Understanding your new pregnancy normal

During pregnancy your body encounters and endures a great number of changes, and as part of your routine care, you will see a variety of health professionals including your midwife and GP. However, it is important to remember that pregnancy is not an illness. Although you may experience pregnancy symptoms that make you feel unwell, for the most part they are not harmful to you or your baby. To deal with these changes and symptoms, it can help to know what is normal.

Morning Sickness

The symptoms of morning sickness include feeling sick (nausea) and being sick (vomiting). It may make you feel tired and can actually last throughout the day and into the night. It is very common, especially in early pregnancy starting around week 6, and although unpleasant is not harmful to you or your baby. Experts believe it is caused by the hormonal changes in the first three months of pregnancy (peaking at 9-10 weeks) and although most women get some relief as pregnancy continues, about 1 in 10 women have symptoms after 20 weeks.

Often, morning sickness is worse in women expecting twins, or in those who have suffered with it before. There are many simple remedies including acupressure bands, ginger (e.g. ginger tea or chews) and eating little and often to make sure your stomach isn’t empty for long periods. Usually, doctors recommend staying off medication in pregnancy if at all possible but if your symptoms are particularly prolonged or severe, your GP may suggest some tablets. Indeed, it is important that you see your GP or call your midwife if you have not passed urine within 8 hours, if your urine is particularly dark or smelly, or if you have abdominal pain, a fever or have been unable to keep fluids down for over 24 hours. 1

Pregnancy Discharge

Hormonal changes in pregnancy increase the blood flow to the reproductive organs, which increases vaginal discharge to help prevent infection getting up into the womb. Towards the end of pregnancy, this will increase further and you may need to wear a pad: sometimes it can be mistaken for urine. If your discharge becomes smelly, is not white/clear, or you have other vaginal symptoms including itchiness or soreness, pain on passing urine or during sexual intercourse, then you should contact your GP or midwife as this could signal an infection.

In the week leading up to delivery, you may have a ‘show’: a thicker discharge containing mucous or a streak of blood. This happens when the mucus plug within the cervix comes away, and is a sign that your body is preparing for birth. 2

Indigestion

Indigestion (or dyspepsia) is caused by acid reflux rising from the stomach up into the oesophagus (gullet). The acid from the stomach leaks up through a muscular sphincter (a tight band which usually prevents leakage) at the bottom of the oesophagus and causes irritation of its lining. Up to 8 in 10 women experience symptoms in pregnancy and this is because there is more pressure on the stomach from the baby as well as pregnancy-related hormonal changes which cause the sphincter to relax.

Pregnancy symptoms can range from only a few minor changes to more severe symptoms, and these are typically worse after eating, but can also occur when you are lying flat or when you are hungry. They may include burping, feeling nauseous and feeling full. Pain is also a symptom, and can be felt in the upper part of the abdomen, behind the breastbone (sternum), or heartburn (a burning feeling travelling form the abdomen upwards).

To help, try reducing your intake of coffee, alcohol and high fat foods. Eat little and often and prop up the head of the bed to help gravity to prevent the leak of acid. You can speak to your GP about using antacids (including Gaviscon) or getting a prescription for tablets. 3

Constipation

Up to 40% of women become constipated during pregnancy because it takes longer for the stool to pass through the bowel due to hormonal changes. This means the faeces lose more water and are harder, making them more difficult to pass. Constipation itself can cause abdominal pain, bloating and flatulence. To try and counteract these changes, take on plenty of fluids, a high fibre diet (wholemeal bread, fruit and vegetables and pulses) and get regular exercise. You can also speak to your GP about using laxatives. 4, 5

Tiredness

Tiredness is common during pregnancy, especially in the first and third trimesters. In the early stages, hormonal changes can make you feel tired, emotional and nauseous. Later in pregnancy tiredness can be due to the extra weight you have to carry around. Occasionally it can be due to anaemia (something that can be excluded by your midwife or GP with blood tests). Try to rest as much as possible and some women find that regular light exercise can help.

Backache and Pelvic pain

Back pain: the combination of the extra weight you are carrying, your altered posture and the softening of the ligaments in the back cause increased back pain in pregnancy. There are a few things you can do to help reduce the pain, or to prevent it happening in the first place. Staying active throughout pregnancy with regular light exercise (walking or yoga) has been shown to reduce symptoms. Furthermore, avoid heavy lifting, try not to sit or stand for long, take warm baths and take simple pain relief such as paracetamol. If these simple measures do not help it may be worth speaking to your GP about a physiotherapy referral.

Pelvic Girdle pain: 14-22% of pregnant women get pelvic girdle pain. This pain can be severe and usually develops in the later stages of pregnancy but can start as early as 14 weeks. Typically it begins over the pubic bone but can spread to the hips and into the abdomen, around the lower back and down and between the legs. It is not harmful to your baby but can make it difficult for you to move around and get comfortable. You may notice that it is more severe when you are walking, turning over in bed, negotiating stairs or when moving your legs apart (e.g. standing on one leg or getting out of the car).

Experts believe the pain is caused by softening of the ligament that holds the joint at the front of the pelvis together. This happens in normal pregnancy to widen the pelvis for labour and delivery of the baby. To help with the pain, try putting a pillow between your legs when lying down to help maintain the normal shape of the pelvis. Regular paracetamol and physical activity can also help. It is important you let your GP or midwife know, as physiotherapy may provide benefit, while some women may benefit from the extra support of a belt or crutches. 6, 7, 8

Shortness of Breath

It is common for women to feel breathless throughout pregnancy, but mostly towards the later stages. This is because of the pressure of the expanding womb in the abdomen pushing the diaphragm upwards, which in turn reduces the space the lungs have to expand. This gives a sensation of being short of breath, and may make you feel like you need to breathe deeply and more quickly. In turn this may make you feel worse as the oxygen levels in your blood increase and the carbon dioxide levels decrease (through hyperventilation). This makes you feel panicky, faint, dizzy and can cause tingling. It is important to remember this is only a feeling of shortness of breath and usually there is no underlying cause.

The serious causes of shortness of breath include asthma and anaemia; you should know about these from your previous medical history and the bloods taken by the GP and midwife. Pulmonary embolism (blood clot in the lung) and fluid on the lung are both rare. To try and reduce your symptoms you should rest and relax. Breathing exercises can help.

Itching

Itching affects more than 20% of pregnant women and typically occurs in the last 12 weeks (all over body itch or just confined to one area). Often it is due to dry skin and skin stretching, especially on the abdomen. In rare cases, itching can be caused by a problem with the liver known as obstetric cholestasis (or intrahepatic cholestasis of pregnancy) whereby bile acids and other chemicals build up in the body. This may cause harm to the baby and needs investigation. If you have itching without a rash it is important to inform your GP or midwife who can perform a blood test to rule out liver problems.

General measures to help cope with itching include moisturising with a simple moisturiser, which can also be used as a soap. This can be bought in pharmacies (look for a suitable emollient cream that is safe to use in pregnancy). A cream containing menthol can also help symptoms. If itching is severe, try to avoid scratching as this will only make it worse: you could try rubbing an ice cube or cold pack over the area which will reduce blood flow and calm symptoms. 9, 10

Haemorrhoids

Haemorrhoids (or piles) are small swollen blood vessels around the anus. In pregnancy they are caused by increased pressure in the pelvis from the weight of the baby in the womb, and also from increased risk of constipation as discussed above. They can cause fresh red bleeding when opening your bowels, and may also lead to pain and itching. To prevent piles, try to avoid constipation, but if you have symptoms speak with your midwife or GP who may recommend creams or suppositories. Usually haemorrhoids will improve in the weeks after delivery when the pressure in the pelvis returns to normal. 1

Varicose veins

Like haemorrhoids, varicose veins are swollen blood vessels (veins) which can appear anywhere on the lower limb, and also sometimes in the vulva (the outer lips of the vagina) during pregnancy. As with haemorrhoids, they bulge due to the increased weight in the pelvis. To reduce their appearance and symptoms (they sometimes ache or itch) you can wear support stockings, elevate legs where possible and keep as active as possible.

Leg cramps

Leg cramps are especially common in pregnancy’s later stages, and especially at night time when fluid retention and muscle fatigue are at their highest. When they occur, elevation and massage of the affected leg can help. Also make sure to keep well hydrated during the day and eat a diet rich in calcium (milk or yoghurt) and magnesium (bananas). You can also try topical magnesium cream before bedtime. There is minimal evidence for other over the counter supplements.

Sensory changes

Swelling in your ankles and hands during pregnancy can sometimes cause nerves to become compressed, resulting in tingling and numbness (especially at night). Carpal tunnel syndrome is tingling in the thumb and first two fingers, and occurs in up to 70% of pregnant women. The main treatment in pregnancy is wearing a wrist splint, but speak to your GP if symptoms are troublesome.11

Conclusion

Overall, despite the fact that all of these pregnancy symptoms are common and not dangerous, they may cause you some discomfort and possibly even distress. If you are worried about any symptoms, discuss them with your midwife who may be able to offer reassurance and ways to help, or they may recommend seeing your GP.

Main points

• During pregnancy your body will undergo many changes. Most changes and symptoms are normal.
• Morning sickness is a common pregnancy symptom. It peaks at around 9-10 weeks and can usually be relieved, although not eliminated altogether, with some simple home remedies.
• Vaginal discharge is a normal and healthy part of pregnancy. However, some symptoms will need further investigation.
• Up to 8 in 10 women experience indigestion (acid reflux) during pregnancy.
• Constipation is a fact of pregnancy for around 40% of women.
• Tiredness is a normal part of pregnancy but sometimes it may be a symptom of anaemia.
• Back pain is an inherent part of pregnancy and exercise, such as yoga, can reduce symptoms. Paracetamol can provide relief.
• 14-22% of pregnant women experience pelvic girdle pain.
• Pelvic girdle pain can be severe and usually develops in the later stages of pregnancy but can start as early as 14 weeks.
• Itching affects more than 20% of pregnant women and typically occurs in the last 12 weeks (all over body itch or just confined to one area).
• In some rare cases severe pregnancy itching can be caused by a problem with the gallbladder which may cause harm to the baby.
• Haemorrhoids (or piles) are a common complaint in pregnancy – small swollen blood vessels around the anus are caused by the increased pressures of the baby in the womb.
• To reduce the appearance and symptoms of varicose veins you can wear support stockings, elevate legs where possible and keep as active as possible.
• Elevate your legs to reduce the incidence of cramps.
• Up to 70% of women experience carpal tunnel syndrome in pregnancy

References

1 Nausea/vomiting in pregnancy; NICE CKS, June 2013

2 Antenatal care for uncomplicated pregnancies; NICE Clinical Guideline (March 2008, updated 2017)

3 Dyspepsia – pregnancy-associated; NICE CKS, December 2012

4 Rungsiprakarn P, Laopaiboon M, Sangkomkamhang US, et al; Interventions for treating constipation in pregnancy. Cochrane Database Syst Rev. 2015 Sep 4 9:CD011448. doi: 10.1002/14651858.CD011448.pub2.

5Constipation; NICE CKS, October 2015

6 Liddle SD, Pennick V; Interventions for preventing and treating low-back and pelvic pain during pregnancy. Cochrane Database Syst Rev. 2015 Sep 30 9:CD001139. doi: 10.1002/14651858.CD001139.pub4.

7 Vleeming A, Albert HB, Ostgaard HC, et al; European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J. 2008 Jun 17(6):794-819. doi: 10.1007/s00586-008-0602-4. Epub 2008 Feb 8.

8 Pregnancy-related Pelvic Girdle Pain: Guidelines for Health Professionals; Pelvic Obstetric and Gynaecological Physiotherapy (POGP). 2015

9 Itch in pregnancy; NICE CKS, July 2015

10 Vaughan Jones S, Ambros-Rudolph C, Nelson-Piercy C; Skin disease in pregnancy. BMJ. 2014 Jun 3 348:g3489. doi: 10.1136/bmj.g3489.

11 Zyluk A; Carpal tunnel syndrome in pregnancy: a review. Pol OrthopTraumatol. 2013 Oct 7 78:223-7.