• Dyspepsia is upper abdominal discomfort or pain which may be described as a burning sensation, a heaviness, or an ache. It is often related to eating and may be accompanied by other symptoms such as nausea, fullness in the upper abdomen, or belching.
• The most common cause of dyspepsia in pregnancy is gastro-oesophageal reflux. It usually resolves after the birth of the child.

• Take a detailed history:
• Rule out a serious cause by enquiring about atypical or alarm features, and previous history of gastro-oesophageal reflux disease or peptic ulcer disease.
• Ask about symptoms and how they are affecting the woman's quality of life.
• Ask about lifestyle (e.g. eating habits) and treatments already tried (e.g. over-the-counter antacids).
• Examination is usually normal, and investigations are generally not necessary.

In depth

• Reassure the woman that dyspepsia symptoms rarely cause complications and will probably resolve after the birth.
• Give written lifestyle advice as first-line management, especially in the first trimester of pregnancy. 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.

In depth

• Antacids or alginates are recommended as first-line treatments if symptoms are relatively mild and 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.

In depth

• Refer urgently to a gastroenterologist if there are alarm features, such as: chronic gastrointestinal bleeding; progressive unintentional weight loss; progressive difficulty in 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, pre-eclampsia).

In depth