Gastroesophageal reflux disease (GERD) in pregnancy presents a special challenge for the clinician, predominantly because of the potential side effects of pharmacologic interventions on the fetus. Lifestyle and dietary modifications, change in sleeping posture, and antacid medications are emphasized, as these options pose little risk to the fetus. When these interventions are not successful, sucralfate, a mucosal protectant with little to no systemic absorption, should be considered next. Therapy with H₂ receptor antagonists or proton pump inhibitors can be considered in patients with refractory symptoms; though not approved for this use, they are likely safe, particularly in third trimester. Prokinetic agents should be used with extreme caution or avoided altogether in the pregnant patient.