Reflux symptoms usually respond to tobacco and alcohol abstinence, small meals, head of the bed elevation, and avoidance of postprandial recumbency. So-called "trigger" foods are also avoided and usually include fatty foods, tomato-based foods, and cofee. Oral antacids are first-line therapy. If severe symptoms persist, sucralfate (Carafate) is given along with a protonpump inhibitor or an H2-receptor antagonist (see Table 54-3). Both classes are generally safe for use in pregnancy (Briggs, 2015; Mahadevan, 2006b). Of these, a 1-g sucralfate tablet is taken orally 1 hour before each of the three meals and at bedtime for up to 8 weeks. Antacids are not used within Y2 hour before or after sucralfate doses. If relief is not attained, then endoscopy should be considered. Misoprostol is contraindicated because it stimulates labor (Chap. 26, p. 508).
In nonpregnant patients, surgical fundoplication is performed (Kahrilas, 2015). Although the procedure is not done during pregnancy, Biertho and colleagues (2006) described 25 women who had undergone laparoscopic Nissen fundoplication before pregnancy. Only 20 percent had relux symptoms during pregnancy.
he older literature is informative regarding hiatal hernias in pregnancy. Upper gastrointestinal radiographs performed in 195 women in late pregnancy showed that 20 percent of 116 multiparas and 5 percent of 79 nulliparas had a hiatal hernia (Rigler, 1935). Of 10 women studied postpartum, hernia persisted in three at 1 to 18 months.
he relationship of hiatal hernia with reflux esophagitis, and thus symptoms, is not clear. One study demonstrated no relationship between reflux and hernia and showed that the lower esophageal sphincter functioned efectively even when displaced intrathoracically (Cohen, 1971) . Nevertheless, during pregnancy, these hiatal hernias may cause vomiting, epigastric pain, and bleeding from ulceration. Schwentner (201a1) reported severe herniation requiring surgical repair in a woman with a 12-week gestation. Curran and coworkers (1999) described a 30-week pregnancy complicated by gastric outlet obstruction from a paraesophageal hernia.
These are caused by herniations of abdominal contents through either the foramen of Bochdalek or vforgagni. Fortunately, they rarely complicate pregnancy. Kurzel and associates (1988) reviewed the outcomes of 18 pregnant women with such a hernia and who developed acute obstruction. Because the maternal mortality rate was 45 percent, they recommend repair during pregnancy even if a woman is asymptomatic. Herniation has been reported in one pregnant woman from a previous traumatic diaphragmatic defect and in another who had antirelux surgery in early pregnancy (Brygger, 2013; Flick, 1999). Several case reports also describe spontaneous diaphragmatic rupture from increased intraabdominal pressure during delivery (Chen, 2012; Sharifah, 2003).