Common Symptoms in Pregnancy

Minor symptoms are very common in pregnancy. The initial symptoms of early pregnancy include amenorrhoea, nausea, tiredness, breast soreness or tingling and urinary frequency. All symptoms occurring during pregnancy should be carefully assessed in case they represent more serious health problems. Otherwise it is essential to provide reassurance and advice. Medications are not usually required and are best avoided if possible.¹

Nausea and vomiting¹

• Nausea is the most common gastrointestinal symptom of pregnancy, occurring in 80-85% of all pregnancies during the first trimester, with vomiting an associated complaint in approximately 50% of women.
• The severity of nausea and vomiting varies greatly and occurs more commonly in multiple pregnancies and molar pregnancies.
• The severity of nausea and vomiting varies greatly among pregnant women. The majority of women with nausea and vomiting report symptoms within 8 weeks of their last menstrual period (94%), with over one-third of women (34%) reporting symptoms within 4 weeks of their last menstrual period.
• Most women (87–91%) report cessation of symptoms by 16–20 weeks of gestation and only 11–18% of women report having nausea and vomiting confined to the mornings.
• Hyperemesis gravidarum refers to pregnant women in whom fluid and electrolyte disturbances or nutritional deficiency from intractable vomiting develops early in pregnancy. This condition is much less common with an average incidence of 3.5/1000 deliveries.
• Persistence of nausea and vomiting into the second or third semester suggests another possible cause, which include urinary tract infections, gastritis, biliary tract disease or hepatitis.
• In later pregnancy, other possibilities include polyhydramnios, pre-eclampsia or HELLP syndrome.
• Most cases of nausea and vomiting in pregnancy are self-limiting, and settle without complication as the pregnancy progresses.²

Management

• Advice includes eating crackers or dry toast on waking and before getting out of bed, eating frequent small meals, maintaining a high fluid intake with fluids taken between rather than with meals, avoiding spicy and fatty foods and avoiding lying down immediately after eating.
• Interventions for nausea and vomiting that do not require prescription include ginger, acupressure and vitamin B. Prescribed treatments for nausea and vomiting include antihistamines and phenothiazines.
• Pyridoxine (vitamin B6) appears to be effective in reducing the severity of nausea but the results from trials of P6 acupressure (pressure on the P6 acupuncture point which is 2 inches proximal to flexor wrist crease, between the 2 long tendons) are equivocal.³ Ginger is also claimed to be effective.
• Prescribed treatment in the first trimester is usually not indicated unless the symptoms are severe and debilitating. Promethazine, prochlorperazine and metoclopramide have been found to be effective.

Heartburn¹

• Heartburn is described as a burning sensation or discomfort felt behind the sternum or throat or both. It may be accompanied by acid regurgitation reaching the throat or the mouth, causing a bitter or sour taste in the mouth.
• Heartburn is estimated to occur in 30-50% of all pregnancies.⁴ One study reported an increased frequency of heartburn with gestation, with 22% of women reporting heartburn in the first trimester, 39% in second and 72% in third trimester.
• The pathogenesis of heartburn during pregnancy is unclear.
• Heartburn is not associated with adverse outcomes of pregnancy.
• Heartburn should be distinguished from epigastric pain associated with pre-eclampsia.
• Treatment options include lifestyle modification, use of antacids (including alginate preparations, such as Gaviscon®) or alkali mixtures, H₂ receptor antagonists and proton pump inhibitors.
• Information on lifestyle modification includes awareness of posture, maintaining upright positions, especially after meals, sleeping in a propped up position and dietary modifications such as small frequent meals, eat slowly, reduce high-fat foods and also gastric irritants such as caffeine.⁵
• Alginate preparations reduce reflux symptoms but magnesium trisilicate has been shown to be equally effective.
• H₂ receptor antagonists have been shown to be effective and safe in pregnancy.
• A meta-analysis of the safety of proton pump inhibitors reported no association with fetal malformations but the manufacturer of omeprazole advises caution with its use in pregnancy due to toxicity shown in animal studies and does not advise its use unless there is no alternative.

Constipation¹

• Constipation during pregnancy may not only be associated with poor dietary fibre intake but also with rising levels of progesterone causing a reduction in gastric motility and increased gastric transit time.
• Constipation is a commonly reported and tends to decrease with gestation.
• Advice includes drinking plenty of fluids, high fibre foods and get plenty of exercise.
• Wheat or bran fibre supplements are effective in increasing stool frequency.
• When fibre supplementation is not effective, stimulant laxatives have been shown to be more effective but cause more abdominal pain and diarrhoea than bulk-forming laxatives.
• No evidence currently exists for the effectiveness or safety of osmotic laxatives (e.g. lactulose) or faecal softeners in pregnancy.

Haemorrhoids¹

• A low-fibre diet and pregnancy are both precipitating factors for haemorrhoids.
• One study found that 8% of pregnant women experienced haemorrhoidal disease in the last three months of pregnancy.
• Treatment for haemorrhoids includes diet modification, topical soothing preparations and surgical intervention.
• Surgery is rarely considered an appropriate intervention for the pregnant woman since haemorrhoids may resolve after delivery.⁵

• Urinary frequency is a very common symptom of pregnancy but may represent an underlying problem, e.g. urinary tract infection or gestational diabetes mellitus.
• Associated symptoms suggesting an underlying problem include dysuria and haematuria (UTI) or dehydration and thirst (gestational diabetes).

• 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.

• 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 need to be considered.
• Associated symptoms suggesting an underlying cause include pyrexia, cough (respiratory tract infection) or wheeze (asthma).

• Fainting is more common during pregnancy.
• Reassurance and advising the woman to avoid hot atmospheres are usually all that is required.
• Hypotension should be excluded.

• Local causes are usually due to infections, e.g. scabies, thrush.
• Generalised itching is common in the third trimester and disappears after delivery.
• Cholestasis of pregnancy needs to be excluded by checking liver function tests (raised AST/ALT; alkaline phosphatase is increased in normal pregnancy and so is an unreliable marker of cholestasis in pregnancy).
• Treatment in the absence of any underlying cause is with simple emollients.

• The quality and quantity of vaginal discharge often changes in pregnancy. Women usually produce more discharge during pregnancy.
• If the discharge has a strong or unpleasant odour, is associated with itch or soreness or associated with pain on passing urine, infection needs to be excluded as the woman may have bacterial vaginosis, vaginal trichomoniasis or candidiasis.
• A 1-week course of a topical imidazole is an effective treatment for vaginal candidiasis in pregnant women. The effectiveness and safety of oral treatments for vaginal candidiasis in pregnancy is uncertain and these should not be offered.
• Vaginal discharge may also be caused by a range of other physiological or pathological conditions such as vulval dermatoses or allergic reactions.

• Headache is common in pregnancy. It usually resolves after the first trimester but may persist throughout pregnancy.
• Reassurance, rest and paracetamol are usually all that is required.
• However a careful evaluation of the headache is required to ensure there is no more sinister underlying cause e.g. pre-eclampsia (raised blood pressure, oedema).
• Non-pregnancy related causes of headache should also be considered, e.g. migraine. Any associated focal neurological features (possible cerebrovascular disease) or fever (possible meningitis) should be referred for urgent investigation and management.

• As the uterus grows, pulling and stretching of pelvic structures causes pelvic pain, which usually resolves by 22 weeks.

• Many women develop backache during pregnancy and it often first develops during the 5th to 7th months of pregnancy.
• The estimated prevalence of backache during pregnancy ranges between 35% and 61%.
• Encourage light exercise and simple analgesia, and consider physiotherapy referral.
• Women should be informed that exercising in water, massage therapy and group or individual back care classes might help to ease backache during pregnancy.

• Symphysis pubis dysfunction has been described as a collection of signs and symptoms of discomfort and pain in the pelvic area, including pelvic pain radiating to the upper thighs and perineum.
• Complaints vary from mild discomfort to severe and debilitating pain that can impede mobility.
• The reported incidence of symphysis pubis during pregnancy varies from 0.03% to 3%.
• There is little evidence for effective management options but the use of elbow crutches, pelvic support and prescribed pain relief may help.

• 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.

• Fluid retention leads to compression of peripheral nerves, leading to peripheral paraesthesia. This most often leads to carpal tunnel syndrome but other nerves can be affected, e.g. lateral cutaneous nerve of the thigh.
• Carpal tunnel syndrome is characterised by tingling, burning pain, numbness and a swelling sensation in the hand that may impair sensory and motor function of the hand.
• Carpal tunnel syndrome is not an uncommon complaint among pregnant women and estimates of incidence during pregnancy range from 21% to 62%.
• Interventions to treat carpal tunnel syndrome include wrist splints, corticosteroid injections and analgesia.
• There is a lack of research evaluating effective interventions for carpal tunnel syndrome.

• Varicose veins are a common complaint in pregnancy.
• 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, encourage walking and avoid standing still.
• Compression stockings can improve the symptoms but will not prevent varicose veins from emerging.