Clinical Practice Guidelines Antenatal Care — Module II


Common conditions during pregnancy



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7Common conditions during pregnancy


A number of conditions are common during pregnancy. While these conditions are not harmful to the pregnancy, women may seek advice about managing symptoms. Recommendations are based on evidence about the accuracy of assessments in predicting complications in pregnancy and the effectiveness of interventions in reducing symptoms.

Table 7 presents a summary of advice on common conditions during pregnancy considered a priority for inclusion in these Guidelines. Advice on other conditions, such as vaginal discharge and backache is included in the NICE Guidelines (NICE 2008).



Table 7: Summary of advice for women about common conditions during pregnancy

Common condition

Advice

Section

Nausea and vomiting

Although distressing and debilitating for some women, nausea and vomiting usually resolves spontaneously by 16 to 20 weeks pregnancy and is not generally associated with pregnancy complications.

Module I 7.8

Discontinuing iron-containing multivitamins may be advisable while symptoms are present.

Constipation

Increasing dietary fibre intake and taking bran or wheat fibre supplements may relieve constipation.

Module I 7.9

Stimulating laxatives are more effective than preparations that add bulk but are more likely to cause diarrhoea or abdominal pain.

Reflux (heartburn)

Heartburn may be improved by having small frequent meals, and reducing foods that cause symptoms on repeated occasions.

7.1

Medications may also be considered for relieving heartburn.

Haemorrhoids

Haemorrhoids may be improved by increasing fibre in the diet and drinking plenty of water. If clinical symptoms remain troublesome, standard haemorrhoid creams can be considered.

7.5

Varicose veins

Varicose veins will not generally cause harm to the woman or baby and usually improve after the birth.

7.8

Pelvic girdle pain

Pregnancy-specific exercises, physiotherapy, acupuncture or use of a support garment may provide some relief from pelvic girdle pain.

7.11

Carpal tunnel syndrome

There is little evidence on the effectiveness of treatments for carpal tunnel syndrome.

7.14

7.1Reflux (heartburn)


Reflux (heartburn) is a common symptom in pregnancy. Most women can relieve mild symptoms by modifying their diet and lifestyle. Women with persistent or more severe symptoms may also require advice about specific treatments.

Background


Reflux (heartburn) is very common antenatally. While it is considered a normal part of a healthy pregnancy, symptoms may be frequent and distressing to women.

Reflux is generally a symptom of gastro-oesophageal reflux disorder (GORD), where some gastric contents are regurgitated into the oesophagus, causing discomfort and a burning sensation behind the sternum and/or throat. Acid regurgitation may also reach the pharynx, resulting in a bitter or sour taste in the mouth. While the exact causes of the increase in reflux during pregnancy are not clear, it is thought that hormonal effects on antireflux barriers in the lower oesophagus and on gastric function may play a part (Ali & Egan 2007; Majithia & Johnson 2012). When symptoms persist, further investigation may identify other causes — eg women who have had bariatric surgery, stomach cancer and Helicobacter pylori infection, which is common in newly arrived refugees (Tiong et al 2006; Cherian et al 2008) — and treatment after the birth may be needed.


Incidence during pregnancy


Reflux is estimated to occur in 30–50% of pregnancies, with the incidence up to 80% in some groups (Richter 2003; Ali & Egan 2007). Symptoms tend to become both more severe and frequent as pregnancy progresses.

Older women and those having second or subsequent pregnancies are more likely to experience heartburn (Dowswell & Neilson 2008). There is also evidence suggesting that pre-pregnancy heartburn and weight gain during pregnancy increase the risk of heartburn during pregnancy (Rey et al 2007).


Discussing reflux

Summary of the evidence


Reflux is not associated with adverse pregnancy outcomes and therefore treatment aims to relieve symptoms. There is limited evidence on the effectiveness and safety of current interventions. Generally, the first approach is advice on diet and lifestyle, either to reduce acid production or avoid reflux associated with postural change (Richter 2005).
Lifestyle approaches

Narrative reviews recommend lifestyle modifications for mild symptoms, including (Tytgat et al 2003; Ali & Egan 2007):

abstaining from alcohol, tobacco and medications that may increase symptoms (eg anticholinergics, calcium channel antagonists);

having smaller more frequent meals;

avoiding lying down within 2–3 hours of eating; and

elevating the head of bed by 10–15 cm.

Consensus-based recommendation vi

Offer women experiencing mild symptoms of heartburn advice on lifestyle modifications and avoiding foods that cause symptoms on repeated occasions.


Treatments

A range of medications affecting different physiological processes (eg antacids, histamine-2 [H2] receptor antagonists, proton pump inhibitors) may be used to relieve persistent or severe symptoms (Dowswell & Neilson 2008).

RCT evidence on the safety of reflux medications during pregnancy is limited (Richter 2005). Available evidence from lower level studies suggests that the use of antacids, proton pump inhibitors and H2 blockers for reflux during pregnancy presents no known significant safety concern for either the mother or baby:

antacids are considered safe in pregnancy and may be preferred by women as they give immediate relief; calcium-based formulations are preferable to those that contain aluminium (Tytgat et al 2003);

the use of proton pump inhibitors during pregnancy is not associated with an increased risk for major congenital birth defects, spontaneous miscarriage, preterm birth, perinatal mortality or morbidity (Diav-Citrin et al 2005; Gill et al 2009a; Gill et al 2009b; Pasternak & Hviid 2010; Majithia & Johnson 2012; Matok et al 2012); and

the use of H2 blockers in pregnancy is not associated with any increase in risk of spontaneous miscarriage, preterm birth or small-for-gestational-age baby (Gill et al 2009b).

One small RCT (n=36) (da Silva et al 2009) found that the use of acupuncture in pregnancy may reduce reflux symptoms.

Recommendation 17 Grade C

Give women who have persistent reflux information about treatments.


Practice summary: reflux


When: A woman is experiencing reflux.

Who: Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander Health Practitioner; Aboriginal and Torres Strait Islander Health Worker; multicultural health worker; accredited dietitian.

Provide advice: Advise women that the causes of reflux vary between individuals and avoiding the food and drinks that cause them reflux may reduce symptoms. Sleeping on the left side, raising the head of the bed, and not lying down after eating may also help. Reassure women that symptoms usually subside after pregnancy, but may recur in a subsequent pregnancy.

Discuss treatments: Discuss any remedies the woman may be using to treat reflux. Advise women that if symptoms persist or become more severe, medication can be considered.

Take a holistic approach: Assist women to identify food and drinks that may cause reflux and to find culturally appropriate alternatives. Consider costs if prescribing medication to treat reflux.


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