Proton Pump Inhibitors in Pregnancy

Guidelines for PPI Use

• The European Society of Cardiology recommends that PPIs are allowed throughout pregnancy and breastfeeding 1, 2
• The European Society of Cardiology guidelines suggest using PPIs when symptoms are not adequately controlled by other measures, with a step-up approach starting with lifestyle and dietary modifications, then antacids and alginates, histamine H2 receptor antagonists, and finally PPIs 1, 2

Clinical Considerations and Precautions

• The European Society of Cardiology guidelines state that PPIs can be used throughout all trimesters of pregnancy when clinically indicated, and should be used at the lowest effective dose and duration necessary to control symptoms 1, 2
• The European Society of Oncology recommends that PPIs can be used if necessary as part of the treatment regimen for women with cancer requiring supportive care during pregnancy 3

Safety of Proton Pump Inhibitors During Pregnancy

Clinical Considerations

• The American Gastroenterological Association (AGA) recommends using the lowest dose, frequency, and duration of PPIs in patients requiring PPI therapy, and when PPIs are necessary, they should be prescribed at the lowest effective dose to control symptoms 4
• The AGA emphasizes the safety of PPIs for the treatment of GERD in their clinical practice update 4

Safety of Proton Pump Inhibitors for Lactating Women

Precautions and Concurrent Medications

• NSAIDs such as ibuprofen, diclofenac, and naproxen, which are safe during breastfeeding, can be used concurrently with PPIs for pain management, as recommended by the American Academy of Family Physicians 5

PPI Safety in Pregnancy

Comparative Safety Evidence

• The American College of Obstetricians and Gynecologists was not cited, however, pantoprazole has lower potency compared to esomeprazole or rabeprazole, with 40 mg pantoprazole being equivalent to 9 mg omeprazole, according to the Annual Review of Medicine 6

PPIs for Ulcer Prophylaxis in Pregnant NSAID Users

Preferred Gastroprotective Agent

• In pregnant women who require NSA‑type analgesics and have a risk of peptic ulcer disease, prescribing a proton‑pump inhibitor is recommended as the first‑line gastroprotective therapy. (American Family Physician, 2009) 7

Comparative Efficacy

• Proton‑pump inhibitors provide superior ulcer‑prevention efficacy compared with double‑dose H₂‑receptor antagonists in NSA‑treated pregnant patients. (American Family Physician, 2009) 7

Contraindicated Alternatives

• Misoprostol must be avoided for gastroprotection in any woman who is pregnant or could become pregnant because of its abortifacient properties. (American Family Physician, 2009) 7

NSAID Use Timing

• NSA‑type drugs should generally be discontinued in the late third trimester (approximately 6–8 weeks before expected delivery) owing to increased risks of prolonged pregnancy, labor complications, and adverse fetal effects. (American Family Physician, 2009) 8
• Prolonged NSAID exposure during pregnancy, especially in the third trimester, is discouraged even when a PPI is co‑prescribed for ulcer prophylaxis. (American Family Physician, 2009) 8

Antibiotic‑Related Pitfall

• Amoxicillin‑clavulanic acid should be avoided in pregnant patients when an antibiotic is required because it has been associated with a higher incidence of necrotizing enterocolitis in neonates. (American Journal of Obstetrics & Gynecology, 2024) 9