Symptoms and discomforts of pregnancy

Symptoms and discomforts of pregnancy are those presentations and conditions that result from pregnancy but do not significantly interfere with activities of daily living or pose any significant threat to the health of the mother or baby, in contrast to pregnancy complications. Still, there is often no clear separation between symptoms versus discomforts versus complications, and in some cases the same basic feature can manifest as either a discomfort or a complication depending on the severity. For example, mild nausea may merely be a discomfort (morning sickness), but if severe and with vomiting causing water-electrolyte imbalance it can be classified as a pregnancy complication (hyperemesis gravidarum).

Examples

Nausea (morning sickness)

Morning sickness occurs in about seventy percent of all pregnant women, and typically improves after the first trimester.^[1] Although described as "morning sickness", women can experience this nausea during the afternoon, evening, and throughout the entire day. Unfortunately there is no strong evidence showing one treatment that works for all women. Ginger may help some women but the results change from study to study.^[2]

Bleeding

It is common to have bleeding in early pregnancy, this is associated with implantation bleeding and can be mistaken for a regular period. However implantation bleeding is usually much lighter and in many cases sanitary napkins aren't necessary. Although excessive bleeding in the first trimester can also be associated with miscarriage.

Back pain

Back pain is common in pregnancy, can be very debilitating and can worsen in later pregnancy.^[3][4] Estimates of prevalence ranging from 35% to 61% have been reported, with half or more beginning from the fifth month.^[4] It is believed to be caused by changing posture and can be worse in the evening.^[4] Trials have shown benefit from exercising in water, massage therapy, and back care classes.^[3] Evidencethat acupuncture, craniosacral therapy, osteomanipulative therapy or a multi-modal intervention (manual therapy, exercise and education) may also be of benefit.^[3] Very low-^[4]quality evidence suggest that specially-designed pillow reduce night-time lowback pain.^[5] Back care classes for pregnancy include a variety of exercises and guidance. General exercise that is not tailored to strengthen the back may not prevent or reduce back pain, but more research is needed to be sure.^[6][7] Maternity support belts have not been shown to reduce low back pain in pregnancy.^[8] They may have some adverse effects, including pain and skin irritation for the mother, and potential effects on the fetus.^[8]

Pelvic girdle pain

Pelvic girdle pain is complex and multi-factorial and likely to be represented by a series of sub-groups with different underlying pain drivers from peripheral or central nervous system,^[9] altered laxity/stiffness of muscles,^[10] laxity to injury of tendinous/ligamentous structures^[11] to 'mal-adaptive' body mechanics.^[9] Musculo-skeletal mechanics involved in gait and weightbearing activities can be mild to grossly impaired. PGP can begin peri or postpartum. Land or water based exercise may help prevent and treat lower back and pelvic pain but research on this subject is low quality.^[12] There is pain, instability or dysfunction in the symphysis pubis and/or sacroiliac joints. Moderate-quality evidence from a systematic review suggest that exercise or acupuncture reduced pelvic pain or lumbo-pelvic pain more than usual care.^[5]

Carpal tunnel syndrome

Occurs in between an estimated 21% to 62% of cases, possibly due to edema.^[13]

Leg cramps

Leg cramps (involuntary spasms in calf muscles) can affect between 30% to 50% of women during pregnancy, especially during the last three months of pregnancy.^[14] Leg cramps can be extremely painful and whilst they usually last only a few seconds, they can last for minutes.^[15] It is not clear whether some oral drug treatments (such as magnesium, calcium, vitamin B or vitamin C) are effective in treating leg cramps during pregnancy, nor whether these treatments are safe for the mother or her baby.^[16] There is no evidence to assess the effectiveness and safety of other non-drug treatments such as heat therapy, massage or stretching the muscles (or dorso-flexion of the foot).^[16]

Constipation

Constipation is believed to be caused by decreased bowel mobility secondary to elevated progesterone (normal in pregnancy), which can lead to greater absorption of water, but it can also be caused or worsened by iron supplementation.^[4] It causes the "smooth muscle" along the walls of the intestines to relax. Thus, making sure that the future mother will absorb as much nutrients from her diet as possible in order to nourish the fetus and herself. As a side effect the feces can get extremely dehydrated and hard to pass.^[17] Constipation can decrease as pregnancy progresses, with a rate as high as 39% at 14 weeks of gestation reducing to 20% at 36 weeks in one study at a time when iron supplementation was common.^[4]

Dietary modification with more fiber or fiber supplementation. Also, increased PO fluids, stool softeners, bulking agents and eating fruit and fiber enriched foods often help. There is not enough evidence to say how best to treat constipation in pregnancy.^[18] Stimulant laxatives may help but also cause diarrhoea and abdominal pain. Fibre supplementation may also help.^[18]

A woman experiencing sudden defecation should report this to her practitioner.

Contractions

Occasional, irregular, painless contractions that occur several times per day are normal and are known as Braxton Hicks contractions. Can be aggravated by dehydration which will respond to increased fluid intake. Regular contractions (every 10–15 min) are a sign of preterm labor and should be assessed by cervical exam.

Dehydration

Caused by expanded intravascular space and increased third spacing of fluids. Complications include uterine contractions, which may occur because dehydration causes body release of ADH, which is similar to oxytocin in structure. Oxytocin itself can cause uterine contractions and thus ADH can cross-react with oxytocin receptors and cause contractions.

Edema

Compression of the inferior vena cava (IVC) and pelvic veins by the uterus leads to increased hydrostatic pressure in lower extremities. Treatment includes raising legs above the heart, advising patient to sleep on her side to prevent the uterus from impinging on the inferior vena cava, reflexology, water emersion^[19] & compression stockings.

Regurgitation and heartburn

Regurgitation and heartburn in pregnancy are caused by relaxation of the lower esophageal sphincter (LES) and increased transit time in the stomach (normal in pregnancy), as well as by increased intraabdominal pressure, caused by the enlarging uterus.

Regurgitation and heartburn in pregnancy can be at least alleviated by eating multiple small meals a day, avoiding eating within three hours of going to bed, and sitting up straight when eating.^[20]

If diet and lifestyle changes are not enough, antacids and alginates may be required to control indigestion, particularly if the symptoms are mild.^[20] If these, in turn, are not enough, proton pump inhibitors may be used.^[20]

If more severe, it may be diagnosed as gastroesophageal reflux disease (GERD).

Varicose veins

Dilation of veins in legs caused by relaxation of smooth muscle and increased intravascular pressure due to fluid volume increase. Treatment involves elevation of the legs and pressure stockings to relieve swelling along with warm sitz baths to decrease pain. There is a small amount of evidence that rutosides (a herbal remedy) may relieve symptoms of varicose veins in late pregnancy but it is not yet known if rutosides are safe to take in pregnancy.^[19] Risk factors include obesity, lengthy standing or sitting, constrictive clothing and constipation and bearing down with bowel movements

Hemorrhoids

Haemorrhoids (piles) are swollen veins at or inside the anal area, resulting from impaired venous return, straining associated with constipation, or increased intra-abdominal pressure in later pregnancy.^[21] They are more common in pregnant than non-pregnant women.^[21] It is reported by 16% of women at 6 months postpartum.^[22] Most pregnant women in countries where the diet is not heavily fiber-based may develop hemorrhoids,^[23] although they will usually be asymptomatic.^[21] Hemorrhoids can cause bleeding, itching, soiling or pain, and they can become strangulated.^[21] Symptoms may resolve spontaneously after pregnancy, although hemorrhoids are also common in the days after childbirth.^[21] Conservative treatments for hemorrhoids in pregnancy include dietary modification, local treatments, bowel stimulants or depressants, or phlebotonics (to strengthen capillaries and improve microcirculation).^[23] Treatment with oral hydroxyethylrutosides may help improve first and second degree hemorrhoids, but more information on safety in pregnancy is needed.^[23] Other treatments and approaches have not been evaluated in pregnant women.^[23]

Pica

Pica is a craving for nonedible items such as dirt or clay. It is caused by iron deficiency which is normal during pregnancy and can be overcome with iron in prenatal vitamins or, if severe, parenteral iron

Round Ligament or Lower abdominal pain

Caused by rapid expansion of the uterus and stretching of ligaments such as the round ligament. This pain is typically treated with paracetamol (acetaminophen).

Increased urinary frequency

Caused by increased intravascular volume, elevated GFR (glomerular filtration rate), and compression of the bladder by the expanding uterus. It may appear rather suddenly by head engagement of the fetus into cephalic presentation. Patients are advised to continue fluid intake despite this. Urinalysis and culture should be ordered to rule out infection, which can also cause increased urinary frequency but typically is accompanied by dysuria (pain when urinating).

Diastasis recti or abdominal separation

During pregnancy, many women experience a separation of their stomach muscles, known as diastasis recti. It affects the rectus abdominis muscle.

The rectus abdominis muscle is divided down the middle by the tendinous line called the linea alba.^[24] It is kept in line by the transverse abdominal and oblique abdominal muscles. During pregnancy, the growth of the fetus exerts pressure on abdominal cavity muscles, in particular the rectus abdominis. In pregnancies that experience rapid fetus growth or women with particularly weak abdominal muscles, this pressure can sometimes causes the rectus abdominis muscle to separate along the linea alba, creating a split between the left and right sides of the rectus abdominis.^[25]

About one-third of all pregnant women experience diastasis recti at some point in their pregnancy, however it is much more likely to occur during the second trimester or third trimester of pregnancy. However, separation also frequently occurs during labor and delivery, or with women carrying more than one baby.^[26] Many cases of diastasis recti correct themselves after birth, but some do not. In cases where it persists, exercise may help improve the condition, and sometimes surgery is needed to correct the problem to prevent pain and future complications.^[27][28]

Striae gravidarum

Striae gravidarum (pregnancy-related stretch marks) occur in 50% to 90% of women,^[29] and are caused both by the skin stretching and by the effects of hormonal changes on fibers in the skin.^[30] They are more common in younger women, women of color, women having larger babies and women who are overweight or obese, and they sometimes run in families.^[30] Stretch marks generally begin as red or purple stripes (striae rubra), fading to pale or flesh-color (striae alba) after pregnancy that will generally be permanent.^[29][30][31] They appear most commonly on the abdomen, breasts, buttocks, thighs, and arms, and may cause itching and discomfort.^[29][30] Although several kinds of multi-component creams are marketed and used, along with vitamin E cream, cocoa butter, almond oil and olive oil, none have been shown to prevent or reduce stretch marks in pregnancy.^[29][30] The safety for use in pregnancy of one herbal ingredient used in some products, Centella asiatica, has been questioned.^[30] Some treatments used to reduce scarring, such as topical tretinoin lasers,^[31] are sometimes used on stretch marks, but evidence on them is limited.^[30] Topical tretinoin has been shown to cause malformations in animals, without adequate human studies on safety in human pregnancies.^[32]

See also

• Complications of pregnancy
• Maternal physiological changes in pregnancy

References