Common problems in pregnancy

Minor symptoms are very common in pregnancy. The symptoms should be properly assessed and appropriately treated; whilst women are often keen to avoid medication in pregnancy, particularly in the first trimester, conditions like nausea and vomiting can be safely treated.¹

Nausea and vomiting in early pregnancy ²³⁴⁵

• Nausea and vomiting in pregnancy (NVP) is common, affecting 90% of women, and is one of the commonest indication for hospital admission during pregnancy.

• It is defined as nausea and/or vomiting which starts before 16/40 and for which there is no other cause.

• The term 'morning sickness' should be avoided, as NVP can occur at any time during the day and it is felt by those affected to trivialise the condition.

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

• Women who are concerned about risks of medication and want more detail might usefully be signposted to the best use of medicines in pregnancy (BUMPS) website. The equivalent resource for healthcare professionals is the UK teratology information service (UKTIS).

• Hyperemesis gravidarum (HG) is less common; depending on the criteria used, it occurs in up to 10% of pregnancies, with around 2% of pregnant women admitted for HG. It should be diagnosed on clinical symptoms, of nausea and/or vomiting which is severe enough to cause an inability to eat and drink normally and which strongly limits daily activities of living. Signs of dehydration are complementary to the diagnosis (but not necessary); in particular, ketonuria should not be used to assess severity.

• The Pregnancy-Unique Quantification of Emesis (PUQE) and HyperEmesis Level Prediction (HELP) tools may be helpful in the assessment of a woman with NVP - realistically, the longer length of the HELP score means that it's more likely to be used in secondary care, with the PUQE score being an easier tool for primary care. A PUQE score up to 6 is mild NVP, 7-12 is moderate and 13-15 is severe.

• The RCOG guidance on NVP was updated in 2024 and gives the following recommendations:

  • Women with mild NVP should be managed in the community with anti-emetics.

  • Consider inpatient care if there is one of the following:

    • Continued nausea and vomiting, with inability to keep down oral antiemetics.

    • Continued nausea and vomiting associated with clinical dehydration or weight loss >5% of body weight, despite oral antiemetics.

    • Confirmed or suspected co-morbidity (such as UTI and inability to tolerate oral antibiotics).

    • Co-morbidities such as epilepsy, diabetes, HIV, hypoadrenalism or psychiatric disease, where symptoms and inability to tolerate oral intake and medication could present further complications.

  • Consider the following regarding pharmacological treatment options:

    • If women do not respond to a single antiemetic, a combination should be used.

    • For women with persistent or severe HG, the parenteral, transdermal, or rectal route may be necessary and more effective than an oral regimen.

    • Corticosteroids should be reserved for cases where standard therapies have been ineffective and used in combination with antiemetics. The recommendation is for IV hydrocortisone, so this is an inpatient option.

    • A delayed-release combination of doxylamine and pyridoxine (vitamin B6) is the only licensed treatment of NVP in the UK so can be used first-line for mild-moderate NVP requiring treatment.

    • First-line antiemetics - doxylamine and pyridoxine, cyclizine, prochlorperazine, promethazine, chlorpromazine.

    • Second-line antiemetics - metoclopramide, domperidone, ondansetron.

  • Women who are concerned about the safety of antiemetics in pregnancy can be given the following information:

    • There is safety data for antiemetics such as anti (H1) histamines (promethazine, cyclizine, doxylamine), phenothiazines (prochlorperazine) and pyridoxine-doxylamine.

    • There is evidence that ondansetron is safe. Its use should not be discouraged if first line antiemetics are ineffective. Women can be reassured regarding a very small increase in the absolute risk of orofacial clefting with ondansetron use in the first trimester, which should be balanced with the risks of poorly managed HG.

    • Metoclopramide is safe and can be used alone, or with anti-emetics; it is second-line because of the risk of extrapyramidal symptoms for the woman, rather than because of any risk to the foetus.

See the separate Nausea and vomiting in pregnancy article for more information.

Dyspepsia^{1 6}

• 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. UKTIS states that there is no data which shows an increased risk of malformation following first trimester PPI exposure, but data for drugs other than omeprazole is limited. There is some (limited and conflicting) evidence that gastric acid suppression during pregnancy may increase the likelihood of atopy in the infant.

Constipation⁷⁸

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

• 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 (for example, 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^{9 10}

• 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 discharge¹¹¹

• 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.

• 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 to secondary care for a review; there is an increased risk of preterm birth with women who have unexplained vaginal bleeding.

Backache¹²

• 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.

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 dysfunction^{1 12}

• 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. 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 syndrome¹³

• 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 anaesthesia, 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.¹⁴

Paracetamol use in pregnancy¹⁵

Many studies have looked at neurodevelopmental outcomes following the use of paracetamol - UKTIS makes the following points:

• The results of these studies are conflicting.

• An increased likelihood of ADHD have been shown, but when one of the meta-analyses accounted for confounding, there was no statistically significant difference related to confounding use.

• The conclusions that can be drawn are limited and a causal association remains unproven.

• Some (but not all) studies have shown a link between frequent paracetamol use at 20-32 weeks and an increased incidence of childhood wheeze or asthma.

• A rise in maternal core body temperature of (particularly of 2°C or more in the first trimester) may increase the risk of neural tube defects, but data are conflicting. Severe or chronic pain may impact fetal outcome via effects on maternal cardiovascular function and uteroplacental perfusion. This should be considered when interpreting safety data.

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