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Chapter: Obstetrics and Gynecology: Preconception and Antepartum Care

Preconception and Antepartum Care: Common Symptoms

Headaches are common in early pregnancy and may be severe. The etiology of such headaches is not known.





Headaches are common in early pregnancy and may be severe. The etiology of such headaches is not known. Treatment with acetaminophen in usual doses is recom-mended and is generally adequate. A persistent headache unrelieved by acetaminophen should be further evaluated.



The presence of significant edema in the lower extremi-ties (dependent edema) and/or hands is very common in pregnancy and, by itself, is not abnormal. Fluid retention can be associated with hypertension, however, so that blood pressure as well as weight gain and edema must be evaluated in a clinical context before the findings are pre-sumed to be innocuous.


Nausea and Vomiting


The majority of pregnant women experience some degree of upper gastrointestinal symptoms in the first trimester of pregnancy. Classically, these symptoms are worse in the morning (the so-called morning sickness). However patients may experience symptoms at other times or even throughout the day. Most mild cases of nausea and vom-iting can be resolved with lifestyle and dietary changes, including consuming more protein, vitamin B6, or vita-min B6 with doxylamine. Usually, nausea and vomiting improve significantly by the end of the first trimester. Effective and safe treatments for more serious cases include antihistamine H1-receptor blockers and phenothiazines. Themost severe form of pregnancy-associated nausea and vom-iting is hyperemesis gravidum, which occurs in less than 2% of pregnancies. This condition may require hospitaliza-tion, with fluid and electrolyte therapy and medications.



Heartburn (gastric reflux) is common, especially post-prandially, and is often associated with eating large meals or spicy or fatty foods. Patient education about smaller and more frequent meals and blander foods, combined with not eating immediately before retiring, is helpful. Antacids may be helpful, used judiciously in pregnancy.




Constipation is physiologic in pregnancy, associated withincreased transit time, increased water absorption, and often decreased bulk. Dietary modifications, including increased fluid intake and increased bulk with such foods as fruits and vegetables, are usually helpful. Other useful interventions may include use of surface-active bowel softeners such as docusate, supplemental dietary fibers such as psyllium hydrophilic mucilloid, and lubricants.




In early pregnancy, patients often complain of extreme fatigue that is unrelieved by rest. There is no specifictreatment, other than adjustment of the woman’s sched-ule to the extent possible to accommodate this temporary lack of energy. Patients can be reassured that the symp-toms disappear in the second trimester.


Leg Cramps


Leg cramps, usually affecting the calves, are commonduring pregnancy. A variety of treatments, including oral calcium supplement, potassium supplement, or tonic water have been proposed over the years, none of which are uni-versally successful. Massage and rest are often advised.

Back Pain


Lower back pain is common, especially in late pregnancy. The altered center of gravity caused by the growing fetus places unusual stress on the lower spine and asso-ciated muscles and ligaments. Treatment focuses on heat, massage, and limited use of analgesia. A specially fitted maternal girdle may also help, as will not wearing shoes with high heels.


Round Ligament Pain


Sharp groin pain, especially as pregnancy advances, is common, often quite uncomfortable, and disturbing to patients. This pain is often more pronounced on the right side because of the usual dextrorotation of the gravid uterus. The woman should be reassured that the pain represents stretching and spasm of the round ligaments. Modification of activity, especially more gradual move-ment, is often helpful; analgesics are rarely indicated.


Varicose Veins and Hemorrhoids


Varicose veins are not caused by pregnancy, but often first appear during the course of gestation. Besides the disturb-ing appearance to many patients, varicose veins can cause an aching sensation, especially when patients stand for long periods of time. A support hose can help diminish the discomfort, although it has no effect on the appearance of the varicose veins. Popular brands of support hose do not provide the relief that prescription elastic hose can. Hemorrhoids are varicosities of the hemorrhoidal veins.

Treatment consists of sitz baths and local preparations. Varicose veins and hemorrhoids regress postpartum, although neither condition may abate completely. Surgical correction of varicose veins or hemorrhoids should not be undertaken for approximately the first 6 months post-partum to allow for the natural involution to occur.


Vaginal Discharge


The hormonal milieu of pregnancy often causes an increase in normal vaginal secretions. These normal secretions must be distinguished from infections such as vaginitis, which has symptoms of itching and malodor, and bacterial vaginosis, which has been linked to preterm labor. Spontaneous rupture of membranes, which is characterized by leakage of thin, clear fluid, is another possible cause that must be considered.


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