• Take a detailed history and assess the severity of symptoms and the impact on the woman's quality of life. Rule out serious causes for the symptoms.
• Give advice on lifestyle changes, such as eating and sleeping habits, stopping smoking, and avoiding aggravating risk factors, including the use of other drugs. For many women, advice alone is sufficient.
• If symptoms are severe, or if lifestyle changes are inadequate, consider drug treatment.
• Antacids and alginates usually control symptoms effectively.
• Consider treatment with a systemic acid-suppressing drug if symptoms are severe, or if antacids and alginates do not produce an adequate response. Ranitidine or omeprazole are appropriate choices.
• Consider referral to a specialist if symptoms fail to respond to drug treatment, or there is concern about the underlying disease.

• Take a detailed history. Ask about:
• Symptoms and how they are affecting the woman's quality of life: heartburn and acid reflux are common, but people may also describe upper abdominal discomfort, retrosternal pain, anorexia, bloating, fullness, or early satiety.
• Previous history of gastro-oesophageal reflux disease or peptic ulcer disease.
• Features suggesting a serious cause (alarm features) or an illness unrelated to pregnancy (e.g. symptoms of fever, rigours, vomiting, and malaise).
• Lifestyle (e.g. diet and medication) that may worsen dyspepsia.
• Treatments already tried, especially over-the-counter medication (antacids).
• Examination is usually normal, and investigations are generally not necessary.

• Signs: epigastric tenderness may be present, but is a poor discriminating sign [NICE, 2005].
• Investigations: are usually carried out in secondary care and may include:
• An endoscopy.
• Testing for Helicobacter pylori, which may be delayed until after delivery, since eradication therapy is contraindicated during pregnancy [Mahadevan and Kane, 2006].

These recommendations are largely based on expert opinion [Ali and Egan, 2007], and pragmatic advice:

• Knowing the individual's diet and lifestyle, the symptom severity, and previously tried treatments will allow the healthcare professional to judge the next step in dyspepsia management.

• Reassure the woman that dyspepsia symptoms are common in pregnancy and will likely resolve after birth, and that complications are rare.
• Give written lifestyle and dietary advice as first-line management, especially in the first trimester. Advise the woman to:
• Adopt healthy eating habits, eat smaller meals more frequently, not eat within 3 hours of going to sleep, and avoid known irritants (e.g. alcohol, coffee, fruit juices, chocolate, and fatty and spicy foods).
• Prop up the bed head when sleeping (lying flat may increase acid reflux).
• Avoid medications if appropriate (e.g. sedatives, calcium-channel antagonists, antidepressants, nonsteroidal anti-inflammatory drugs).
• Stop smoking (if applicable).
• Advise the woman to return if symptoms are not controlled with lifestyle changes, or if worsening or new symptoms develop.

• See the CKS topic on Smoking cessation if the woman is having difficulty stopping smoking.

• CKS could find no trial evidence of lifestyle modifications for managing dyspepsia in pregnancy. These recommendations are largely based on expert opinion [Madanick and Katz, 2006; Mahadevan and Kane, 2006; Ali and Egan, 2007], and extrapolated from the National Institute for Health and Clinical Excellence guidance Dyspepsia: Management of dyspepsia in adults in primary care [NICE, 2005]:
• Lifestyle modifications are safe and inexpensive, and encourage individual participation. Although there is no evidence that lifestyle changes help symptoms of dyspepsia in pregnancy, more important general health benefits can be gained [MeReC, 1998; NICE, 2005].
• Lifestyle modifications are thought to resolve symptoms in up to 25% of non-pregnant people with uncomplicated gastro-oesophageal reflux disease [Madanick and Katz, 2006], but this evidence is based on small and inconclusive epidemiological studies [NICE, 2005].

• Antacids or alginates are recommended as first-line treatments if symptoms are relatively mild or are not controlled adequately by lifestyle changes.
• Antacid products containing combinations of aluminium and magnesium are recommended on an 'as required' basis.
• Calcium-containing products are recommended for short-term or occasional use.
• Alginate products are particularly useful if symptoms of gastro-oesophageal reflux are dominant.
• If symptoms are severe, or persist despite treatment with an antacid or alginate, consider prescribing an acid-suppressing drug:
• Ranitidine is an established drug but is not licensed for use in pregnancy.
• Omeprazole is a more effective alternative. It is licensed for use in pregnancy, but there is less experience of its use in this context.

Further information on specific drugs and their use in pregnancy is provided by the UK Teratology Information Service (UKTIS), formerly the National Teratology Information Service (NTIS), (part of the Regional Drug & Therapeutics Centre — www.nyrdtc.nhs.uk, telephone: 0844 892 0909).

Antacids and alginates:

• A variety of antacids are available on prescription or over-the-counter. The choice of product should be made according to the woman's preference. However, products containing sodium bicarbonate and magnesium trisilicate are not recommended.
• For more information on the antacids available, and their contraindications and adverse effects, see section on Antacids and alginates in Prescribing information.

Acid-suppressing drugs:

• For information on the dosing regimens, contraindications, and adverse effects of ranitidine and omeprazole, see Prescribing information.
• Only ranitidine and omeprazole are recommended for the treatment of dyspepsia in pregnant women. Other histamine antagonists (cimetidine, famotidine, and nizatidine) and proton pump inhibitors (esomeprazole, lansoprazole, pantoprazole, and rabeprazole) should be avoided.

Antacids and alginates:

• Antacids relieve symptoms of dyspepsia by neutralizing stomach acid, and alginates protect the oesophagus by forming a protective 'raft' when they come into contact with stomach acid. Most evidence for their safety and effectiveness in pregnancy is derived from historical use, as there is a lack of evidence from controlled trials.
• Antacids are often not licensed specifically for use in pregnant women, but most are considered to be safe. The choice of antacid should be made according to individual preference, although some products should be avoided:
• Products containing magnesium or aluminium are generally preferred. They have limited absorption and have caused no teratogenic effects in animal studies [Schaefer, 2001]. However, aluminium products have a tendency to cause constipation, and magnesium products may have a laxative effect [BNF 54, 2007].
• Products whose principal ingredient is a calcium salt are widely available over-the-counter, but are only recommended by CKS for short-term or occasional use. Calcium products have a limited duration of action, and have been reported to cause acid rebound reflux on discontinuation [Sweetman, 2005], although this has been refuted as being a calcium-specific effect [Texter, 1989]. At very high doses, calcium can cause milk-alkali syndrome [American Gastroenterological Association, 2006].
• Products containing sodium bicarbonate or magnesium trisilicate (a common constituent of magnesium-only products) should be avoided as they can precipitate metabolic alkalosis and fluid overload [Ali and Egan, 2007] or cause serious adverse effects in the fetus [Madanick and Katz, 2006].
• Alginates are particularly useful where reflux symptoms predominate, as they physically block acid from entering the oesophagus. Some alginate products, such as Gaviscon^®, are preferred as they are specifically licensed for use in pregnancy [ABPI Medicines Compendium, 2005; ABPI Medicines Compendium, 2007].

Acid suppressing drugs:

• Ranitidine is an H₂-receptor antagonist, and indirectly prevents the secretion of acid into the stomach. Most evidence for the safety of ranitidine comes from observational studies, although ranitidine has been an established choice in pregnancy for many years with no reports of harm to the fetus. There is only limited direct evidence for the effectiveness of ranitidine in pregnancy; however its efficacy can reasonably be extrapolated from studies conducted in the general population.
• Omeprazole is a proton pump inhibitor (PPI) and directly prevents the production of acid in the stomach. There are no controlled trials addressing the safety of omeprazole in pregnancy; the best available evidence comes from numerous observational studies. Likewise, evidence for the effectiveness of omeprazole in treating dyspepsia in pregnancy is extrapolated from studies in the general population, where it is known to be more effective than ranitidine [Christopher, 2005].
• CKS does not recommend a preference of ranitidine or omeprazole in the treatment of dyspepsia in pregnancy; both are reasonable choices.
• Ranitidine is recommended first-line by most experts [Madanick and Katz, 2006; Ali and Egan, 2007]. This is because it is more established than omeprazole, with more overall confidence in its safety during pregnancy. However, it is not specifically licensed for this purpose [ABPI Medicines Compendium, 2009].
• Omeprazole is a newer drug and therefore there is less experience with it. However, some experts believe it is a suitable choice, arguing that if the drug is safe to use second-line, then it should be safe to use first-line [Christopher, 2005]. In a review of the use of proton pump inhibitors (PPIs) in pregnancy, UK Medicines Information concluded that 'PPIs are a reasonable therapeutic option in pregnancy' [UKMi, 2007]. In addition, omeprazole is specifically licensed for use in pregnancy [ABPI Medicines Compendium, 2008].

• Refer urgently to a gastroenterologist if there are alarm features, such as: chronic gastrointestinal bleeding; progressive unintentional weight loss; progressive difficulty swallowing (dysphagia); or persistent vomiting.
• Refer non-urgently to a gastroenterologist if:
• Symptoms do not adequately respond to antacids, alginates, ranitidine, or omeprazole.
• The woman is unable to eat sufficiently because of symptoms.
• The diagnosis is in doubt (e.g. biliary colic).
• There is a previous history of peptic ulcer disease; Barrett's oesophagus; or known dysplasia, atrophic gastritis, or intestinal metaplasia; and symptoms are inadequately controlled on usual medication.
• Refer to an obstetrician if symptoms suggest a pregnancy-related disorder other than dyspepsia (e.g. HELLP syndrome [haemolysis, elevated liver enzymes, and low platelets], pre-eclampsia).

• The classical alarm features of weight loss, an epigastric mass, or iron deficiency anaemia may be difficult to interpret in pregnancy.
• An endoscopy can be safely undertaken in pregnancy, but is generally avoided unless symptoms are severe, there is diagnostic uncertainty, or there are alarm features suggesting gastrointestinal bleeding.

• CKS could find no UK guidelines on referral criteria for dyspepsia in pregnancy. These recommendations are based on expert opinion [Ali and Egan, 2007], and extrapolated from the National Institute for Health and Clinical Excellence guidance Dyspepsia: Management of dyspepsia in adults in primary care [NICE, 2005].