Helicobacter pylori infection in pregnancy
Pregnancy-related eradication therapy is generally deferred until postpartum in the absence of severe clinical disease. [1] In pregnancy, symptom-directed acid suppression can be used while deferring eradication. [2]
Indications for treatment during pregnancy
Eradication therapy during pregnancy is not recommended routinely. [1] Treatment during pregnancy is considered when severe hyperemesis gravidarum symptoms are present and when risk–benefit supports eradication therapy. [1]
Medication selection algorithm
Preferred approach
- Defer H. pylori eradication until postpartum. [1]
- Provide symptomatic relief with an H2 blocker or a proton-pump inhibitor (PPI). [2]
Regimens when treatment is required for severe disease
- Triple therapy for 14 days with a PPI plus clarithromycin plus metronidazole or amoxicillin is suggested as first-line treatment in pregnant patients requiring treatment for hyperemesis gravidarum. [1]
Contraindicated or avoided drug components in pregnancy
- Bismuth quadruple regimens that contain tetracycline (PPI, metronidazole, tetracycline, and bismuth) are not recommended in pregnancy due to teratogenic potential. [1]
- Bismuth and tetracycline are not recommended in pregnancy. [2]
Initiation thresholds and practical timing
Eradication testing of cure should be performed after completion of therapy when eradication is pursued. [2] Treatment is typically deferred until postpartum unless severe hyperemesis gravidarum symptoms require therapy during pregnancy. [1]
Symptomatic management while deferring eradication
- Histamine-2 receptor antagonists or PPIs are used for symptomatic relief during pregnancy when eradication is deferred. [2]
Treatment failure and recurrence considerations
- Failure rates after eradication therapy occur in a minority of patients and re-treatment decisions should be based on post-treatment assessment when eradication is pursued. [2]
- Recurrence or persistence after therapy should prompt consideration of alternative regimens and specialist input. [2]
Postpartum eradication strategy and follow-up
Postpartum eradication is recommended when pregnancy was managed with deferral. [1] Test-of-cure with a urea breath test is used to determine need for retreatment after eradication therapy when eradication is pursued. [2]
Post-treatment test-of-cure requirements
- Urea breath testing for test of cure is required after eradication completion. [2]
- Proton-pump inhibitor therapy should be held for at least 2 weeks before urea breath testing. [2]