FDA recommends antacids as the first-line treatment for heartburn in pregnancy. This narrative review summarizes the mechanism, features, and limitations related to different antacid ingredients and techniques available to study the acid neutralization and buffering capacity of antacid formulations. Using supporting clinical evidence for different antacid ingredients, it also discusses the importance of antacids as OTC medicines and first-line therapies for heartburn, particularly in the era of the COVID-19 pandemic, in which reliance on self-care has increased. The review will also assist pharmacists and other healthcare professionals in helping individuals with heartburn to make informed self-care decisions and educating them to ensure that antacids are used in an optimal, safe, and effective manner.

Functional gastrointestinal disorders. Overlap syndrome Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine and Gastroenterological Scientific Society of Russia

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[Conservative Therapy of Reflux Disease and its Limits]

Gastrooesophageal reflux disease (GORD) is common. Proton pump inhibitors (PPI) are regarded as first line therapy for all clinical manifestations. However, their efficacy is inadequate for at least 30% of patients and they are occasionally poorly tolerated. Moreover, some patients would prefer an alternative therapy. Alginate cause mechanical reflux inhibition by forming a gelatinous layer in the so-called acid pocket, an acid reservoir that forms on the surface of the chyme in the gastric corpus immediately after food intake. They may be used an alternative to treat the symptoms of uncomplicated GORD and as an add-on to PPIs if these do not improve symptoms adequately. If the reflux symptoms persist or if reflux oesophagitis does not heal, differentiated diagnostic testing must be performed, using endoscopy and functional analysis. Extraoesophageal manifestations of GORD include cough, compulsive clearing of the throat, problems with the voice and globus sensation. These often do not respond to antireflux therapy. Recent data indicate that these are complex hypersensitivity syndromes and that reflux is only one of several possible triggers.

Long-term use of proton pump inhibitors as a risk factor for various adverse manifestations

The long-term use of proton pump inhibitors (PPIs) can lead to increased gastric pH, hypochlorhydria and in some cases to achlorhydria when compared to other acid-suppressing agents like histamine-2 (H2) receptor blockers and antacids. These consequences by the use of long-term PPIs may lead to significant vitamin (B₁₂ and C) and mineral (iron, calcium and magnesium) deficiencies which needs gastric acid for their absorption and bioavailability. Long-term use of PPIs by the pregnant patients may impose a potential risk of congenital malformations. Various studies have recommended the life style modifications and antacid use as first choice among pregnant womens by preserving PPIs (omeprazole as a safe choice of PPI) for severe conditions of gastroesophageal reflux disease. The long-term acid suppression by PPIs can also lead to enteric, respiratory and urinary tract infections. The hypochlorhydria by chronic PPIs use may induce hypergastrinemia, which ultimately mediates the gastric polyps, gastric carcinoids and gastric cancer. The concomitant use of PPIs with antiplatelet drugs like clopidogrel can impose the patients to major adverse cardiac events. This review has enlisted the comprehensive information regarding the adverse effects induced by long-term use of PPIs and their possible relations. Considerable studies like case-control, randomized trials, cohort studies and meta-analysis were reported in supporting these adverse effects. The clinicians and patients should be cautious about these effects so that they can avoid the serious outcomes. PPIs should be avoided for long-term use mainly in older adults unless there is a proper indication.