Common problems in pregnancy

Minor symptoms are very common in pregnancy. The symptoms should be properly assessed in case they represent more serious health problems in the pregnancy. Otherwise, it is essential to provide reassurance and advice. Medication is not usually required and is best avoided if possible.¹

Nausea and vomiting in early pregnancy²

• Nausea and vomiting are common in early pregnancy, affecting 90% of women and causing a clinically significant problem in 35% of those affected.

• Hyperemesis gravidarum occurs in less than 1% of pregnancies.

• Most cases of nausea and vomiting in pregnancy are self-limiting and settle without complication as the pregnancy progresses.

• Where intervention is required, Cochrane reviews have not found benefit of any one treatment over another.³

• The National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summary (CKS) recommends that If an anti-emetic is required in pregnancy:

  • Prescribe an antihistamine (oral cyclizine or oral promethazine), or a phenothiazine (oral prochlorperazine), and reassess after 24 hours.

  • If the response to the treatment is good, continue treatment with the chosen antiemetic, and review the woman once a week later.

  • If the response to treatment is inadequate, but the woman is not dehydrated and there is no ketonuria, switch to another antiemetic from a different class:

    • Oral metoclopramide or oral ondansetron are second-line options, but should not be prescribed for longer than five days.

    • Oral domperidone is also a second-line treatment option, but should not be prescribed for longer than seven days.

    • Exposure to ondansetron during the first trimester of pregnancy is associated with a small increased risk of the baby having a cleft lip and/or cleft palate.

For pregnant women with moderate-to-severe nausea and vomiting:¹

• Consider intravenous fluids, ideally on an outpatient basis.

• Consider acupressure as an adjunct treatment.

• Consider inpatient care if vomiting is severe and not responding to primary care or outpatient management. This will include women with hyperemesis gravidarum.

See the separate Nausea and Vomiting in Pregnancy - including Hyperemesis Gravidarum article for more information.

Dyspepsia^{1 4}

• Dyspepsia is common in pregnancy and becomes more prevalent as pregnancy progresses. 40-80% of women have dyspepsia at some stage of their pregnancy.

• Symptoms of heartburn may be helped by lifestyle changes such as:

  • Sitting up rather than lying down just after eating.

  • Sleeping in a propped-up position by raising the foot of the bed.

  • Changing the way the woman eats - for example, small frequent meals, not eating within three hours of going to bed.

  • Reduce gastric irritants such as fatty or spicy foods, fruit juice, chocolate and caffeine.

• Antacid preparations such as Gaviscon® reduce reflux symptoms. Antacid products containing combinations of aluminium and magnesium or calcium may be used as required, but those containing sodium bicarbonate or magnesium trisilicate should be avoided in pregnancy.

• Acid suppressant medication such as omeprazole may be considered if symptoms are severe and not controlled with antacids. There is no evidence of harm to the fetus but manufacturers usually recommend avoidance in pregnancy.

Constipation⁵

• Constipation is very common in pregnancy, affecting up to 40% of women.⁶

• It can be improved by a high fluid intake, eating high-fibre foods and getting plenty of exercise.

• When this doesn't work, laxatives such as senna which stimulate the bowel into action are most effective, although they may cause more abdominal pain and diarrhoea than bulk-forming laxatives.
  

Respiratory distress

• Many women feel breathless as the growing uterus pushes the diaphragm upwards into the chest cavity as the pregnancy advances. Other mechanisms such as hormonal influences also contribute as some women may feel breathless earlier in pregnancy.

• The woman may be significantly breathless and other possible causes of respiratory distress (eg, asthma, pulmonary embolism, anaemia and heart valve disease) may need to be ruled out.

Fatigue and insomnia

• Tiredness, or fatigue, is very common in early pregnancy and reaches a peak at the end of the first trimester.

• Rest, trying to do a little less and reassurance that all is well can help a great deal.

• Fatigue also occurs in late pregnancy, when it is important to make sure the patient does not have anaemia.

• Insomnia is also very common and due to a combination of anxiety, hormonal changes and general discomfort.

• Mild physical exercise before sleep may help - sleeping tablets should be avoided.

Pruritus^{7 8}

• Pruritus has been found to affect as many as 23% of pregnant women.

• Generalised itching is common in the last twelve weeks of pregnancy and disappears after delivery.

• Localised itching is usually due to infections, such as scabies and thrush.

• Dermatological conditions specific to pregnancy which present with a rash include polymorphic eruption of pregnancy, atopic eruption of pregnancy and pemphigoid gestationis.

• Exclude obstetric cholestasis by checking LFTs (raised AST/ALT; alkaline phosphatase is increased in normal pregnancy and so an unreliable marker of cholestasis in pregnancy). There is no rash and it must be considered, as it may cause fetal complications. If a woman presents with an unexplained itch without a rash, LFTs should be monitored every 1-2 weeks until the itch resolves.

• Emollients are the mainstay of treatment in pregnancy.

Haemorrhoids¹

• Treatment for haemorrhoids includes diet modification, topical soothing preparations (such as Anusol HC®) and surgery.

• Surgery is rarely considered an appropriate intervention for pregnant women, as haemorrhoids may resolve after delivery.

Varicose veins

• Varicose veins are more likely to become apparent when a woman is pregnant. Whilst varicose veins most commonly occur in the legs they also frequently develop in the vulva where they can cause throbbing and aching. They are more common in those with a genetic susceptibility.

• When varicose veins are present, feet and ankles can also become swollen, in which case deep vein thrombosis and pre-eclampsia should be excluded.

• Treatment is by elevation of legs when sitting, use of compression stockings, and encouragement to walk and to avoid standing still.

Vaginal discharge¹

• Women usually produce more vaginal discharge during pregnancy.

• If the discharge has a strong or unpleasant odour, is associated with itch or soreness or associated with dysuria, then infection should be excluded.

• Trichomonas vaginalis is associated with adverse pregnancy outcomes but the effect of metronidazole for its treatment in pregnancy is unclear.⁹

• A topical imidazole is an effective treatment for thrush but a seven-day course may be required in pregnancy. The effectiveness and safety of oral treatments for thrush in pregnancy are uncertain and these should be avoided.

Unexplained vaginal bleeding after 13 weeks¹

• Offer anti-D immunoglobulin to women who present with vaginal bleeding after 13 weeks of pregnancy if they are rhesus D-negative and at risk of isoimmunisation.

• Refer pregnant women with unexplained vaginal bleeding after 13 weeks to secondary care for a review.

• For pregnant women with unexplained vaginal bleeding after 13 weeks, assess whether to admit them to hospital, taking into account:

  • The risk of placental abruption.

  • The risk of preterm delivery.

  • The extent of vaginal bleeding.

  • The woman's ability to attend secondary care in an emergency.

• For pregnant women who present with unexplained vaginal bleeding, offer to carry out placental localisation by ultrasound if the placental site is not known.

• For pregnant women with unexplained vaginal bleeding who are admitted to hospital, consider corticosteroids for fetal lung maturation if there is an increased risk of preterm birth within 48 hours. Take into account gestational age.

• There is an increased risk of preterm birth with women who have unexplained vaginal bleeding.

Backache

• Many women develop backache during pregnancy and it often first develops during the fifth to seventh months of pregnancy.

• Encourage light exercise and simple analgesia, and consider physiotherapy referral.

• Evidence shows exercise to be of benefit.¹⁰

Pelvic pain

• Mild crampy pains are normal in very early pregnancy. As the uterus grows, pulling and stretching of pelvic structures causes ligament pain, which usually resolves by 22 weeks. Pain is usually lateral and shooting in nature.

• Obstetric causes of acute pelvic pain include miscarriage, ectopic pregnancy, red degeneration of a fibroid, torsion of ovarian mass, rupture of ovarian cyst, preterm labour, placental abruption and uterine rupture.

See also the separate Pelvic Pain article.

Pelvic girdle pain/symphysis pubis dysfunction¹

• Pelvic girdle pain (PGP) is the newer term for the condition which used to be known as symphysis pubis dysfunction (SPD). It describes pregnancy-associated pain, instability and dysfunction of the symphysis pubis joint and/or sacroiliac joint.

• 14-22% of pregnant women may have PGP.

• There is a collection of symptoms of discomfort and pain in the suprapubic or low back area, which may radiate to the upper thighs and perineum.

• Discomfort can vary from mild to severe pain. There may be difficulty walking or weight bearing, limited and/or painful hip abduction, discomfort lying in certain positions, and a limited endurance of time sitting.

• For women with pregnancy-related pelvic girdle pain, consider referral to physiotherapy services for exercise advice and/or a non-rigid lumbopelvic belt.

• There is evidence for efficacy of osteomanipulative therapy and for combined treatments of manual therapy plus exercise plus education.¹⁰ There is also some evidence that acupuncture may be effective. It may be necessary to provide women with belts or crutches and there may be a need for analgesia in pregnancy and advanced planning for delivery. Management is usually collaborative and involves physiotherapists, midwives, obstetricians and the GP.

• Pain resolves within six months of delivery in the majority of affected women.

Carpal tunnel syndrome¹¹

• Pregnancy is a well-known risk factor for carpal tunnel syndrome. The reported incidence varies considerably but hand symptoms are relatively common, affecting up to 60% of pregnant women.

• Symptoms can occur at any stage, including the postpartum period.

• Risk factors include multiple births and age over 30.

• Symptoms often improve but do not resolve after delivery, and can develop or persist postpartum. Symptoms starting earlier in pregnancy are more likely to persist after delivery.

• Conservative non-surgical treatments, including a neutral angle or 20° cock-up wrist splinting, or local steroid injections, are often sufficient.

• Severe or refractory cases can be considered for carpal tunnel release surgery, done under local anesthesia, especially earlier in the pregnancy or after delivery.

Leg cramps

• Leg cramps are common in pregnancy.

• They occur in late pregnancy and are usually worse at night.

• Massaging the affected leg and elevation of the foot of the bed may help.

• Of the various supplements claimed to help leg cramps in pregnancy, the best evidence is for magnesium lactate; however, evidence remains conflicting.¹²

Paracetamol use in pregnancy

An epidemiological study of women in pregnancy has examined the possible association between paracetamol use at 18-32 weeks of pregnancy and adverse neurocognitive outcomes in children.¹³

The study considered 135 neurocognitive variables, of which 12 showed a statistically significant, including 4 with a highly statistically significant, association.These variables all related to behavioural issues and included hyperactivity and attention problems.

There was a stronger association in boys than in girls, and the differences in behaviour were most apparent in the pre-school period, largely resolving by age 7-8 years. This is an observational study so no firm conclusions about a causal link can be drawn, but the authors took significant steps to adjust for confounding factors.

Dr Mary Lowth is an author or the original author of this leaflet.