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National Collaborating Centre for Women's and Children's Health (UK). Antenatal Care: Routine Care for the Healthy Pregnant Woman. London: RCOG Press; 2008 Mar. (NICE Clinical Guidelines, No. 62.)

  • January 2019: Recommendation on screening for German measles (rubella) has been withdrawn by NICE as this is no longer offered by the NHS. December 2018: Recommendations - have been stood down and replaced with a link to up-to-date advice from the UK Chief Medical Officer. January 2017: A footnote was added to recommendation linking to the NICE diagnostics guidance on high-throughput non-invasive prenatal testing for fetal RHD genotype (DG25). March 2016: Recommendations - have been deleted as the guideline they were taken from has since been updated. For guidance on assessing risk of gestational diabetes, see the section on risk assessment in the NICE guideline on diabetes in pregnancy. December 2014: Recommendations to were replaced by recommendations in the NICE guideline on antenatal and postnatal mental health. November 2014: Recommendation was updated to take into account NICE's guideline on vitamin D: increasing supplement use among at-risk groups. June 2010: The recommendations about smoking in pregnancy in section 1.3.10 of this guideline have been further developed in how to stop smoking in pregnancy and following childbirth NICE guideline PH26. We have removed the following recommendation from the antenatal care guideline, as well as the quick reference guide and information for the public: Women who are unable to quit smoking during pregnancy should be encouraged to reduce smoking.

January 2019: Recommendation on screening for German measles (rubella) has been withdrawn by NICE as this is no longer offered by the NHS. December 2018: Recommendations - have been stood down and replaced with a link to up-to-date advice from the UK Chief Medical Officer. January 2017: A footnote was added to recommendation linking to the NICE diagnostics guidance on high-throughput non-invasive prenatal testing for fetal RHD genotype (DG25). March 2016: Recommendations - have been deleted as the guideline they were taken from has since been updated. For guidance on assessing risk of gestational diabetes, see the section on risk assessment in the NICE guideline on diabetes in pregnancy. December 2014: Recommendations to were replaced by recommendations in the NICE guideline on antenatal and postnatal mental health. November 2014: Recommendation was updated to take into account NICE's guideline on vitamin D: increasing supplement use among at-risk groups. June 2010: The recommendations about smoking in pregnancy in section 1.3.10 of this guideline have been further developed in how to stop smoking in pregnancy and following childbirth NICE guideline PH26. We have removed the following recommendation from the antenatal care guideline, as well as the quick reference guide and information for the public: Women who are unable to quit smoking during pregnancy should be encouraged to reduce smoking.

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Antenatal Care: Routine Care for the Healthy Pregnant Woman.

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6Management of common symptoms of pregnancy

6.1. Nausea and vomiting in early pregnancy

The causes of nausea and vomiting in pregnancy are not known and, although the rise in human chorionic gonadotrophin (hCG) during pregnancy has been implicated, data about its association are conflicting.164 Nausea and vomiting occurs more commonly in multiple pregnancies and molar pregnancies.165 Nausea is the most common gastrointestinal symptom of pregnancy, occurring in 80–85% of all pregnancies during the first trimester, with vomiting an associated complaint in approximately 52% of women.166,167 [EL = 3] Hyperemesis gravidarum refers to pregnant women in whom fluid and electrolyte disturbances or nutritional deficiency from intractable vomiting develops early in pregnancy. This condition is much less common with an average incidence of 3.5/1000 deliveries 168 and usually requires hospital admission.

The severity of nausea and vomiting varies greatly among pregnant women. The majority of women with nausea and vomiting report symptoms within 8 weeks of their last menstrual period (94%), with over one-third of women (34%) reporting symptoms within 4 weeks of their last menstrual period.166,167 [EL = 3] Most women (87–91%) report cessation of symptoms by 16–20 weeks of gestation and only 11–18% of women report having nausea and vomiting confined to the mornings.166,167 [EL = 3]

One systematic review of observational studies found a reduced risk associated with nausea and vomiting and miscarriage (OR 0.36, 95% CI 0.32 to 0.42) and conflicting data regarding reduced risk for perinatal mortality.165 [EL = 3] No association with nausea and vomiting and teratogenicity has been reported.169 [EL = 3]

Despite reassurance that nausea and vomiting does not have harmful effects on pregnancy outcomes, nausea and vomiting can severely impact on a pregnant woman’s quality of life. Two observational studies have reported on the detrimental impact that nausea and vomiting may have on day-to-day activities, including interfering with household activities, restricting interaction with children, greater use of healthcare resources and time lost off work. 170,171 [EL = 3]

Interventions for nausea and vomiting that do not require prescription include ginger, acupressure and vitamin B. Prescribed treatments for nausea and vomiting include antihistamines and phenothiazines.


One RCT of ginger treatment (250 mg four times daily) compared with placebo reported a significant reduction in the severity of nausea and vomiting (P = 0.014) and a reduction in episodes of vomiting (P = 0.021) after four days in the treatment group.172 [EL = 1b] No difference in the rates of miscarriage, caesarean section or congenital anomalies was observed between the two groups.

Two systematic reviews on various treatments for nausea and vomiting in pregnancy reported on the results of one RCT of ginger which was a double-blind, placebo-controlled crossover trial of 27 women who were hospitalised for hyperemesis and used ginger (250 mg four times daily).173,174 [EL = 1b] Both the degree of nausea and number of attacks of vomiting were reduced with the ginger treatment (P = 0.035).174 [EL = 1b]

Another RCT assessed ginger syrup to alleviate nausea and vomiting in pregnancy.175 The intervention included 1 tablespoon of ginger syrup or placebo in 4 to 8 fluid ounces of water four times daily. Higher improvement on a nausea scale was observed by women in the ginger group and vomiting resolved in 67% of the women in this group by day 6 compared with only 20% in the control group. [EL = 1b]

P6 acupressure

The P6 point (Neiguan) point is located on the volar surface of the forearm approximately three fingerbreadths proximal to the wrist.

Three systematic reviews of RCTs on P6 acupressure for the relief of nausea and vomiting were found.173,174,176 [EL = 1a] The reviews used different inclusion criteria and each included four or more of seven RCTs. Six out of the seven trials showed a positive effect for stimulation of the P6 pressure point. The seventh trial (n = 161) showed no difference between acupressure and sham acupressure or no treatment.174,176 [EL = 1a] This trial did not present its data in a form that could be included in a meta-analysis.173 [EL = 1a]

The review that excluded three of the seven trials did so because they were of crossover design without separate results from the first cross over period being available. A meta-analysis of dichotomised data from two of the trials reported evidence of benefit (Peto OR 0.35, 95% CI 0.23 to 0.54) but the continuous data from a third trial did not (in contrast to the finding in the reviews above).

More recent RCTs have also reported a reduction in symptoms of nausea and vomiting among women with acupressure wristbands compared with women with dummy bands or no treatment at all.177–180 [EL = 1b] A possible placebo effect with sham acupressure was also reported in two of the studies.178,180

The risk of adverse effects of acupressure on pregnancy outcome was assessed in one RCT.181 No differences in perinatal outcome, congenital abnormalities, pregnancy complications and other infant outcomes were found between the acupressure, sham acupressure or no treatment. [EL = 1b]

Antihistamines (promethazine, prochlorperazine, metoclopramide)

In a meta-analysis of 12 RCTs that included a comparison of antiemetics (antihistamines ± pyridoxine) with placebo or no treatment, there was a significant reduction in nausea in the treated group (Peto OR 0.17, 95% CI 0.13 to 0.21).173 [EL = 1a] Although the results suggest an increase in drowsiness associated with antihistamines (Peto OR 2.19, 95% CI 1.09 to 4.37),173 a review of the safety of antihistamines in relation to teratogenicity found no significant increased risk (24 studies, n > 200 000; OR 0.76, 95% CI 0.60 to 0.94).182 [EL = 2a] Metoclopramide, however, has insufficient data on safety to be recommended as a first-line agent, though no evidence of association with malformations has been reported.183


One systematic review of three RCTs (n = 389 women) found that phenothiazines reduced nausea or vomiting when compared with placebo (RR 0.31, 95% CI 0.24 to 0.42).182 [EL = 1a] However, this analysis included different phenothiazines as a group and one of the RCTs recruited women after the first trimester. The bulk of evidence demonstrates no association between teratogenicity and phenothiazines (nine studies, n = 2948; RR 1.03, 95% CI 0.88 to 1.22).171,182 [EL = 2a and 3]

Pyridoxine (vitamin B6)

RCTs in the two reviews that studied pyridoxine considered doses of 25–75 mg up to three times daily.173,174 [EL = 1a] Although the review suggests a reduction in nausea, it was not effective in reducing vomiting (Peto OR 0.91, 95% CI 0.60 to 1.38). Although concerns about possible toxicity at high doses have not yet been resolved and it is not recommended for use, one cohort study found no association between pyridoxine and major malformations (n = 1369, RR 1.05, 95% CI 0.60 to 1.84).182 [EL = 2a] The Committee on Toxicity of Foods has recommended a safe upper limit of 10 milligrams a day for pyridoxine in the UK.

Cyanocobalamin (vitamin B12)

Two RCTs assessed the effect of cyanocobalamin (one trial gave multivitamins containing cyanocobalamin) compared with placebo and found a significant reduction in nausea and vomiting (pooled RR 0.49, 95% CI 0.28 to 0.86).182 [EL = 1a] No studies assessing the safety of cyanocobalamin were located but this vitamin is thought to play a role in inhibiting malformations associated with neural tube defects.


Ginger, P6 acupressure and medication with antihistamines reduce the frequency of nausea in early pregnancy. Pyridoxine (vitamin B6) also appears to be effective, although concerns about the toxicity of vitamin B6 remain. Cyanocobalamin (vitamin B12) is also effective in reducing nausea and vomiting, although no data on its safety were located.

Most cases of nausea and vomiting resolve within 16 to 20 weeks with no harm to the pregnancy, prescribed treatment in the first trimester is usually not indicated unless the symptoms are severe and debilitating.77


Women should be informed that most cases of nausea and vomiting in pregnancy will resolve spontaneously within 16 to 20 weeks of gestation and that nausea and vomiting are not usually associated with a poor pregnancy outcome. If a woman requests or would like to consider treatment, the following interventions appear to be effective in reducing symptoms [A]:

  • nonpharmacological:


    P6 (wrist) acupressure

  • pharmacological:


Information about all forms of self-help and nonpharmacological treatments should be made available for pregnant women who have nausea and vomiting. [Good practice point]

Future research

More information on maternal and fetal safety for all interventions for nausea and vomiting in pregnancy (except antihistamines) is needed.

Further research into other nonpharmacological treatments for nausea and vomiting in pregnancy is recommended.

6.2. Heartburn

Heartburn is described as a burning sensation or discomfort felt behind the sternum or throat or both. It may be accompanied by acid regurgitation reaching the throat or the mouth, causing a bitter or sour taste in the mouth. The pathogenesis of heartburn during pregnancy is unclear but may be the consequence of the altered hormonal status interfering with gastric motility, resulting in gastro-oesophageal reflux. It is not associated with adverse outcomes of pregnancy and therefore its treatment is intended to provide relief of symptoms rather than to prevent harm to the fetus or mother. Heartburn should be distinguished from epigastric pain associated with pre-eclampsia. This may be done by checking the woman’s blood pressure and urine for proteinuria.

Heartburn is a frequent complaint during pregnancy. One large study involving 607 pregnant women reported an increased frequency of heartburn with gestation, with 22% of women reporting heartburn in the first trimester, 39% in second and 72% in third trimester.184 [EL = 3] Another study reported a weekly prevalence of 60% from the 31st week of gestation until delivery.185 [EL = 3] An English study that separated white Europeans from Asian women reported a slightly higher prevalence of 76–87% for white Europeans and 78–81% for Asians.186 [EL = 3]

Treatment options for heartburn include lifestyle modification, use of antacids or alkali mixtures, H2 receptor antagonists and proton pump inhibitors, which aim to alleviate symptoms by reducing the acid reflux.

Information on lifestyle modification includes awareness of posture, maintaining upright positions, especially after meals, sleeping in a propped up position and dietary modifications such as small frequent meals, reduction of high-fat foods and gastric irritants such as caffeine. Antacids, which neutralise and bind bile acids, may also be considered for the relief of heartburn. An RCT of antacid treatment compared with placebo found that 80% of women reported relief of heartburn pain within 1 hour compared with 13% from the placebo group.187 [EL = 1b]

Alginate preparations, such as Gaviscon® (Reckitt and Coleman), reduce reflux by inhibiting the regurgitation of gastric contents. One RCT compared alginate with magnesium trisilicate and both were found to relieve symptoms of heartburn and no differences in the effects of each treatment were reported.188 [EL = 1b] The manufacturers of Gaviscon® state that it may be taken during pregnancy.189

Another RCT compared acid and alkali mixtures with placebo and reported that there was no difference in relief of heartburn symptoms when women were given either the acid or alkali mixtures but better relief was achieved using these rather than using a placebo.190 [EL = 1b]

H2 receptor antagonists or blockers, which reduce acid secretion and volume, have also been reported to treat heartburn effectively and safely in pregnant women. Two trials that investigated the effect of ranitidine, an H2 receptor blocker, given once and twice daily, compared with a placebo found that there was a significant improvement in heartburn symptoms, especially when ranitidine was taken twice daily, morning and afternoon.191,192 [EL = 1b] H2 blockers in the first trimester have also been assessed for safety in a cohort of 178 women and no association with fetal malformations was found.193 [EL = 2a] Nevertheless, the manufacturers of ranitidine and cimetidine advise the avoidance of these products unless essential.77

A meta-analysis (five cohort studies, n = 593 infants) of the safety of proton pump inhibitors such as omeprazole, which suppress gastric acid secretion also reported no association between exposure to proton pump inhibitors and fetal malformations.194 [EL = 2a] However, the manufacturer of omeprazole advises caution with its use in pregnancy owing to toxicity shown in animal studies and does not advise its use unless there is no alternative.77,189


Women who present with symptoms of heartburn in pregnancy should be offered information regarding lifestyle and diet modification. [Good practice point]

Antacids may be offered to women whose heartburn remains troublesome despite lifestyle and diet modification. [A]

6.3. Constipation

Constipation is the delay in the passage of food residue, associated with painful defecation and abdominal discomfort. Constipation during pregnancy may not only be associated with poor dietary fibre intake but also with rising levels of progesterone causing a reduction in gastric motility and increased gastric transit time.

It is a commonly reported condition during pregnancy that appears to decrease with gestation. One study found that 39% of pregnant women reported symptoms of constipation at 14 weeks of gestation, 30% at 28 weeks and 20% at 36 weeks.195 [EL = 3] The results of this study, however, may be over-estimates, as routine iron supplementation was recommended for all pregnant women in the UK at the time the study was conducted and iron consumption is associated with constipation.

One systematic review of two RCTs (n = 215) randomised women to fibre supplements or nothing.196 Wheat or bran fibre supplements were significantly more effective in increasing stool frequency (Peto OR 0.18, 95% CI 0.05 to 0.67). When discomfort was not alleviated by fibre supplementation, stimulant laxatives were more effective than bulk-forming laxatives (Peto OR 0.30, 95% CI 0.14 to 0.61). However, significantly more abdominal pain and diarrhoea was observed when stimulants were used and no differences in nausea were reported. [EL = 1a]

No evidence was found for the effectiveness or safety of osmotic laxatives (e.g. lactulose) or softeners for use in pregnancy.


Women who present with constipation in pregnancy should be offered information regarding diet modification, such as bran or wheat fibre supplementation. [A]

6.4. Haemorrhoids

Haemorrhoids are swollen veins around the anus that are characterised by anorectal bleeding, anal pain and anal itching. This is thought to be a result of the prolapse of the anal canal cushions, which play a role in maintaining continence. A low-fibre diet and pregnancy are both precipitating factors for haemorrhoids.

One recent observational study found that 8% of pregnant women experienced haemorrhoidal disease in the last 3 months of pregnancy.197 [EL = 3]

Treatment for haemorrhoids includes diet modification, creams (such as Anusol-HC®, Kestrel, Anacal®, Sankyo Pharma) oral medication and surgical intervention.

No evidence for the effectiveness or safety of creams used in pregnancy was found. However, the manufacturers of Anusol-HC® and Anacal® state that, ‘no epidemiological evidence of adverse effects to the pregnant mother or fetus’ has been reported.189

One RCT of oral medication or placebo for pregnant women with haemorrhoids found that 84% of women in the treatment group reported an improvement in symptoms compared with 12% in the placebo group, after two weeks. No significant differences in side effects or fetal outcome were reported.198 [EL = 1b]

In another study of oral flavonoid therapy, 50 pregnant women were treated over three phases.199 The majority of women reported an improvement in symptoms (bleeding, pain, rectal exudation and rectal discomfort) after 7 days, the first phase of treatment. Six women complained of nausea and vomiting, which resolved over the course of treatment. [EL = 3]

In extreme circumstances, surgical removal of haemorrhoids has been used. In a study where closed haemorrhoidectomy, under local anaesthesia, was performed on 25 women with thrombosed or gangrenous haemorrhoids in the third trimester, 24 women reported immediate pain relief with no resultant fetal complications related to the surgery.200 [EL = 3] Surgery is rarely considered an appropriate intervention for the pregnant woman since haemorrhoids may resolve after delivery.


In the absence of evidence for the effectiveness of treatments for haemorrhoids in pregnancy, women should be offered information concerning diet modification. If clinical symptoms remain troublesome, standard haemorrhoid creams should be considered. [Good practice point]

6.5. Varicose veins

Varicose veins are caused by the pooling of blood in the surface veins as a result of inefficient valves that would normally prevent blood draining back down the leg. They can occur as blue swollen veins on the calves and inside of the legs, and cause itching and general discomfort. Feet and ankles can also become swollen. They are a common complaint in pregnancy.

One systematic review addressed this issue.119 Three RCTs of three different treatments in 115 women were included. One RCT investigated external pneumatic intermittent compression and another RCT investigated immersion in water and bed rest in pregnant women with leg oedema. The outcomes studied (leg volume, diuresis, blood pressure) did not appear to be important for the women themselves. In addition, only effects immediately after treatment were studied. The third trial administered rutoside capsules or placebo for 8 weeks in the third trimester, which led to a subjective improvement of symptoms at 36 weeks of gestation (Peto OR 0.30 95% CI 0.12 to 0.77). However, no data were provided on the safety or side effects of the administration of rutosides at this stage of pregnancy.

An RCT published after this review was also located.201 The efficacy of compression stockings (compression class I and compression class II) in preventing emergent varicose veins during pregnancy was compared with no stockings among 42 women at less then 12 weeks of gestation. Both classes of compression stockings failed to prevent the emergence of varicose veins but more treated women reported improved leg symptoms (P = 0.045). [EL = 1b]


Women should be informed that varicose veins are a common symptom of pregnancy that will not cause harm and that compression stockings can improve the symptoms but will not prevent varicose veins from emerging. [A]

6.6. Vaginal discharge

The quality and quantity of vaginal discharge often changes in pregnancy. Women usually produce more discharge during pregnancy. If the discharge has a strong or unpleasant odour, is associated with itch or soreness or associated with pain on passing urine, the woman may have bacterial vaginosis (see Section 10.2), vaginal trichomoniasis or candidiasis. However, vaginal discharge may also be caused by a range of other physiological or pathological conditions such as vulval dermatoses or allergic reactions.

Trichomoniasis, infection with the parasitic protozoan Trichomonas vaginalis, is characterised by green-yellow frothy discharge from the vagina and pain upon urination and is one of the most commonly sexually transmitted infections. A systematic review of RCTs assessed the effects of trichomoniasis and its treatment during pregnancy.202 Two RCTs were located. Both trials used metronidazole as the treatment intervention. However, the dose used in one trial (2 g, 48 hours apart and repeated after 2 weeks), conducted in the USA, was double the dose used in the other trial, which was conducted in South Africa. Both studies demonstrated high rates of cure (two RCTs, n = 703, RR 0.11, 95% CI 0.08 to 0.17) but a higher risk for preterm birth was observed in the treatment group in the US study when compared with the placebo group (RR 1.78, 95% CI 1.19 to 2.66). No significant differences in low birthweight were observed between the two groups in either trial and the South African study also reported no differences in mean birthweight or gestational age when compared with the control group, who received no treatment. Therefore, although trichomoniasis is associated with adverse pregnancy outcomes,203 the effect of metronidazole for its treatment during pregnancy remains unclear. [EL = 1a]

There is no evidence that vaginal candidiasis (also called thrush), which is caused by the yeast Candida albicans, harms the unborn child. One systematic review of ten RCTs assessed the effectiveness of topical treatments for vaginal candidiasis in pregnant women.204 Meta-analysis showed that imidazoles (miconazole cream and clotrimazole pessaries) were more effective than nystatin pessaries or placebo for symptomatic relief and resolution of persistent candidiasis (five RCTs, n = 793, Peto OR 0.21, 95%I 0.16 to 0.29 for nystatin pessaries; one RCT, n = 100, Peto OR 0.14, 95% CI 0.06 to 0.31 for placebo). Two RCTs (n = 91) also demonstrated that treatment with miconazole or econazole for 1 week was just as effective as treatment for 2 weeks (Peto OR 0.41, 95% CI 0.16 to 1.05). However, treatment for 4 days was not as effective as treatment for 1 week (two RCTs, n = 81, Peto OR 11.07, 95% CI 4.21 to 29.15). One RCT (n = 38) found that terconazole cream was as effective as clotrimazole cream for treatment of vaginal candidiasis (Peto OR 1.41, 95% CI 0.28 to 7.10). [EL = 1a]

Although one-dose oral treatments for the treatment of vaginal candidiasis are now available, their safety or efficacy in pregnancy has not yet been evaluated.


Women should be informed that an increase in vaginal discharge is a common physiological change that occurs during pregnancy. If this is associated with itch, soreness, offensive smell or pain on passing urine, there maybe an infective cause and investigation should be considered. [Good practice point]

A 1 week course of a topical imidazole is an effective treatment and should be considered for vaginal candidiasis in pregnant women. [A]

The effectiveness and safety of oral treatments for vaginal candidiasis in pregnancy is uncertain and these should not be offered. [Good practice point]

6.7. Backache

The definition of back pain or back discomfort during pregnancy is subjective, due to the nature of this discomfort. The estimated prevalence of backache during pregnancy ranges between 35% and 61%.205–210 Among these women, 47–60% reported backache first developing during the 5th to 7th months of pregnancy. It was also reported that the symptoms of backache were worse in the evenings. [EL = 3]

Back pain during pregnancy has been attributed to an altered posture due to the increasing weight in the womb and increased laxity of supporting muscles, as a result of the hormone relaxin. Back pain during pregnancy is potentially debilitating, since it can interfere with a woman’s daily activities and sleep patterns, particularly during the third trimester.

A systematic review assessed three RCTs to identify the most appropriate interventions for the prevention and treatment of back pain in pregnancy.211 The three RCTs investigated three types of interventions: water gymnastics compared with no intervention, Ozzlo pillows compared with standard pillows, and acupuncture compared with physiotherapy. [EL = 1a] Women who participated in water gymnastics took less sick leave when compared with women who had no specific intervention (OR 0.38, 95% CI 0.16 to 0.88). In the second trial, Ozzlo pillows, which are hollowed out nest-shaped pillows, were more effective in relieving back pain and improving sleep for women at more than 36 weeks of gestation compared with a standard pillow (OR 0.32, 95% CI 0.18 to 0.58 for backache relief; OR 0.35, 95% CI 0.20 to 0.62 for sleep). In the third RCT, ten acupuncture sessions were rated more helpful when compared with ten group physiotherapy sessions in pregnant women who developed back pain before 32 weeks of pregnancy (OR 6.58, 95% CI 1.00 to 43.16).

Two additional studies not included in the systematic review were identified. One RCT compared the effect of massage therapy with relaxation classes and found that back pain relief scores diminished significantly with the women who had received massage therapy when compared with the women in the relaxation group (n = 26 women, P < 0.01)212 [EL = 1b]

The other study, which was excluded from the systematic review because it was quasi-randomised, was conducted in Sweden and compared three management options for backache. These were: group back-care classes, individual back-care classes and routine antenatal care (control).213 Women who received either individual or group back-care classes reported an improvement in pelvic or back pain compared with the control group (n = 407, P < 0.05). Women who received individual classes also reported a significant improvement in pain relief while those in the control group and those receiving group sessions did not report any pain relief. The group receiving individual training also reported significantly less sick leave (P < 0.05) than those in the control group and those who had group training. [EL = 1b]

Another Swedish study compared the effects of a physiotherapy programme (five visits for teaching on anatomy, posture, vocational ergonomics, gymnastics and relaxation) and an exercise programme compared with no specific intervention on 135 pregnant women with backache.214 This cohort study found a significantly reduced number of sick leave days taken during pregnancy by an average of 24 days per woman (P < 0.001). [EL = 2a]

Other interventions identified for the treatment of backache and reported to have a beneficial effect were autotraction, a chiropractic, mechanical treatment for back pain,215 spinal manipulative therapy,216 rotational mobilisation exercise217 and manual joint mobilisation applied to symptomatic vertebral segments.218 [EL = 3] However, all these studies had problems with study design or the data were derived from a small sample size.


Women should be informed that exercising in water, massage therapy and group or individual back care classes might help to ease backache during pregnancy. [A]

Future research

Although many treatments exist for backache in pregnancy, there is a lack of research evaluating their safety and effectiveness.

6.8. Symphysis pubis dysfunction

Symphysis pubis dysfunction has been described as a collection of signs and symptoms of discomfort and pain in the pelvic area, including pelvic pain radiating to the upper thighs and perineum. Complaints vary from mild discomfort to severe and debilitating pain that can impede mobility.

The reported incidence of symphysis pubis during pregnancy varies in the literature from 0.03% to 3%. In Leeds, a hospital survey of women (n = 248) in whom a diagnosis of symphysis pubis dysfunction had been made, estimated that 1/36 deliveries were associated with symphysis pubis dysfunction either during pregnancy or soon after delivery.219 Among the respondents (57% response rate), 9% reported that symptoms first occurred in the first trimester, 44% reported symptoms in the second trimester, 45% in the third trimester and 2% during labour or the postnatal period. [EL = 3]

There is little evidence in the literature on which to base clinical practice. No higher levels of evidence than case reports were located on effective therapies for symphysis pubis dysfunction, although the use of elbow crutches, pelvic support and prescribed pain relief have been suggested.220 [EL = 4] It is important to remember that many medications for pain relief for bones and joints may not be appropriate for use in pregnancy.

Future research

More research on effective treatments for symphysis pubis dysfunction is needed.

6.9. Carpal tunnel syndrome

Carpal tunnel syndrome results from compression of the median nerve within the carpal tunnel in the hand. It is characterised by tingling, burning pain, numbness and a swelling sensation in the hand that may impair sensory and motor function of the hand.

Carpal tunnel syndrome is not an uncommon complaint among pregnant women and estimates of incidence during pregnancy range from 21% to 62%.221–223 [EL = 3]

Interventions to treat carpal tunnel syndrome include wrist splints224,225 and wrist splints plus injections of corticosteroid and analgesia.226 However, case series reports were the highest level of evidence identified that evaluated these therapies and the studies were not of good quality.

Future research

There is a lack of research evaluating effective interventions for carpal tunnel syndrome.

Copyright © 2008, National Collaborating Centre for Women’s and Children’s Health.

No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

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Bookshelf ID: NBK51880


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