establishing a link between this drug and birth defects.1 3 The .... The drugs of choice in pregnancy include ..... Division of Sterling Drug Ltd. Aurora, Ontario L4G ...
I
-1
0
I
-..
Anne Biringer, MD, CCFP
Common Physical Discomforts of Pregnancy SUMMARY
RESUME
Although pregnancy is a time of health, the Meme si la grossesse est en soi un etat normal, les changements physiologiques de la grossesse engendrent physiologic changes of pregnancy often souvent des malaises. Le medecin de famille est bien bring discomfort. The family physician is place pour normaliser l'experience de la femme enceinte ideally placed to normalize the pregnant et pour suggerer des solutions. Cet article examine les woman's experience and to suggest malaises les plus frequents de la grossesse, les place dans remedies. This article examines several of le contexte de la physiologie maternelle et offre des sugspdcifiques pour soulager ces sympt6mes. Le gestions of the commonly experienced discomforts de famille qui prendra le temps de bien renseigmedecin pregnancy, places them in the context of ner sa patiente, de discuter avec elle et de la rassurer maternal physiology, and offers specific pourra apaiser son anxiet6 et l'aider a vivre agr6ablement suggestions for alleviating symptoms. By sa grossesse. providing information, discussion, and reassurance, the family doctor can decrease the pregnant woman's anxiety and help her enjoy her pregnancy. (Can Fam Physician 1988; 34:1965-1968.) Key words: pregnancy, discomfort, management Dr. Biringer is an Assistant Professor in the Department of Family and Community Medicine at the University of Toronto. She practises in the Family Practice Unit, Mt. Sinai Hospital, Toronto. Requests for reprints to: Dr. A. Biringer, Family Practice Unit, Mt. Sinai Hospital, 800 University Avenue, Toronto, Ont. M5G 1X5 D REGNANCY is a time to expect rLhealth. However, as the pregnant woman's physiology and psychology changes, she may experience certain physical discomforts. The number and quality of complaints and the severity
of the symptoms that any one woman may experience is variable. With few CAN. FAM. PHYSICIAN Vol. 34: SEPTEMBER 1988
exceptions, the problems discussed below are not threatening to the life or integrity of the mother or her fetus. They can range, however, from being a nuisance to being incapacitating to the woman. It is helpful for the physician to anticipate these symptoms, put them in the context of the normal physiologic changes of pregnancy, and suggest simple manoeuvres to alleviate the discomfort. Although some of these symptoms are addressed in childbirtheducation classes, it cannot be assumed that all women have received the benefit of this teaching or are comfortable "bothering the doctor with trivial problems". It is the physician's role to legitimize these concerns, anticipate the occurrence of physical discomforts of pregnancy, and suggest remedies.
Nausea and Vomiting Nausea and vomiting are common complaints during the first 14 to 18 weeks of pregnancy. About 80% of women experience some gastrointestinal disturbance during pregnancy.' Fortunately, only 0.35% develop true hyperemesis gravidarum with weight loss, electrolyte and acid-base disturbance,' and consequent danger to the pregnancy. The etiology is unclear, although circulating human chorionic gonadotropin (HCG) and individual susceptibility appear to be contributing factors. Management of pregnancy-related nausea and vomiting includes reassurance that the condition is self-limited and, in fact, associated with a better 1965
pregnancy outcome.2 Practical measures include eating small frequent meals, with an emphasis on dry foods such as crackers, dry toast, baked potato, or white chicken meat, and taking liquids between meals. The woman should be instructed to eat in small amounts at least every two hours from the time she awakens (starting with crackers while she is still in bed) until bedtime and to avoid spicy, acidic, or greasy foods. She may find chewing gum or nibbling on celery helpful. She should discontinue her iron therapy until the nausea has passed and avoid contact with cooking odours, brushing her teeth, and other potentially nauseating situations at those times of the day that she finds herself most likely to vomit. Fortunately, most women respond to conservative therapy. If weight loss, ketonuria, and electrolyte imbalance develop, hospitalization is required. For the woman who is losing weight and is at risk for nutritional deficiencies, the use of antinauseants is appro-
priate. With the withdrawal of Bendectin (doxylamine and pyridoxine) from the market in 1983, there are no antinauseants approved specifically for use in pregnancy. Despite the number of law suits against Bendectin, to date there have been no reports conclusively establishing a link between this drug and birth defects. 1 3 The combination of doxylamine and pyridoxine has been used in over 30 million pregnancies and is the antinauseant that has been most extensively studied. It is available in Canada under the trade name Diclectin. Other antinauseants effective against morning sickness and judged as "probably safe in pregnancy" include doxylamine alone, dimenhydrinate, meclizine, or cyclizine.3 4
Constipation Constipation is extremely common in pregnancy and is the result of a number of factors. These include reduced motility because of smooth muscle relaxation (from increased levels of progesterone and decreased levels of motilin), mechanical obstruction by the uterus, and increased water resorption from the colon.5 Constipation is often exacerbated by the routine prescription of iron containing prenatal vitamins. Treatment consists of the usual strategies such as ingestion of fibre, increased fluids, and exercise. If the 1 966
above measures are inadequate, bulkadding agents such as methycellulose and psyllium mucilloid are safe for use in pregnancy.3 The use of non-absorbable oil preparations should be discouraged because of their possible interference with the absorption of lipid-soluble vitamins.
Hemorrhoids The development or aggravation of hemorrhoids in pregnancy is the result of increased pressure in the hemorrhoidal veins caused by obstruction of venops return by the gravid uterus and the tendency towards constipation in pregnancy. Treatment consists of softening the stools, Sitz baths and, occasionally, topical agents. Thrombosed external hemorrhoids require incision and evacuation. However, further surgical treatment need not be undertaken, as most hemorrhoids become asymptomatic after delivery.
cated, should be postponed until after delivery or, perhaps, until the end of the childbearing years. The discomfort of vulvar varicosities may be relieved by lying down with a covered bag of ice chips (or a small bag of frozen peas) against the perineum. During the day, the pressure of a sanitary napkin against the perineum may provide relief.
Aches and Pains
The weight of the gravid uterus causes a compensatory lumbar lordosis during pregnancy. This displacement frequently causes back pain, which may be severe at times. Treatment consists of back education, the wearing of proper footwear, and rest. Occasionally, severe back pain requires analgesia. The ligaments of the pubic symphysis and sacroiliac joints loosen during pregnancy secondary to the effects of relaxing.7 Although this change facilitates vaginal delivery, it frequently Heartburn leads to pelvic discomfort and groin Decreased gastrointestinal motility ache Tailor sitting and upward displacement and com- and a late in pregnancy. relieve some may squat supported pression of the stomach by the gravid The woman should be caudiscomfort. uterus combine to produce reflux of of joints that relaxation the tioned gastric contents into the esophagus. pled with the increased lordosis coucan Small frequent meals, avoidance of lead to unsteadiness of gait and trauma fatty or spicy foods, and elevation of the head of the bed may help. If antac- from falls. ids are required, magnesium-containing substances appear to be safe in Vaginal Discharge pregnancy.3 The use of aluminum-conThe increased vaginal discharge taining preparations is less advisable because they aggravate constipation, which most pregnant women describe reduce the absorption of phosphate, is usually physiologic. There is increased formation of mucus by the cerand interact with minerals.6 vical glands under the influence of estrogen.5 Complicating diagnosis is the Swelling and Varicosities fact that monilia can be cultured from the vagina of about 25 % of women apalmost univeris edema Dependant sal in late pregnancy because of occlu- proaching term and trichomonas sion of the pelvic veins and inferior vaginalis in up to 20%.5 Neither of vena cava as a result of pressure from these vaginal infections require treatthe enlarged uterus. Treatment consists ment if the woman is asymptomatic. If of avoidance of prolonged standing (the treatment is required, metronidazole patient should be advised to keep mov- should be avoided, particularly in the ing while on her feet), elevation of the first trimester, because of the possibillower extremities, and the wearing of ity of teratogenicity. The drugs of include choice in pregnancy support hose if desired. Varicosities of the legs and vulva are clotrimazole for trichomoniasis and the result of the physiologic changes of clotrimazole or miconazole for pregnancy and perhaps a congenital moniliasis.8 Once infection has been ruled out, predisposition towards varicose veins. Treatment is as for dependant edema. the woman can be reassured that her The woman should avoid crossing her vaginal discharge is a normal part of legs or sitting with her thighs pressed pregnancy. Routine hygiene and avoidagainst the chair edge. Surgery, if indi- ance of douching is recommended. CAN. FAM. PHYSICIAN Vol. 34: SEPTEMBER 1988
Pigmentation Estrogen and progesterone have been shown to have a melanocytestimulating effect. Thus, they may be responsible for the formation of the linea nigra, the darkening of the areolae, and the pigment changes of the face and cheeks known as the "mask of pregnancy".7 Although these changes recede considerably after pregnancy, it is wise to avoid excessive sunlight and use a sun-blocking agent.
Striae Gravidarum Approximately two-thirds of all pregnant women develop striae gravidarum on their abdomen, buttocks, thighs or breasts.9 Caused by rupture of the elastic fibres in the dermis, these reddish marks fade to silver after pregnancy, but never disappear. Despite the claims ofthe cosmetic companies, nothing can prevent stretch marks, as their presence appears to be caused solely by genetic predisposition.7 Avoidance of excessive weight gain is helpful, and body massage with emollients is pleasurable and relaxing even if ineffective for striae.
Bleeding Gums In pregnancy, the gums, again under the influence of estrogen, become hyperemic and softened. Normal toothbrushing may cause bleeding that is not necessarily a sign of gum or dental disease. There is no good evidence that pregnancy per se incites tooth decay,5 but women should continue regular dental care during pregnancy. The epulis of pregnancy is a focal vascular swelling of the gums which regresses spontaneously after delivery.
Shortness of Breath Even early in pregnancy, as many as 60 % -70 % of women experience an increased awareness of the desire to
breathe.7 This increased respiratory effort is probably caused by a number of factors including increased progesterone, reduced PaCO2 levels and an awareness of the increased tidal volume of pregnancy.5 The woman may require reassurance from her physician. Later in pregnancy, as residual volume decreases and weight increases, there may be an even greater sensation of shortness of breath. Sitting up straight and sleeping propped up on pilCAN. FAM. PHYSICIAN Vol. 34: SEPTEMBER 1988
lows may help to some extent. The patient should be reassured that her respiratory function is not impaired.
tile, and colostrum may be expressed. A well-fitting support bra is recommended for comfort.
Urinary Symptoms
Rhinitis
The pregnant woman experiences urinary frequency in the first trimester as the enlarging uterus exerts pressure on the bladder and, again, near the end of the pregnancy as the presenting part descends into the pelvis. Nocturnal frequency can be partially diminished if the woman consumes her day's liquids by three to four hours before retiring. A midstream urine for culture should be obtained if symptoms suggest urinary tract infection.
Nasal stuffiness and occasional nosebleeds are commonly encountered in pregnancy. The increased estrogen produces perivascular edema and enlargement of the nasal turbinates. '0 Superficial vessels in the hyperemic mucosa may rupture and result in epistaxis. Since these symptoms disappear after pregnancy, treatment consists of reassurance, standard treatment of epistaxis, and avoidance of topical nasal decongestants. Use of a humidifier and locally applied petroleum jelly may be helpful in the dry environment.
Fatigue Early in pregnancy, most pregnant women complain of excessive fatigue. This usually remits by the second trimester but it can be extremely frustrating for a healthy active woman. Reassurance and common-sense adjustments to lifestyle are appropriate until the problem resolves. The physician should be sensitive to the strain that this lack of energy may impose on the couple's relationship. Fatigue frequently returns in the third trimester with the sheer physical effort of carrying the increased weight of pregnancy.
Dizziness and Fainting Many pregnant women experience dizziness or syncope, particularly when standing for prolonged periods or in warm weather. This symptom is thought to be related to a decrease in cardiac output resulting from lowered venous return from the legs and dilation of peripheral vessels to dissipate body heat. Practical measures are to avoid prolonged standing and to avoid lying flat on the back, which causes supine hypotension. When faintness occurs, the pregnant woman should sit down or lie on her left side to decrease pressure on the inferior vena cava. Hot tubs and saunas should be avoided for the same reasons.
Leg Cramps Although leg cramps are experienced by 15 %-30% of pregnant women, the etiology is unclear. "I Preventive measures include adequate calcium intake (even though the function of serum calcium in the etiology of cramps is not confirmed), and avoiding hyperextension of the foot (i.e., pointing the toes). Gentle stretches of the affected muscle relieve the acute discomfort. 12
Headache Headache is a common complaint early in pregnancy. There is usually no demonstrable cause, and most headaches diminish or disappear by midpregnancy. Treatment should be symptomatic, with medication limited to acetaminophen if required. Later in pregnancy, headache may be a symptom of toxemia.
Overview
It has been shown that, in general, a pregnant couple's stress decreases when the physician provides information, discussion and reassurance. 'I The family physician is seen as a significant source of support by the pregnant woman and, for this reason, is in an ideal position to counsel her about common physical discomforts of pregBreast Changes nancy. However, it is only after differTenderness and tingling of the entiating the physiologic changes of breasts are among the first symptoms of normal pregnancy from pathologic pregnancy. After the second month, conditions that the physician is able to the breasts increase in size and be appropriately reassuring. Because many of these symptoms nodularity because of estrogen, progesterone and prolactin. The nipples be- are almost universal, it is helpful if the come darker, larger, and more erec- physician anticipates or assumes their 1967
;6pticrom Sodium cromoglycate ophthalmic solution 2% w/v-Anti Allergic Agent Indications: Treatment of seasonal allergic conjunctivitis and vernal keratoconjunctivitis. Contraindications: Hypersensitivity to components of OPTICROM. Warning: The number of drops to be instilled into the eye per day should be specified to the patient. Regular dosage is important. Any remaining contents should be discarded four weeks after opening. Precautions: Possible immunologic changes resulting in reactions such as polymyositis, pneumonitis and heart failure, urticaria and anaphylaxis, have been reported rarely with sodium cromoglycate preparations administered by inhalation. Clinical experience in children under five (5) years of age is limited. During clinical use there have been, to date, no reports of adverse effects on the mother or the fetus that could be ascribed to the use of sodium cromoglycate. Nevertheless, as with all medications, caution must be exercised during pregnancy. During treatment with OPTICROM soft contact lenses should not be worn. Adverse Reactions: Causes of erythema, urticaria or maculo-papular rash have been reported with other sodium cromoglycate preparations. These have cleared within a few days on withdrawal of the drug. Occasional headache, sneezing, cough and unpleasant taste in the mouth have been reported after nasal or inhalation therapy. Eosinophilic pneumonia has been reported rarely after administration by inhalation. Symptoms and Treatment of Overdosage: There have been no reported cases in humans of overdosage of the drug. Symptomatic treatment is suggested should accidental ingestion occur. Dosage and Administration: Note: In patients with seasonal allergic conjunctivitis, clinical response to OPTICROM may be expected within ten days, in those with vernal keratoconjunctivitis, within a few weeks. Dose: One or two drops into each eye four times daily. Each drop of 2% ophthalmic solution delivers approximately 0.04 mL of solution containing 0.8 mg sodium cromoglycate. The maximum single dose (per eye) is 2 drops or 1.6 mg sodium cromoglycate. The maximum total daily dose is 16 drops or 12.8 mg sodium cromoglycate. Availability: OPTICROM is supplied in a plastic dropper bottle containing 10 mL of a sterile 2% solution of sodium cromoglycate preserved with benzalkonium chloride. Product Monograph available on request to health professionals. OPTICROM and FISONS are registered trade marks of Fisons plc Fisons Corporation Limited registered user OFisons Corporation Limited 1988
FISOnic!L
CHILDREN'S PANADOL* acetaminophen Analgesic - Antipyretic Indications: As a nonsalicylate analgesic-antipyretic for the relief of pain in a wide variety of arthritic and rheumatic conditions involving musculo-skeletal pain, as well as in other painful disorders such as headache, dysmenorrhea, myalgias, neuralgias. Acetaminophen is also indicated for the symptomatic reduction of fever due to the common cold and other bacterial or viral infections. Contraindications: Hypersensitivity to acetaminophen. Adverse Effects: The incidence of gastrointestinal upset is less than after salicylate administration. Hepatic toxicity has been associated with acetaminophen overdose. Abnormal liver function has been associated with therapeutic doses ranging from 3 to 8 g per day. In patients with compromised liver function, acetaminophen could exacerbate liver insufficiency. Renal papillary necrosis has been reported following prolonged acetaminophen administration of up to 19 g per day. Renal insufficiency may occur as an effect secondary to liver failure. Anemia has been reported in patients with gastrointestinal bleeding who were often analgesic abusers, had chronic gastric ulcers or where
gastrointestinal bleeding was already present. Neutropenia, methemoglobinemia and thrombocytopenia have rarely occurred. Rarely, asthmatic attacks have been precipitated by acetaminophen. Skin rashes and fixed dermatitis with pruritus have been rarely reported. Dosage: Children: 10 to 15 mg/kg every 4 to 6 hours, not to exceed 65 mg/kg/24 hours. Or the following single doses may be repeated every 4 hours, not to exceed 5 times daily. Maximum Maximum Single Daily Dose Dose Age Newborn to under 4 months 4 months to under 12 months 12 months to under 2 years 2 and 3 years 4 and 5 years 6, 7 and 8 years 9 and 10 years 11 and 12 years 13 years and older
(mg) 40 80 120 160 240 320 400 480 640
(mg) 200
400 600 800 1200 1600 2000 2400 3200
Note: Acetaminophen drops are approximately 5 times as concentrated as the liquid form. Supplied: Drops: Each mL contains acetaminophen 80 mg-bottles of 15 and 25 mL. Liquid: Each 5 mL contains acetaminophen 80 mg-bottles of 100 mL. Chewable Tablets 80 mg: -bottles of 24. Full Prescribing Information Is
Flsions CorporatIon LImited
Available On Request
1968
CE)'
Sterling Products Division of Sterling Drug Ltd. Aurora, Ontario L4G 3H6 *Reg. Trade Mark
References 1. Biringer A. Antinauseants in pregnancy: teratogens or not? Can Fam Physician 1984; 30:2123-5.
2. Medalie JH. Relationship between nausea and/or vomiting in early pregnancy and abortion. Lancet 1957; ii:117-9. 3. Atlay RD, Weekes AR. Treatment of gastrointestinal disease in pregnancy. Clin Obstet Gynaecol 1988; 13(2):335-47. 4. Berkowitz R, Coustan S, Mochizuki T. Handbook for prescribing medications during pregnancy. 2nd ed. Boston: Little, Brown and Co., 1986. 5. Pritchard JA, MacDonald PC, Grant NF. Williams obstetrics. 17th ed. Norwalk, Conn.: Appleton-Century-Crofts, 1985. 6. Canada. Health and Welfare Canada. The Federal-Provincial Subcommittee on Nutrition, 1986. Nutrition in pregnancy: national guidelines. Ottawa: Minister of Supply and Services, 1987. 7. Gabbe SG, et al. Obstetrics: normal and problem pregnancies. Churchill, 1986. 8. Treatment of sexually transmitted diseases. Medical Letter 1988; 30(757):5-10. 9. Feldman GB, Felshman A. Complete handbook of pregnancy. New York: G.P.Putnam's Sons, 1984. 10. Cherry SH, Berkowitz RL, Kase NG, eds. Ravinsky and Guttmacher's medical, surgical and gynecologic complications of pregnancy. 3rd ed. Baltimore: Williams and Wilkins, 1985. 11. Hammar M, Larsson L, Tegler L. Calcium treatment of leg cramps in pregnancy: effects on clinical symptoms and total serum and ionized calcium concentrations. Acta Obstet Gynecol Scand 1981;
60(4):345-7. 12. Kitzinger S. Complete book of pregnancy and childbirth. London: Dorling, Kindersly Ltd., 1980. 13. Williamson P, English E. Stress and coping in first pregnancy: couple-family physician interaction. J Fain Pract 1981; 13(5):629-35.
70 Gou9h, Road. Ma,kham. Ontano L3F18G9
Op-21 E-2/88
presence. This reassures the woman who is experiencing them and prepares the patient who has not yet encountered a particular symptom. Although there is no definitive therapy for any of these discomforts, it is important that the physician put them into the context of normal physiologic changes of pregnancy and make specific suggestions to alleviate symptoms. Thus, the woman may feel better physically, her anxiety is decreased, and she is more able to enjoy the myriad physical and psychological changes U that pregnancy brings.
LcPJ
CAN. FAM. PHYSICIAN Vol. 34: SEPTEMBER 1988
