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. Medications are not usually required and are best avoided if possible.¹

Nausea and vomiting in early pregnancy²

• Nausea occurs in 80-85% of all pregnancies during the first trimester, with vomiting an associated complaint in approximately 50% of women.
• Hyperemesis gravidarum only occurs in about 3/1,000 pregnancies.
• Most cases of nausea and vomiting in pregnancy are self-limiting, and settle without complication as the pregnancy progresses.

See separate article Nausea and Vomiting in Pregnancy - including Hyperemesis Gravidarum for further detail.

Heartburn

• Heartburn is estimated to occur in 30-50% of all pregnancies.³
• Information on lifestyle modification includes awareness of posture, maintaining upright positions (especially after meals), sleeping in a propped-up position, and dietary modifications (e.g. small frequent meals, eating slowly, reduction of high-fat foods and caffeine).⁴
• Alginate preparations reduce reflux symptoms but magnesium trisilicate has been shown to be equally effective.
• Both H₂ receptor antagonists and proton pump inhibitors have been shown to be effective and safe in pregnancy.

Constipation

• Constipation is commonly reported and tends to increase with gestation.
• Advice includes drinking plenty of fluids, high-fibre foods and getting plenty of exercise.
• When fibre supplementation is not effective, stimulant laxatives have been shown to be more effective but cause more abdominal pain than bulk-forming laxatives.⁵
• No evidence currently exists for the effectiveness or safety of osmotic laxatives (e.g. lactulose) or faecal softeners in pregnancy.

Respiratory distress

• In many women respiratory distress occurs because of the growing uterus as the pregnancy advances.
• The woman may be significantly breathless and other possible causes of respiratory distress (e.g. asthma, pulmonary embolism) need to be considered.

Fatigue and insomnia

• Fatigue is very common in early pregnancy and reaches a peak at the end of the first trimester.
• Rest, lifestyle adjustment and reassurance are usually all that is required.
• Fatigue also occurs in late pregnancy, when anaemia should be excluded.
• Insomnia is also very common and due to a combination of anxiety, hormonal changes and physical discomfort.
• Mild physical exercise before sleep may help but drug treatment should be avoided.

Pruritus

• Local causes are usually due to infections, e.g. scabies, thrush.
• Generalised itching is common in the third trimester and disappears after delivery. Giant urticaria may look impressive but is not serious.
• Treatment is with simple emollients but cholestasis of pregnancy needs to be excluded by checking liver function tests (raised AST/ALT; alkaline phosphatase is increased in normal pregnancy and so an unreliable marker of cholestasis in pregnancy).

Haemorrhoids

• Treatment for haemorrhoids includes diet modification, topical soothing preparations and surgery.
• Surgery is rarely considered an appropriate intervention for pregnant women, since haemorrhoids may resolve after delivery.⁴

Varicose veins

• Feet and ankles can also become swollen, in which case deep vein thrombosis and pre-eclampsia need to be excluded.
• Treatment is by elevation of legs when sitting, support, and encouragement to walk and to avoid standing still.

Vaginal discharge

• 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 needs to be excluded.
• Trichomoniasis 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 the effectiveness and safety of oral treatments for thrush in pregnancy are uncertain and these should be avoided.
• Topical imidazole appears to be effective in treating symptomatic vaginal candidiasis in pregnancy but treatment for seven days may be required.⁶

Pelvic pain

• As the uterus grows, pulling and stretching of pelvic structures causes ligament pain, which usually resolves by 22 weeks.
• See separate article discussing Pelvic Pain, which may present as a result of a variety of obstetric and non-obstetric causes.
• Obstetric causes of acute pelvic pain include miscarriage, ectopic pregnancy, rupture of ovarian cyst, preterm labour, placental abruption and uterine rupture.

Backache

• Many women develop backache during pregnancy and it often first develops during the 5th to 7th months of pregnancy.
• Encourage light exercise and simple analgesia, and consider physiotherapy referral.
• Exercising in water, massage therapy and group or individual back care classes have been shown to be effective interventions.⁷

Symphysis pubis dysfunction

• This is a collection of symptoms of discomfort and pain in the pelvic area, including pelvic pain radiating to the upper thighs and perineum.
• Discomfort can vary from mild to severe pain.
• Management is usually conservative; there is no evidence for any specific treatment but elbow crutches, pelvic support and prescribed pain relief may help.
• Pain resolves within 6 months of delivery in the majority of affected women.⁸

Peripheral paraesthesia

• Fluid retention leads to compression of peripheral nerves.
• This often leads to carpal tunnel syndrome, which can affect up to one half of all pregnancies.
• Often, no specific treatment is required. Interventions include wrist splints, steroid injections and analgesia, but there is a lack of research evaluating effective interventions.
• Other nerves can be affected, e.g. the lateral cutaneous nerve of the thigh.

Leg cramps

• Leg cramps occur in 1 in 3 pregnancies.
• 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 or citrate.⁹

Document references

1. Antenatal care: routine care for the healthy pregnant woman, NICE Clinical Guideline (March 2008)
2. Nausea and vomiting in pregnancy, Clinical Knowledge Summaries (May 2008)
3. Dyspepsia - pregnancy-associated, Clinical Knowledge Summaries (May 2008)
4. Roy PK et al, Gastrointestinal Disease and Pregnancy, eMedicine, Apr 2009
5. Jewell DJ, Young G; Interventions for treating constipation in pregnancy. Cochrane Database Syst Rev. 2001;(2):CD001142. [abstract]
6. Young GL, Jewell D; Topical treatment for vaginal candidiasis (thrush) in pregnancy. Cochrane Database Syst Rev. 2001;(4):CD000225. [abstract]
7. Pennick VE, Young G; Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD001139. [abstract]
8. Leadbetter RE, Mawer D, Lindow SW; Symphysis pubis dysfunction: a review of the literature. J Matern Fetal Neonatal Med. 2004 Dec;16(6):349-54. [abstract]
9. Young GL, Jewell D; Interventions for leg cramps in pregnancy. Cochrane Database Syst Rev. 2002;(1):CD000121. [abstract]

Internet and further reading

• Mazzotta P, Magee LA; A risk-benefit assessment of pharmacological and nonpharmacological treatments for nausea and vomiting of pregnancy. Drugs. 2000 Apr;59(4):781-800. [abstract]
• Routine antenatal care algorithm, NICE 2008

Acknowledgements