Approximately two thirds of pregnant patients develop heartburn. The origin is multifactorial, but the predominant factor is a decrease in LES pressure caused by female sex hormones, especially progesterone. Mechanical factors play a small role. Serious reflux complications during pregnancy are rare; therefore EGD and other diagnostic tests are infrequently needed. Symptomatic GERD during pregnancy should be managed with a step-up algorithm beginning with lifestyle modifications and dietary changes. Antacids or sucralfate are considered the first-line medical therapy. If symptoms persist, H2RAs should be used. Ranitidine is probably preferred because of its documented efficacy and safety profile in pregnancy, even in the first trimester. Proton-pump inhibitors are reserved for the woman with intractable symptoms or complicated reflux disease. Lansoprazole may be the preferred PPI because of its safety profile in animals and case reports of safety in human pregnancies.