Common concerns during pregnancy

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Common concerns during pregnancy

This section is about common concerns that may be experienced in pregnancy, such as nausea and vomiting, indigestion and heartburn, tiredness, food cravings and constipation.

Nausea and Vomiting ('Morning Sickness')

Nausea and vomiting occurs most commonly in the first trimester of pregnancy. Symptoms should ease as the pregnancy progresses and typically will clear up by weeks 16-20. Around half of women experience vomiting, and nausea affects around 85% of pregnant women. The common term of 'morning sickness' is often misleading as it is normal for nausea and vomiting to occur at any time of the day. Though the exact cause is unknown, it’s suggested that the sickness is due to a hormone imbalance. Though it can be highly unpleasant, the good news is that nausea and vomiting isn’t usually harmful to the mother or the baby. However, about 1% of women can develop severe nausea and vomiting, this is known as Hyperemesis Gravidarum (HG), which may be dangerous for mum and baby and can require medical attention.

Hyperemesis Gravidarum (HG)

HG describes nausea which can lead to vomiting up to 50 times a day, leading to dehydration, ketosis (a dangerous condition in pregnancy), weight loss, and low blood pressure. In these severe cases, mums may not be getting the nutrients and fluids they need for themselves and their babies. It’s suggested that HG is linked to genetics and runs in families, so it could be helpful to know if there is a family history of HG.

The National Institute for Health and Care Excellence (NICE) advises pregnant women seek medical attention if they have:

  • Very dark urine, or have not passed urine for more than 8 hours
  • Abdominal pain or fever
  • Severe weakness
  • Vomiting blood
  • Repeated unstoppable vomiting
  • Inability to keep any fluids or food down for 24 hours

Staying healthy when sickness strikes

It can be difficult to remain healthy when feeling nauseous, especially as smells can increase this feeling. When this is the case, mums-to-be could try to:

  • Get plenty of rest
  • Avoid wearing tight clothes
  • Drink small amounts of fluids often throughout the day, rather than in large amounts in one go
  • Avoid drinking cold, tart, or sweet beverages
  • Avoid skipping meals. Instead try eating small, frequent meals high in carbohydrate and low in fat.
  • Avoid any foods or smells that trigger symptoms. Cold meals may be more easily tolerated if nausea is smell-related.

Acupressure has also been found to be useful in some cases, and support from friends and family can help.

Meal and Snack Ideas
Plain savoury snacks can be helpful, for example, toast, crackers and crispbread. Try adding simple savoury toppings to boost nutrient intake – for example yeast extract provides B vitamins, cheddar cheese gives some extra calcium, and peanut butter provides vitamin E and zinc, as well as protein.

Lunch and Dinner
Bean or vegetable soups can be a great choice at this stage as they are comforting, nutritious and can maintain hydration.

Drinks
As well as eating regularly, it is essential to remain hydrated, especially after vomiting, so try to drink fluids regularly throughout the day. As well as providing water and some vitamins and minerals, drinks such as smoothies can provide calories, which can be useful if nausea causes a loss of appetite. Some women find that other herbal teas such as peppermint or chamomile can help deal with nausea. As there is limited information on the safety of herbal teas in pregnancy, it has been recommended to limit the amount you drink to four cups a day. Try to be aware of drinks containing caffeine. The caffeine allowance during pregnancy is currently 200mg a day but as caffeine is dehydrating, it is important to maintain water consumption throughout the day.

Ginger
Ginger is safe and effective in reducing nausea and vomiting in pregnancy. It helps by emptying the stomach, keeping food down. Ginger products such as fresh ginger or ginger teas can be useful to reduce symptoms.

Vitamin B6
Vitamin B6 (pyridoxine) and its compounds are often used in morning sickness drugs. Though it may not reduce vomiting, it can help reduce nausea with minimal side effects. Around 10 – 25mg of pyridoxine is recommended every eight hours with a maximum of 200mg a day.

Keeping Active
Although it may seem an unpleasant idea when feeling ill, some mums-to-be find that keeping active actually helps them deal with nausea and vomiting symptoms at this stage of pregnancy. Gentle exercises, such as yoga and swimming, can be useful as the stretching can be helpful during labour too. It is important to maintain a healthy lifestyle, but NICE recommends avoiding vigorous exercise and contact sports, as this can put pressure on joints and increase the risk of falling over or sustaining an injury.

Indigestion and heartburn

How common is indigestion?

Indigestion is very common during pregnancy and has been reported to affect up to 8 in 10 women in late pregnancy.

Indigestion can occur at any stage of pregnancy, but is most common:

  • during later pregnancy (27 weeks onwards)
  • in women who had indigestion before they became pregnant
  • in women who have had a previous pregnancy

What are the symptoms of indigestion?

Symptoms normally occur after eating and can include:

  • Burping
  • Feeling uncomfortably full (bloated)
  • Regurgitation (food coming back up from the stomach)
  • Heartburn (burning sensation or ache in your chest)
  • Nausea (feeling sick)
  • Vomiting

The good news though is that these symptoms rarely cause complications and in most women symptoms will disappear shortly after delivery. However, symptoms may be frequent, severe and/or distressing.

What causes indigestion in pregnancy?

Indigestion in pregnancy is thought to be due to both mechanical and hormonal reasons. You are more likely to have indigestion when you are pregnant because of hormone changes. Rising pregnancy hormone levels (oestrogen and progesterone) are thought to be responsible for relaxing the lower oesophageal sphincter – a ring of muscles that act as a gateway between your oesophagus (food pipe from your mouth) and your stomach. This allows stomach acid to leak back up (acid reflux) and cause a burning or uncomfortable feeling in the chest, often known as heartburn.

In later pregnancy, it has also been suggested that indigestion can be due to the pressure on the stomach from the growing womb, and this can also increase the likelihood of acid reflux. The increased pressure may also delay stomach emptying and affect how fast your food can pass through the gut.

Management of heartburn in pregnancy

A range of strategies have been used to relieve symptoms, including advice on diet and medication. However, there is very little good scientific research on dietary suggestions such as restricting fatty foods or reducing meal size.

Expert opinion is that diet and lifestyle changes may help, and should remain the first line treatment for heartburn in pregnancy. Lifestyle and dietary changes are safe and inexpensive, and they also allow the person to be involved in their choice of management. However, if heartburn is severe and causes considerable discomfort, medication may be advised after consultation with a healthcare professional.

Tips to avoid indigestion

Unfortunately there is no way to guarantee you will avoid indigestion, but here are some diet and lifestyle tips suggested by health guidelines, which may help:

  • Try having frequent smaller meals, rather than big meals
  • Avoid eating too much - you do not need to ‘eat for two’ during pregnancy
  • Try sitting up straight when you eat to help release some of the pressure on your stomach
  • Keep a note of foods, drinks or activities that seem to trigger indigestion for you and if possible, try to avoid them at this stage. These may include:
    • spicy foods
    • fatty foods
    • caffeine
    • acidic citrus products/fruit juices (e.g. orange or tomato juice)
    • fizzy drinks
  • Try drinking a glass of milk when heartburn strikes
  • Avoid eating or drinking anything other than water for three hours before going to bed
  • Sleep in a propped up position by using pillows, or raising the head end of your bed to help keep the stomach acids down
  • Avoid smoking - this can harm your baby, but can also cause indigestion
  • Avoid drinking alcohol, as this can contribute to indigestion. In 2016, the Department of Health updated the guidelines for alcohol consumption, and has clarified that no level of alcohol is safe to drink during pregnancy. For more information on alcohol during pregnancy, follow this link
  • Check with your GP about any medications that may be causing or worsening symptoms, these can include non-steroidal anti-inflammatory drugs (NSAIDs), like ibuprofen and aspirin, medications widely used to treat a range of conditions

If changes to your diet and lifestyle don't work and your indigestion is really bothering you, speak to your GP or midwife.

There are certain indigestion medications which are safe to use during pregnancy, and your GP or midwife can tell you which ones you can use. 

Tiredness During Pregnancy

Tiredness and difficulty sleeping is common throughout pregnancy.

In the first 12 weeks, you may feel particularly tired and this is believed to be because of the hormonal changes you are going through at this time.

From around 16 weeks, and as you continue to get bigger, you may find it harder to get comfortable at night which can lead to sleeplessness and cause tiredness the following day. Also, after 16 weeks, when you lie flat on your back the growing baby presses on the main blood vessels. The effect is that less blood is pumped around your body and this may lead to low blood pressure (hypotension), so you may want to sleep on your side instead. Later on in pregnancy you may feel tired because of the extra weight you are carrying.

Tiredness in pregnancy could also be linked to a lack of iron in your body (known as iron-deficiency anaemia). Iron is needed during pregnancy for the blood supply to your growing baby, so it is important to eat plenty of foods high in iron to prevent deficiency, which can lead to your baby having a low birth weight.

Some groups of women may have a higher risk of iron deficiency if their intake of iron was low before becoming pregnant, such as young women and those on a vegetarian or vegan diet. You will be offered a range of blood tests during pregnancy, including one for anaemia, and you will be advised if you need to take supplements or boost the amount of iron needed from your diet.

Iron is found in red meat (such as lean beef), pulses (such as lentils and beans, e.g. kidney beans), wholemeal bread, green leafy vegetables (such as spinach and watercress), dried fruit (e.g. apricots) and fortified foods like breakfast cereals. There are certain things in the diet that can affect how much iron is absorbed from your food. Vitamin C helps your body absorb iron from plant sources, so having a small glass of fruit juice (150ml) with a meal can help you get the most from your food. On the other hand, milk, tea and coffee can stop your body absorbing iron, so try not to drink them with meals (caffeine-containing drinks should also be limited during pregnancy).

It is important to eat a variety of foods to ensure that you obtain all the nutrients you and your baby need. Unfortunately, no single food or nutrient will guarantee you a good night’s sleep, but making sure you have enough of certain vitamins and minerals is important (see table below).

Nutrient Role Food Sources
Folate Contributes to normal red blood cell formation
  • Beans and other pulses (e.g. black eye beans or lentils)
  • Vegetables (e.g. asparagus or spinach)
  • Berries (e.g. strawberries)
 Riboflavin (vitamin B2) Contributes to the reduction of tiredness and fatigue
  • Dairy (e.g. milk or plain yogurt)
  • Nuts and seeds (e.g. almonds or pumpkin seeds)
  • Oily fish (e.g. mackerel or sardines)*
  • Eggs

Niacin (vitamin B3)

Contributes to the reduction of tiredness and fatigue
  • Fish (e.g. haddock, salmon or tuna)*
  • Lean meat and poultry (e.g. chicken, turkey or lean cuts of beef)
Vitamin B6 Contributes to normal red blood cell formation
  • Nuts, pulses and seeds (e.g. walnuts, peanuts or sesame seeds)
  • Oily fish (e.g. mackerel or tuna)*
  • Certain fruit (e.g. avocados or bananas)
Vitamin B12 Contributes to normal red blood cell formation
  • Meat and other animal-based foods (e.g. milk, eggs, lean meat or fish)*
Vitamin C Contributes to the reduction of tiredness and fatigue
  • Fruits (e.g. blackberries, oranges or strawberries)
  • Vegetables e.g. broccoli, peppers or peas
Magnesium Contributes to the reduction of tiredness and fatigue
  • Dark leafy greens (e.g. baby spinach)
  • Nuts and seeds (e.g. almonds, cashews or sunflower seeds)

*Fish is an excellent source of various vitamins and minerals, and oily fish contains essential omega-3 fats, but some types of fish should be avoided or limited (see above).

Food cravings

During pregnancy, some women have cravings for particular foods, and food aversions. Despite these being quite common, there is not much research about their causes and so we do not fully understand why this happens.

Food cravings are strong urges for particular foods, which are more specific than normal feelings of hunger and can be very difficult to resist. The type of food which is craved is quite varied and may differ over the course of the pregnancy. A study in the USA, looking at pregnancy websites, found commonly reported cravings were for chocolate, sweets, pizza, crisps and fruit. Other foods reported have included ice cream, pickles and curry.

Food cravings can occur during all stages of pregnancy, but tend to disappear after the birth of the baby. It is not fully known why food cravings occur. One popular explanation is the changes in the body’s hormone levels during pregnancy, although the evidence to support this is lacking. Women often report an increase in taste and smell sensitivity, and there may be a link between changing sensory perceptions and food cravings, but the nature of this is unknown. Food cravings are not likely to be caused by a need for increased calories as they tend to occur in the early part of pregnancy, long before calorie requirements increase in the 3rd trimester.

It is important to distinguish food cravings from a condition called 'pica', which is the eating of non-food items (for example soil, clay, soap, toothpaste and ice), and is also reported to be more common in pregnancy. If you are craving eating something which isn’t a food, it is important to speak to your midwife or doctor, as consuming it may be harmful to you and/or your baby.

We know that it is important for both mum and baby to avoid gaining too much weight during pregnancy (follow this link for more information). Cravings for high sugar or high fat foods in pregnancy may mean your daily calorie intake goes beyond what your body needs. Cravings for foods such as sweets, desserts and chocolate have been shown to increase calorie intake in pregnant women.

Formal guidelines for coping with cravings in pregnancy are not available, but eating a small amount of the food you crave and/or trying to substitute it for a low calorie variety or healthier alternative may be an option. For example, if you are craving sweet food, try eating a sweet tasting piece of fruit such as a piece of pineapple or a small handful of berries. A couple of squares of dark chocolate may also be able to satisfy a chocolate craving, saving you from eating a whole milk chocolate bar. Below are a few ideas to make common food cravings a bit healthier:

Craved food You could try…
Sweets (chocolate and other confectionery) A sweet tasting piece of fruit, dried fruit or fruit canned in its natural juice
Savoury high-calorie food (e.g. chips, pizza, takeaways) Oven baked low-fat chips, a small slice of pizza with vegetable topping and lots of salad, or homemade curries, stir fries and noodle dishes
Meat   Lean cuts of meat with the fat trimmed off
Dairy (savoury e.g. cheese)   Reduced fat cheese
Dairy (sweet e.g. milkshake) Low-fat fruit yogurt, or make your own milkshake with fruit (e.g. bananas or berries)
Carbohydrate foods (e.g. crisps, cereals) Wholegrain baked crisps, no added sugar breakfast cereal
Cold food (e.g. ice cream) Fruit sorbet or frozen yogurt

Constipation

Constipation is a common symptom experienced in pregnancy, and it is associated with poorer quality of life.

What causes constipation during pregnancy?

Production of the hormone progesterone is increased during pregnancy which is important for the healthy development of the baby. Progesterone causes relaxation of some of the bowel muscles which makes it harder for food and bodily waste to move through the gut, thus slowing down the intestinal movements, sometimes causing constipation.

Other causes of constipation can also include reduced physical activity and changes in dietary habits.

Taking iron supplements during pregnancy can also cause constipation, so it is a good idea to make sure that you are eating plenty of iron-rich foods to avoid the need to take supplements.

What are the signs of constipation?

  • A reduction of the frequency at which you would normally pass stools
  • Hard stools which are difficult to pass
  • Lower abdominal pain
  • The feeling that not all faeces have been excreted
  • Feeling bloated or sick

How to treat and manage constipation

Initial treatment of constipation in pregnancy should be non-pharmacological, that is without the use of medication, and can involve:

  • Increasing dietary fibre
  • Physical activity
  • Increasing fluid intake

These recommendations are largely based on expert opinion. Managing constipation in this way generally has few side effects, although increasing fibre intake quickly can cause bloating and flatulence. If you typically eat a low fibre diet, it is advisable to increase intake of fibre gradually to minimise these effects.

Fibre

Fibre is vital in helping to prevent constipation, as it helps food pass through the digestive system more easily. On average, most people in the UK have lower fibre intakes than the recommended 30 g/day, so fibre intake should be increased. Naturally occurring fibre comes from plants, and foods containing fibre include fruit, vegetables, beans and other pulses, and wholegrain cereals.

Foods which are good sources of fibre (contain at least 3g of fibre per 100g of the food) include:

  • Peas, sweetcorn, green beans, broccoli and onions
  • High-fibre breakfast cereals, such as wholegrain cereals and porridge
  • Wholegrain starchy carbohydrates, such as wholemeal bread and wholemeal pasta
  • Potatoes with skins on
  • Beans and pulses like baked beans and humous
  • Nuts and seeds, for example, hazelnuts, pistachio nuts, cashew nuts and peanut butter

Sorbitol

Sorbitol is a compound found within fruit which can act as a natural laxative. Fruits (and their juices) that have a high sorbitol content include:

  • Apples
  • Apricots
  • Grapes (and raisins)
  • Peaches
  • Pears
  • Plums (and prunes)

The concentration of sorbitol is higher in dried fruit.

In general, a balanced diet containing wholegrains, pules, fruit and vegetables is advised. This is not only part of the treatment for constipation, but recommended for general health. Eating five portions of a variety of fruits and vegetables per day is recommended by the government to reduce the risk of some cancers, heart disease, and many other chronic conditions, including constipation.

A small glass (150ml) of fruit juice counts as one of your recommended five daily portions of fruit and vegetables. However, juice can only ever count as one portion a day, no matter how much you drink. This is because it doesn't contain the fibre found in whole fruits and vegetables. Fruit juice also contains free sugars that can damage teeth, so it's best to drink it with a meal because this can help protect teeth.

Fluids

In order to help prevent constipation, your fluid intake is important, particularly with a high-fibre diet. The recommended intake for fluids is about 8-10 glasses a day. Water is a great choice but tea, coffee, unsweetened fruit juice and smoothies can all count towards your fluid intake. Alcohol does not count towards your fluid intake. Remember that pregnant women should not have more than 200mg of caffeine a day. For more information on hydration in pregnancy see here.

Keeping active

Simply getting up and moving about can help constipation. If you weren't active before you got pregnant, don’t suddenly take up strenuous exercise. If you start an aerobic exercise programme (such as running, swimming, cycling, walking or aerobics classes), tell the instructor that you're pregnant and begin with no more than 15 minutes of continuous exercise, three times a week. Increase this gradually to at least four 30-minute sessions a week. For more information on physical activity in pregnancy click here.
Doing some gentle exercise may not only help alleviate your constipation but also improve your fitness too!

If there is a poor response to these changes, do seek further advice from your GP, pharmacist or health professional.

Information reviewed January 2016

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