common symptoms during pregnancy

REVIEW

Common symptoms duringpregnancySarah Germain

Catherine Nelson-Piercy

Results of cardiac and respiratory investigations duringnormal pregnancy

Electrocardiogram

(ECG)

C Left axis deviation

C Sinus tachycardia

C Atrial and ventricular ectopics

C Runs of supra-ventricular tachycardia

C Transient ST depression and T wave

AbstractThe profound anatomical and physiological changes that occur in themother

as adaptation to normal pregnancy can result in a number of symptoms and

signs that overlap with those associated with disease outside of pregnancy.

These include palpitations, peripheral oedema, dyspnoea, and pruritus.

Underlying cardiovascular and respiratory changes include increased cardiac

output, heart rate, tidal volume and minute ventilation, and fall in blood

pressure. Adaptations in other organ systems include increased glomerular

filtration rate, reduced gastrointestinal motility, and hyperpigmentation.

Most of the symptoms and signs are benign, but clinicians need to be

aware of those which warrant further investigation and may be associated

with disease. These would include dyspnoea associated with more worrying

features such as chest pain or haemoptysis, or hyperpigmentation which is

generalized rather than localized.

In women with pre-existing disease, awareness of the normal adaptation

to pregnancy is crucial in tailoringmanagement, as symptomsmayworsen or

improve depending on the system involved. The stress of pregnancy may

also result in previously sub-clinical disease presenting for the first time.

Keywords adaptation; dypsnoea; hyperpigmentation; normal preg-

nancy; palpitations; physiology; pruritus

Introduction

A pregnant woman may notice the development of a number of

new symptoms during her pregnancy. Many of these are widely

accepted, even amongst the general public, as part of normal

pregnancy, but others may be of more concern. The anatomical

and physiological changes in the mother associated with normal

pregnancy are profound, and it is therefore not surprising that as

the various systems adapt, it can result in changes which overlap

with those seen in disease.

It is important to be aware of these changes so women can

generally be reassured of their benign nature, but also to know

when symptoms and signs may indicate underlying disease and

should be investigated further. The new ‘Back to Basics’ chapter

which has been introduced in the most recent ‘Saving Mothers’

Lives’ report provides useful guidance in this area.

Sarah Germain MA MB BS DPhil MRCP is a Specialist Registrar in Obstetric

Medicine at Queen Charlotte’s Hospital and St. Thomas’ Hospital,

London, UK. Conflicts of interest: none declared.

Catherine Nelson-Piercy MA FRCP FRCOG is a Consultant Obstetric

Physician at Guy’s & St Thomas’ Foundation Trust, Imperial College

Healthcare Trust and Professor of Obstetric Medicine at King’s College

London, UK. Conflicts of interest: none declared.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 21:11 323

For women with pre-existing diseases, these physiological

changes will affect how well they can tolerate pregnancy. This

includes women who may have sub-clinical disease that only

presents itself during pregnancy, when the physiological adapta-

tions provide an additional stress.

Symptoms and signs

Cardiovascular

During normal pregnancy women may experience breathless-

ness, palpitations, easy fatiguability, decreased exercise toler-

ance, presyncope/syncope, and ankle swelling.

On examination there is a sinus tachycardia and often

a collapsing pulse. The apex beat is forceful and displaced (lateral

and upwards). Heart sounds are generally louder. There may be

wide splitting of the first heart sound and splitting of the second

heart sound in the 3rd trimester. A third heart sound is often

present. An ejection systolic murmur (up to grade 2 out of 4) is

frequently heard throughout the praecordium. A venous hum

(heard in upper chest near clavicles due to cardiac output through

the internal jugular veins) and a mammary souffl�e (a ‘blowing

sound’ heard over the breasts during systole or continuous) are

also common, the latter especially during late pregnancy and

lactation. The jugular venous pulse may be more conspicuous but

jugular venous pressurewave remains unchanged. Blood pressure

falls in the 1st and 2nd trimesters, and then increases again in the

3rd trimester, usually to non-pregnant values by term. Peripheral

oedema is virtually universal in late pregnancy.

Alternative diagnoses should always be considered before dis-

missing a symptom as physiological. The need for further investi-

gation should be selective but with a high index of suspicion,

especially if the symptomhas sudden onset, is associatedwith chest

pain, cough, wheeze or other unexplained symptoms, in an immi-

grant woman (especially from areas with a high incidence of

rheumatic feverwho hasn’t seen a doctor previously), and if there is

known underlying disease.Murmurs should be investigated further

if late- or pan-systolic, very loud systolic, or diastolic. The presence

of a fourth heart sound is also usually pathological. Changes on

ECG, echocardiogram and chest X-ray which can be normal during

pregnancy are detailed in Table 1.

inversion in inferior/lateral leads

C Q wave and inverted T wave in III

Echocardiogram C Valves mildly regurgitant

C Valvular annular dilatation

C Chamber enlargement

C Small pericardial effusion

Chest X-ray C Increased cardiothoracic ratio

C Increased vascular markings

Table 1

� 2011 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ogrm.2011.09.001

Cardiovascular changes in normal pregnancy

Physiological variable Direction of change Degree of change

Cardiac output Increases 20% during 1st trimester

40% by 3rd trimester

Heart rate Increases 10e20 beats per minute

Stroke volume Increases 25e30%

Plasma volume Increases 30e50%

Red blood cell mass Increases 15e20%

Blood pressure Decreases 1st and 2nd trimesters

Increases 3rd trimester

10 mmHg by 2nd trimester

Returns to pre-pregnancy levels by term

Systemic vascular resistance (SVR) Decreased 25e30%

Pulmonary vascular resistance (PVR) Decreased 25e30%

Central venous pressure (CVP) Unchanged

Pulmonary capillary wedge pressure (PCWP) Unchanged

Serum colloid osmotic pressure Decreased 10e15%

Water and sodium retention Increased

Table 2

Respiratory changes in normal pregnancy

Physiological variable Direction of

change

Degree of change

Respiratory rate Unchanged

Tidal volume Increased Up to 40%

Minute ventilation Increased Up to 50%

Vital capacity Decreased

Residual volume Decreased

Functional residual

capacity

Decreased 20%

Oxygen consumption Increased 20%

FEV1 and PEFR Unchanged

Respiratory drive and

CO2 sensitivity

Increased

PaO2 Increased

PaCO2 Decreased

Arterial pH Increased Compensated respiratory

alkalosis

Table 3

REVIEW

The main cardiovascular changes induced by pregnancy that

lead to these symptoms and signs are summarized in Table 2.

They include increased cardiac output, sodium and water

retention leading to plasma volume expansion, and decreased

systemic vascular resistance and systemic blood pressure. Earlier

in pregnancy the rise in cardiac output is mainly due to increased

stroke volume, with increased heart rate playing more of a role

later in gestation. Plasma volume is increased, and to a lesser

degree red blood cell mass, which results in a reduced haema-

tocrit and a physiological/dilutional anaemia. A number of

factors including nitric oxide and prostaglandins have been

implicated in the peripheral vasodilatation that is seen, which

leads to reduced systemic vascular resistance and a fall in

systemic blood pressure in the 1st and 2nd trimesters. Blood

pressure then rises again to non-pregnancy values by term. The

reduction in the colloid oncotic pressure/pulmonary capillary

wedge pressure gradient makes pregnant women more suscep-

tible to pulmonary oedema. Pregnant women are more likely to

complain of palpitations than outside of pregnancy. Although

asymptomatic arrhythmias are not uncommon in a similar aged

non-pregnant population, the combination of haemodynamic,

hormonal and autonomic changes in pregnancy may make

a woman aware of a previously asymptomatic arrhythmia, or

render a pre-existing arrhythmia substrate more capable of

sustaining an arrhythmia.

Most of these cardiovascular adaptations begin early in the 1st

trimester, peak at the end of the 2nd trimester and are maintained

until term, although there are exceptions as described. Towards

term they are profoundly affected by maternal position e with

marked reduction in venous return, and consequently stroke

volume and cardiac output, in the supine compared to lateral

position. This has important implications for uteroplacental blood

flow and placental perfusion, which can lead to fetal compromise.

Further changes occur at the time of labour, in particular

additional increase in cardiac output and rise in blood pressure.

Following delivery they gradually return to pre-pregnancy levels,

but this may take many weeks or even months.


Respiratory

Acommon respiratory symptom inup to 70%of pregnantwomen is

dyspnoea or ‘air hunger’. This usually develops progressively from

the first trimester, often occurs at rest or when talking, and may

even improve with exercise. Respiratory rate actually remains

unchanged, but there is a large increase in tidal volume, so that

minute ventilation is increased byup to 50%by term. This is greater

than the increase in oxygen consumption giving a relative hyper-

ventilation, which women become aware of. It may begin before

there is a significant increase in uterine size, and appears to be

progesterone driven, which stimulates respiratory drive and

increases sensitivity to CO2. This hyperventilation leads to a rise in

PaO2 and fall in PaCO2, with the latter facilitating gas exchangewith

the fetus. Anatomical changes include diaphragmatic elevation



Renal changes in normal pregnancy

Haemodynamics

Renal blood flow Increased

Glomerular filtration rate (GFR) Increased

Other

Serum creatinine Decreased

Plasma osmolality Decreased

Plasma sodium Decreased

Urinary protein excretion Increased

REVIEW

(up to 4 cm) and increased thoracic diameter, which again can be

noted early in pregnancy, are at least partly hormonally mediated.

Other changes are summarized in Table 3. Of note, there is no

change in FEV1 (forced expiratory volume in 1 s) or FVC (forced

vital capacity), suggesting large airway function remains stable.

Other respiratory symptoms which may be experienced in

normal pregnancy overlap with those mentioned under the

cardiac section. As discussed earlier, the possibility of underlying

disease should always be considered, before a label of ‘physio-

logical dyspnoea’ is applied. Worrying features which should

prompt further investigation are documented in Box 1.
Tubular function Decreased e can lead to
glucosuria and aminoaciduria
Renal
Table 4
Common renal symptoms in pregnancy are urinary frequency,
nocturia, urgency and stress incontinence. Up to 95% of pregnant

women complain of frequency, the cause of which appears to be

multifactorial including changes in bladder function, and not

solely the effect of the gravid uterus which is more important later

in pregnancy. Nocturia is related to the increased excretion of

sodium and water during the night, compared to non-pregnancy,

which is partly due to mobilization of dependent oedema. The

cause of urgency and incontinence is alsomultifactorial, including

uterine pressure on the bladder and hormonal effects on the

urethral suspensory ligaments.

Peripheral oedema is also common, occurring in 80% of

pregnant women by the end of pregnancy. This is due to

increased sodium and water retention and decreased ability to

excrete a sodium and water load.

Haemodynamic and other renal changes are summarized in

Table 4, and should be considered when interpreting renal

biochemical blood results in pregnancy.

Gastrointestinal and liver

Hepatic changes in normal pregnancy

Direction of

change

Degree of

change

Notes

Serum albumin Decreased 20e40% Due to

haemodilution

Total protein Decreased

Constipation and heartburn are common symptoms during preg-

nancy, occurring in around 40%and up to 80%of pregnantwomen

respectively. These are usually related to reduced gastrointestinal

motility caused by increased oestrogen and progesterone levels.

There is relaxation of the lower oesophageal sphincter, and

increased transit time throughout the gastrointestinal tract,

including stomach, gallbladder, and small and large bowel. Bile is

Associated ‘red flag’ features requiring furtherinvestigation

C Sudden onset

C Onset near term

C Increased respiratory rate

C Chest pain

C Sputum production

C Haemoptysis

C Tachycardia (above that of normal pregnancy change)

C Cough

C Wheeze

C Fever

C Crackles on examination

C Pre-existing lung or cardiac disease

Box 1


also more lithogeneic predisposing to gallstone formation.

Conversely, pregnancy has little effect on gastrointestinal secretion

or absorption.

Women may notice the development of palmar erythema or

spider naevi during pregnancy. These are usually the effect of the

high oestrogen levels, and will resolve after delivery. Further

investigation is only required if there are other features of chronic

liver disease.

Changes in liver biochemical results are detailed in Table 5,

and these should be taken into account when interpreting hepatic

blood results.

Endocrine

Women may notice a small smooth thyroid goitre during preg-

nancy. This is rare in areas of adequate iodine intake but occur in

ALP Increased 2e4

times

Mostly placental

production

ALT, AST

and GGT

Decreased

Bilirubin Decreased

Bile acids Unchanged

Amylase Unchanged/

slightly

increased

Latter stages

of pregnancy

Prothrombin time Unchanged

Total cholesterol

and lipids

Increased

Fibrinogen Decreased

Caeruloplasmin

and transferrin

Increased

Specific binding

proteins

(Generally)

increased

Table 5



REVIEW

up to 70% of pregnant women in iodine-deficient areas. Unless

a woman is known to come from a thyroid deficient area, then

further investigation is usually warranted, and especially if the

gland appears nodular. [This is described further in the article on

‘Thyroid and other endocrine disorders in pregnancy’ in edition

20:9 2010.]

Skin

Practice points

C Maternal anatomical and physiological adaptation to normal

pregnancy is profound and includes changes in every organ

system from increased cardiac output to reduced gastrointes-

tinal motility.

C This may result in new symptoms and/or signs usually

associated with disease outside of pregnancy.

C Most of these symptoms and signs are benign and women can

be reassured, but clinicians looking after pregnant women

should be aware of which can indicate significant disease and

require further investigation.

C This is particularly important for cardiovascular and respiratory

symptoms such as dyspnoea and palpitations.

C Normal ranges for biochemical and haematological variables

may also be altered in pregnancy, and this should be taken

into account when interpreting blood results.

Skin changes that are frequently noticed during pregnancy

including hyperpigmentation, striae, and increased hair growth.

Pruritus is also a common symptom.

Hyperpigmentation usually occurs in discrete, localized areas,

e.g. melasma on the face, and darkening of the linea alba on the

abdomen and skin around the areola. It may be due to oestrogen

and progesterone stimulation of melanocytes. Generalized

hyperpigmentation is more unusual, and should be investigated

further for causes such as Addison’s disease.

Striae are common due to a combination of physical and

hormonal effects on connective tissue. Pathological causes such

as Cushing’s syndrome are rare, but should be considered if there

are other relevant symptoms or signs [see article on ‘Thyroid and

other endocrine disorders in pregnancy’].

Women usually notice increased scalp hair growth during

pregnancy, due to a slowing of progression from the anagen

(growing) to the telogen (resting) stage of the hair cycle. The

percentage of telogen hairs then increases again post-partum when

hair loss is often noted.

Pruritus can occur in about 20%of pregnantwomenwithout an

underlying pathological cause. If there is no associated rash then

obstetric cholestasis and other liver-related causes should be

considered [see article on ‘GI and liver disorders’]. The differential

diagnosis of a pruritic skin rash in pregnancy is discussed further

in the article on ‘Connective tissue disorders and dermatological

disorders in pregnancy’ (19:10 2009).

Conclusion

Normal pregnancy requires adaptation of all maternal organs,

and this may result in symptoms and signs that overlap with

those usually associated with disease outside of pregnancy.

Knowledge of these changes allows the clinician to reassure the

woman in most cases, and to investigate further where indicated.

In those with known disease embarking on pregnancy, it allows


the effect of these physiological changes to be taken into account,

and management tailored accordingly. A

FURTHER READING

Adamson DL, Nelson-Piercy C. Managing palpitations and arrhythmias

during pregnancy. Heart 2007; 93: 1630e6.

Expert consensus document on management of cardiovascular diseases

during pregnancy. The Task Force on the Management of Cardiovascular

Disease During Pregnancy of the European Society of Cardiology.

Eur Heart J 2003; 24: 761e81.

Girling JC, Dow E, Smith JH. Liver function tests in pre-eclampsia: importance

of comparisonwith a reference range derived for normal pregnancy.BJOG

1997; 104: 246e50.

Nelson-Piercy C. Handbook of obstetric medicine. 4th edn. London:

Informa Healthcare, 2010.

Oates M, Harper A, Shakespeare J, Nelson-Piercy C. Back to basics. In:

Lewis G, ed. Centre for Maternal and Child Enquiries (CMACE). Saving

Mothers’ Lives: reviewing maternal deaths to make motherhood safer:

2006e2008. The Eighth Report of the Confidential Enquiries into

Maternal Deaths in the UK. BJOG 2011; 118(suppl. 1): 16e21.



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