Editorial: Functional dyspepsia in pregnancy—Distinct approaches to a special population

Liu et al recently detailed our current knowledge of the physiologic, diagnostic and therapeutic considerations pertaining to functional dyspepsia (FD) in pregnancy.1 FD is a prevalent disorder of gut– brain interaction, and commonly affects women of childbearing age. Pregnancy itself may trigger new dyspeptic symptoms or exacerbate existing FD via a number of mechanisms, including hormonal influences on gastric emptying and intestinal transit, and increases in intraabdominal pressure secondary to uterine enlargement.2,3 Yet, surprisingly little detail is available on the optimal approach to the evaluation and management of dyspeptic symptoms in pregnancy. Additionally, this population has not been specifically addressed in multiple recent societal guidelines and consensus papers.4,5 The authors' thorough summary of the current state of dyspepsia and pregnancy thus represents a welcome addition. As a disorder defined by symptombased criteria, the diagnosis of FD can be challenging, and is further complicated by the physiologic changes of pregnancy imposed on the upper gastrointestinal tract. Most consensus statements agree that in cases of diagnostic uncertainty, upper endoscopy becomes a mandatory step in FD diagnosis.6 However, the recognised low diagnostic yield7 and procedural risks to mother and foetus shift the balance against endoscopic evaluation of dyspepsia in pregnancy. Initial noninvasive Helicobacter pylori testing and eradication (‘testandtreat’) is also recommended early in the FD diagnostic and therapeutic approach. However, the H. pylori testandtreat strategy is less than ideal in pregnancy, given the modest symptom benefit of treatment (number needed to treat of 9)8 and concerns over the lack of safety data for standard H. pylori antibiotics in pregnancy. Acidsuppressive therapy also is not without issues, in light of some signal for increased risk of foetal congenital abnormalities with proton pump inhibitors9 and limited availability of H2receptor antagonists with recent recalls. Conceived as stepwise approaches, most FD guidelines thereafter endorse the use of prokinetics and tricyclic antidepressants, although with restricted options in pregnancy as many of these agents are classified as FDA category C. Thus, these medications are best reserved for pregnant patients with severe, refractory symptoms. In light of these limitations, we propose that an earlier focus on the ‘latter steps’ of the described stepwise algorithms to FD might be warranted in pregnancy. Complementary therapies, such as peppermint oil and ginger, have solid evidence of both efficacy in FD and safety in pregnancy, and are inexpensive and readily available. Braingut behavioural therapies, hypnotherapy and acupuncture are already utilised for other pregnancyrelated disorders and have compelling evidence of benefit in FD.10 Less restrictive, targeted diets that focus on specific FODMAP constituents, such as fructose, are probably safe and are easily implemented in pregnant patients. Given the potential limitations in terms of both efficacy and safety in pregnancy, recognised FD diagnostic and therapeutic strategies may be less applicable to this important subgroup. Rather, distinct approaches that rely on a symptombased positive diagnosis, and that step beyond traditional FD guidelines may result in satisfactory relief while minimising risks in this special population.