Common problems in pregnancy

Pelvic girdle pain (pelvic instability)

Affects 25% of women, severely debilitating in 7%. Thought to result from relaxin-driven laxity of the pelvic ligaments. Provocation testing (pain on pelvic loading at the SI joints, lower lumbar spine, or pubic symphysis) supports the diagnosis. Usually starts in the later 2nd trimester and tends to recur in subsequent pregnancies. Warn that resolution can take up to 12 weeks postnatally.

Refer to physiotherapy services for exercise advice and, where wanted, a non-rigid lumbopelvic support belt. NICE’s committee found the evidence consistent overall with a benefit from physiotherapy-delivered exercise advice, and separately found a non-rigid lumbopelvic belt reduced pain intensity; economic modelling favoured the belt strongly. Referral is to the service, not necessarily an in-person physiotherapist — telehealth delivery counts.

Not recommended routinely: acupuncture and manual therapy. The acupuncture evidence showed some improvement in pain and satisfaction but also more adverse effects, and NHS resourcing was judged inadequate; the manual therapy evidence was sparse and on disparate interventions.

Self-management: pelvic floor exercises; avoid heavy lifting (including toddlers) and stairs; keep knees together getting in/out of bed or the car; avoid breaststroke swimming; a mobility aid (crutches/walking frame) may help; avoid prolonged legs-apart positions during labour.

Analgesia: paracetamol is first line. NSAIDs are best avoided in the first trimester (an association with miscarriage that is not seen with paracetamol) and are contraindicated after 30 weeks because of premature closure of the fetal ductus arteriosus and persistent pulmonary hypertension. High third- trimester doses also reduce fetal renal perfusion and urine output. Topical NSAIDs give negligible blood levels and are relatively safe. Postpartum, ibuprofen and diclofenac are compatible with breastfeeding.

Heartburn

GORD symptoms are common in pregnancy, and pre-existing symptoms often worsen. Recommend diet and lifestyle modification first. If drug therapy is needed, antacids and H2-receptor antagonists are considered safe in pregnancy. PPIs are TGA category B3 (rabeprazole is B1); observational studies show no increased risk of adverse pregnancy outcomes. For a woman already on a PPI planning pregnancy, consider switching to an H2-antagonist or trialling on-demand PPI use, at least for the first trimester. If a PPI is needed in pregnancy, omeprazole has the most clinical experience behind it.

Leg cramps

Common in pregnancy, especially in the third trimester, and enough to disrupt sleep and daily activity.

A pillow at the end of the bed can help avoid prolonged plantar flexion overnight. Avoid quinine (including tonic water).

The Cochrane review of oral treatments is unhelpful in both directions — it is not clear that magnesium, calcium, calcium-vitamin D, vitamin B, vitamin D or vitamin C provides an effective and safe treatment, and the evidence is low or very low certainty throughout. Magnesium may reduce cramp frequency, but the findings were inconsistent. Calcium did not consistently reduce frequency. Calcium-vitamin D and vitamin D had no effect on frequency, duration or pain intensity. No trial has looked at stretching, massage, relaxation or heat.

So the practical advice is low-cost and low-evidence: calf stretches before bed, staying active, staying hydrated, adequate dietary calcium, and supportive footwear. Magnesium is reasonable to trial if a woman wants to, with realistic expectations.

Haemorrhoids

Common with constipation and second-stage straining. Manage with fibre, fluids and a stool softener, plus topical local anaesthetic or astringent preparations. Don’t use GTN in pregnancy. Refer if thrombosed, prolapsed and irreducible, or bleeding enough to contribute to anaemia.