The Pregnant Patient: Managing Common Acute Medical Problems

 

Am Fam Physician. 2018 Nov 1;98(9):595-602.

Author disclosure: No relevant financial affiliations.

Women often see their primary care physicians for common acute conditions during pregnancy. These conditions may be caused by pregnancy (obstetric problems) or worsened by pregnancy (obstetrically aggravated problems), or they may require special consideration during pregnancy because of maternal or fetal risks (nonobstetric problems). Primary care physicians should know the differential diagnosis for common conditions during pregnancy and recognize the important findings of obstetric and urgent nonobstetric problems. The family physician can evaluate and treat most nonobstetric problems, although obstetric problems require referral to a primary maternity care clinician. A tiered approach, including routinely looking for all-cause red flag symptoms and signs, while remaining aware of estimated gestational age, allows for high-quality care and shared decision making between the family physician and the pregnant patient. When treating common causes of nausea and epigastric pain/gastroesophageal reflux, lifestyle modifications are considered the safest and first-choice therapy, followed by well-established low-risk therapies, such as vitamin B6 (pyridoxine) and doxylamine for nausea, and antacids not containing salicylates (found in bismuth combination products) for gastroesophageal reflux. Other common conditions during pregnancy are best treated with low-risk therapies, such as using antihistamines or topical steroids for rashes, first-generation cephalosporins or amoxicillin for cystitis, and physical therapy and acetaminophen for low back pain and headaches.

Women often see their primary care physicians for common acute conditions during pregnancy, even if they are not the primary maternity care clinician. Some conditions are caused directly by pregnancy (obstetric problems) or are worsened by pregnancy (obstetrically aggravated problems), and others require special consideration during pregnancy because of maternal or fetal risks (nonobstetric problems).1  Table 1 outlines the causes of common symptoms during pregnancy.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Treatment of nausea and vomiting in pregnancy should begin with lifestyle modifications. Other treatments, including P6 acupressure, vitamin B6 (pyridoxine), doxylamine, and prescription antiemetics, can be added as needed.

B

7, 8, 10

Pregnant women with more than 100,000 colony-forming units of one bacterial species on urine culture should be treated with antibiotics to prevent pyelonephritis.

A

32

Initial choices for treating musculoskeletal back pain in pregnancy include exercise and physical therapy, but additional therapy with acetaminophen, warm baths, acupuncture, support devices, or epidural steroids may be needed.

C

36, 37

Pregnant women with new-onset headaches or a new type of headache should be further evaluated to distinguish urgent or emergent causes (e.g., meningitis, subarachnoid hemorrhage) from common preexisting conditions (e.g., sinusitis, tension or migraine headaches). Preeclampsia must be ruled out if headaches occur after 20 weeks' gestation.

C

40, 42


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Treatment of nausea and vomiting in pregnancy should begin with lifestyle modifications. Other treatments, including P6 acupressure, vitamin B6 (pyridoxine), doxylamine, and prescription antiemetics, can be added as needed.

B

7, 8, 10

Pregnant women with more than 100,000 colony-forming units of one bacterial species on urine culture should be treated with antibiotics to prevent pyelonephritis.

A

32

Initial choices for treating musculoskeletal back pain in pregnancy include exercise and physical therapy, but additional therapy with acetaminophen, warm baths, acupuncture, support devices, or epidural steroids may be needed.

C

36, 37

Pregnant women with new-onset headaches or a new type of headache should be further evaluated to distinguish urgent or emergent causes (e.g., meningitis, subarachnoid hemorrhage) from common preexisting conditions (e.g., sinusitis, tension or migraine headaches). Preeclampsia must be ruled out if headaches occur after 20 weeks' gestation.

C

40, 42


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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TABLE 1

Causes of Common Symptoms During Pregnancy

SymptomImportant accompanying signs and symptomsCauses

Nausea and vomiting

General: weight loss, dehydration, high-normal or high serum creatinine level, occurring before four weeks (nonobstetric causes) or persisting after 12 weeks estimated gestational age (molar pregnancy)

Nonobstetric or obstetrically aggravated: gastroenteritis, appendicitis, cholecystitis, thyroid disease, kidney stones, gallbladder problems

Nonobstetric: diarrhea, fever, abdominal pain, neck/thyroid pain or enlargement

Obstetric: nausea and vomiting of pregnancy, hyperemesis gravidarum, molar pregnancy, multiple gestation

Obstetric: vaginal bleeding, large uterus for estimated gestational age, refractory

Abdominal pain

General: nausea and vomiting, epigastric/right upper quadrant pain, weight loss, dehydration, high-normal or high serum creatinine level

Nonobstetric or obstetrically aggravated: gastroesophageal reflux disease, peptic ulcer disease, cholecystitis, cystitis, pyelonephritis, appendicitis, kidney stones, constipation, gastritis

Nonobstetric: change with eating and drinking, blood in stool or emesis, melena, fever, jaundice

Obstetric: preeclampsia/HELLP syndrome, acute fatty liver of pregnancy, ectopic pregnancy, spontaneous abortion, abruption, intrauterine fetal demise, round ligament strain, preterm labor

Obstetric: headaches, vision changes, low platelet counts, swelling

Cough

General: dyspnea, hypoxemia

Nonobstetric or obstetrically aggravated: acute/chronic asthma, viral upper respiratory tract infection (including influenza), allergic rhinitis, pneumonia, pertussis

Nonobstetric: wheeze, hemoptysis, fever, myalgia, purulent nasal discharge or sputum

Obstetric: physiologic rhinitis of pregnancy

Rash

General: pustules, vesicles/blisters, erythema, pruritus

Nonobstetric or obstetrically aggravated: acne, eczema, psoriasis, cellulitis/abscess, herpes zoster, human papillomavirus infection, fungal infection, scabies, impetigo, folliculitis

Nonobstetric: condyloma, scaling, lichenification, ulcers, secondary rash on preexisting condition (e.g., eczema, moles)

Obstetric: physiologic pigment change (melasma, linea nigra), striae gravidarum, PUPPP, intrahepatic cholestasis, pustular psoriasis (impetigo herpetiformis), pemphigoid gestationis, atopic eruption of pregnancy (prurigo of pregnancy)

Obstetric: pigmented patches/lines, pruritus with or without papules/blisters, spares the umbilicus (PUPPP)

Dysuria

General: dehydration, uterine contractions

Nonobstetric or obstetrically aggravated: cystitis, vulvovaginal candidiasis, pyelonephritis, sexually transmitted urethritis, herpes genitalis, urolithiasis, recurrent urinary tract infection

Nonobstetric: other urinary symptoms; vulvovaginal discharge, itching, or burning; fever; nausea or vomiting; costovertebral angle tenderness; colicky flank pain; gross hematuria; prior urinary tract infection

Obstetric: nonspecific (urinary frequency and incontinence common)

Low back pain

General: poor function, deconditioning

Nonobstetric or obstetrically aggravated: musculoskeletal strain, loosening of sacroiliac joint, disc herniation, cauda equina syndrome, sciatic nerve/lumbar plexus pressure, pyelonephritis, urolithiasis, sacroiliitis, joint laxity, herniated nucleus pulposus Obstetric: abruption, intrauterine fetal demise, preterm or term labor

Neurologic red flags: saddle anesthesia, urinary retention, rapidly progressive weakness or numbness

Urologic red flags: fever, costovertebral angle tenderness, renal colic

Obstetric: history or evidence of an accident/fall/trauma, vaginal bleeding, severe abdominal pain, change in fetal movement, loss of fluid, uterine tenderness, uterine contractions, urinary tract symptoms

Headache

General: new-onset headache or new headache type, rapidly increasing frequency of headaches

Nonobstetric or obstetrically aggravated: tension or migraine headache, meningitis, sinusitis (viral, allergic, bacterial), subarachnoid hemorrhage, brain tumor

Nonobstetric: purulent nasal discharge, nausea and vomiting, focal neurologic signs or symptoms, fever, neck pain/stiffness, sudden thunderclap headache

Obstetric: preeclampsia

Obstetric: visual disturbance (scotomata), proteinuria, hypertension


HELLP = hemolysis, elevated liver enzymes, and low platelet count; PUPPP = pruritic urticarial papules and plaques of pregnancy.

TABLE 1

Causes of Common Symptoms During Pregnancy

SymptomImportant accompanying signs and symptomsCauses

Nausea and vomiting

General: weight loss, dehydration, high-normal or high serum creatinine level, occurring before four weeks (nonobstetric causes) or persisting after 12 weeks estimated gestational age (molar pregnancy)

Nonobstetric or obstetrically aggravated: gastroenteritis, appendicitis, cholecystitis, thyroid disease, kidney stones, gallbladder problems

Nonobstetric: diarrhea, fever, abdominal pain, neck/thyroid pain or enlargement

Obstetric: nausea and vomiting of pregnancy, hyperemesis gravidarum, molar pregnancy, multiple gestation

Obstetric: vaginal bleeding, large uterus for estimated gestational age, refractory

Abdominal pain

General: nausea and vomiting, epigastric/right upper quadrant pain, weight loss, dehydration, high-normal or high serum creatinine level

Nonobstetric or obstetrically aggravated: gastroesophageal reflux disease, peptic ulcer disease, cholecystitis, cystitis, pyelonephritis, appendicitis, kidney stones, constipation, gastritis

Nonobstetric: change with eating and drinking, blood in stool or emesis, melena, fever, jaundice

Obstetric: preeclampsia/HELLP syndrome, acute fatty liver of pregnancy, ectopic pregnancy, spontaneous abortion, abruption, intrauterine fetal demise, round ligament strain, preterm labor

Obstetric: headaches, vision changes, low platelet counts, swelling

Cough

General: dyspnea, hypoxemia

Nonobstetric or obstetrically aggravated: acute/chronic asthma, viral upper respiratory tract infection (including influenza), allergic rhinitis, pneumonia, pertussis

Nonobstetric: wheeze, hemoptysis, fever, myalgia, purulent nasal discharge or sputum

Obstetric: physiologic rhinitis of pregnancy

Rash

General: pustules, vesicles/blisters, erythema, pruritus

Nonobstetric or obstetrically aggravated: acne, eczema, psoriasis, cellulitis/abscess, herpes zoster, human papillomavirus infection, fungal infection, scabies, impetigo, folliculitis

Nonobstetric: condyloma, scaling, lichenification, ulcers, secondary rash on preexisting condition (e.g., eczema, moles)

Obstetric: physiologic pigment change (melasma, linea nigra), striae gravidarum, PUPPP, intrahepatic cholestasis, pustular psoriasis (impetigo herpetiformis), pemphigoid gestationis, atopic eruption of pregnancy (prurigo of pregnancy)

Obstetric: pigmented patches/lines, pruritus with or without papules/blisters, spares the umbilicus (PUPPP)

Dysuria

General: dehydration, uterine contractions

Nonobstetric or obstetrically aggravated: cystitis, vulvovaginal candidiasis, pyelonephritis, sexually transmitted urethritis, herpes genitalis, urolithiasis, recurrent urinary tract infection

Nonobstetric: other urinary symptoms; vulvovaginal discharge, itching, or burning; fever; nausea or vomiting; costovertebral angle tenderness; colicky flank pain; gross hematuria; prior urinary tract infection

Obstetric: nonspecific (urinary frequency and incontinence common)

Low back pain

General: poor function, deconditioning

Nonobstetric or obstetrically aggravated: musculoskeletal strain, loosening of sacroiliac joint, disc herniation, cauda equina syndrome, sciatic nerve/lumbar plexus pressure, pyelonephritis, urolithiasis, sacroiliitis, joint laxity, herniated nucleus pulposus Obstetric: abruption, intrauterine fetal demise, preterm or term labor

Neurologic red flags: saddle anesthesia, urinary retention, rapidly progressive weakness or numbness

Urologic red flags: fever, costovertebral angle tenderness, renal colic

Obstetric: history or evidence of an accident/fall/trauma, vaginal bleeding, severe abdominal pain, change in fetal movement, loss of fluid, uterine tenderness, uterine contractions, urinary tract symptoms

Headache

General: new-onset headache or new headache type, rapidly increasing frequency of headaches

Nonobstetric or obstetrically aggravated: tension or migraine headache, meningitis, sinusitis (viral, allergic, bacterial), subarachnoid hemorrhage, brain tumor

Nonobstetric: purulent nasal discharge, nausea and vomiting, focal neurologic signs or symptoms, fever, neck pain/stiffness, sudden thunderclap headache

Obstetric: preeclampsia

Obstetric: visual disturbance (scotomata), proteinuria, hypertension


HELLP = hemolysis, elevated liver enzymes, and low platelet count; PUPPP = pruritic urticarial papules and plaques of pregnancy.

General Considerations for Pregnant Patients

To ensure appropriate evaluation and treatment, an accurate calculation of the estimated gestational age is essential. Some symptoms are trimester-specific, whereas others (e.g., abdominal pain, vaginal bleeding) may present throughout the pregnancy (Table 2). Symptoms and signs may vary in importance depending on whether they are caused by pregnancy or are simply common acute findings that may be unrelated to the pregnancy.

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TABLE 2

Estimated Gestational Age and Concerning Symptoms to Help Distinguish Obstetric from Nonobstetric Problems

SymptomPossible obstetric causes by estimated gestational ageNonobstetric causes

Abdominal pain

0 to 20 weeks

Ectopic pregnancy

Spontaneous abortion

20 to 40 weeks

Abruption

Acute fatty liver of pregnancy (epigastric/right upper quadrant pain)

Intrauterine fetal demise

Preeclampsia/HELLP syndrome (epigastric pain)

Preterm labor

Round ligament strain

Appendicitis Cholecystitis Constipation Cystitis Gastritis Gastroesophageal reflux disease Kidney stones Peptic ulcer disease Pyelonephritis

Headache

20 to 40 weeks

Preeclampsia

Brain tumor Meningitis Sinusitis Subarachnoid hemorrhage Tension or migraine headache

Vaginal bleeding

0 to 20 weeks

Ectopic pregnancy

Spontaneous abortion

20 to 40 weeks

Abruption

Cervical change of labor

Placenta previa

Vasa previa

Cervicitis Nonvaginal sources (hemorrhoid, anal fissure, vulvar varicosity)


HELLP = hemolysis, elevated liver enzymes, and low platelet count.

TABLE 2

Estimated Gestational Age and Concerning Symptoms to Help Distinguish Obstetric from Nonobstetric Problems

SymptomPossible obstetric causes by estimated gestational ageNonobstetric causes

Abdominal pain

0 to 20 weeks

Ectopic pregnancy

Spontaneous abortion

20 to 40 weeks

Abruption

Acute fatty liver of pregnancy (epigastric/right upper quadrant pain)

Intrauterine fetal demise

Preeclampsia/HELLP syndrome (epigastric pain)

Preterm labor

Round ligament strain

Appendicitis Cholecystitis Constipation Cystitis Gastritis Gastroesophageal reflux disease Kidney stones Peptic ulcer disease Pyelonephritis

Headache

20 to 40 weeks

Preeclampsia

Brain tumor Meningitis Sinusitis Subarachnoid hemorrhage Tension or migraine headache

Vaginal bleeding

0 to 20 weeks

Ectopic pregnancy

Spontaneous abortion

20 to 40 weeks

Abruption

Cervical change of labor

Placenta previa

Vasa previa

Cervicitis Nonvaginal sources (hemorrhoid, anal fissure, vulvar varicosity)


HELLP = hemolysis, elevated liver enzymes, and low platelet count.

Physiologic changes in pregnancy lead to predictable problems that may impact the patient's function and health, such as musculoskeletal aches and pains, nasal congestion, and nausea. Given the potential risks of some treatments to the fetus, as well as possible maternal adverse effects, the decision of whether and how to treat is based on benefits vs. potential harms.2

The U.S. Food and Drug Administration's new labeling system for safety of medications during pregnancy and breastfeeding no longer uses alphabetical ratings (A, B, C, D, and X) and provides more guidance on risks, including information based on gestational age and lactation and reproductive risks.3,4  After identifying the risks and benefits of treatments, family physicians can engage in shared decision making with their pregnant patients. Table 3 summarizes the evaluation and treatment of common symptoms during pregnancy.542

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TABLE 3

Evaluation and Treatment of Common Symptoms in Pregnancy

Common symptomEvaluationTreatment

Nausea and vomiting

For all: weight, blood pressure, pulse, assessment of oral mucous membranes, orthostatic blood pressure measurement, abdominal examination

For nausea and vomiting of pregnancy

Lifestyle modifications: frequent small meals; avoidance of high-protein or fatty foods and foods with intense tastes or smells; P6 acupressure7,8

Medications: vitamin B6 (pyridoxine), over-the-counter antihistamines (doxylamine), natural ginger (less than 1,500 mg per day)710; antiemetics such as metoclopramide (Reglan) and trimethobenzamide (Tigan) can be used for severe or refractory cases,9,10 although there are concerns about the use of promethazine near term or during delivery and the use of ondansetron (Zofran) in the first trimester911; intravenous hydration as needed

If abdominal pain or tenderness: CBC; consider ultrasonography of gallbladder or appendix

If severe, refractory, begins before four weeks, or persists after 12 weeks estimated gestational age5,6: comprehensive metabolic panel; thyroid-stimulating hormone and beta human chorionic gonadotropin levels; transabdominal ultrasonography; consultation with primary maternity care clinician if evidence of dehydration, poor weight gain, molar pregnancy, or thyroid dysfunction

Epigastric pain/gastroesophageal reflux

For all: temperature, blood pressure, pulse, weight, assessment of oral mucous membranes, UA to check for protein

For gastroesophageal reflux of pregnancy

Initial therapy: frequent small meals; avoidance of smoking, caffeine, peppermint, and chocolate13

Next choices: over-the-counter antacids that do not contain salicylates (found in bismuth combination products); over-the-counter cimetidine (Tagamet), famotidine (Pepcid), and ranitidine (Zantac)1416

If fever or abdominal pain: CBC, LFTs12

For severe or refractory cases: proton pump inhibitors, only in consultation with primary maternity care clinician1416

If nausea, vomiting, colicky pain, positive Murphy sign, or fever: CBC for white blood cell count, lipase, bilirubin, LFTs, right upper quadrant ultrasonography12

If blood in the stool, emesis, or melena: CBC for hemoglobin and hematocrit, fecal occult blood test12

If begins after 20 weeks estimated gestational age and there are headaches, vision changes, abdominal pain, high blood pressure, or proteinuria: CBC for platelets, LFTs, consultation with primary maternity care clinician12

Cough

For all: vital signs with pulse oximetry; ears, nose, throat, and lung examination17

Prevention: hand/cough hygiene, hydration, inactivated influenza and Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccines18,19

If wheezing, fever, hypoxemia, shortness of breath, hemoptysis: consider chest radiography, CBC17

For specific causes

Physiologic rhinitis: nasal saline sprays, nasal opening strips20,21

Asthma: albuterol, inhaled corticosteroids, oral steroids for exacerbations

Allergic rhinitis: antihistamines, nasal steroids20,21

Influenza: administer oseltamivir (Tamiflu) as soon as possible

Pneumonia: antibiotics as indicated

Pertussis: azithromycin (Zithromax)

If myalgia or fever, or it is influenza season: consider empiric influenza therapy, hospitalization, and consultation with primary maternity care clinician17

Rash

For all: full examination of rash; note distribution, appearance, associated symptoms, and timing

Prevention: preconception varicella vaccine (contraindicated during pregnancy)

Based on characteristics

Blisters: consider Tzanck test or herpes simplex virus polymerase chain reaction testing, consultation with primary maternity care clinician

Suspected chickenpox: consider varicella-zoster immune globulin, consultation with primary maternity care clinician

Itching but no rash: LFTs, serum bile acids, consultation with primary maternity care clinician

Scaly: consider potassium hydroxide skin scraping test

Pustular: consider culturing pus

Continue most therapies for chronic conditions,2227 except for methotrexate and retinoids (contraindicated in pregnancy)

If diagnosis still unclear: consider biopsy

Selective use of acute therapy: topical steroids, antihistamines, topical antifungals, antibiotics

Consultation with primary maternity care clinician when considering antivirals for varicella or herpes, or ursodiol (Actigall) for intrahepatic cholestasis of pregnancy28,29

Dysuria

For all: vital signs, assessment of mucous membranes, examination for abdominal/costovertebral angle tenderness, vulvar inspection, UA with microscopy, urine culture30,31

For cystitis/asymptomatic bacteriuria

Initial choice for most: first-generation cephalosporins, nitrofurantoin (avoid at term), penicillins, erythromycins35

Consider if initial choices fail: amoxicillin/clavulanate (Augmentin)35

If UA results show a substantial number of epithelial cells, physiologic leukorrhea contamination should be suspected unless culture shows more than 100,000 colony-forming units of one organism3234

For vulvovaginal candidiasis

Routine, low-risk therapy: oral nystatin, vaginal clotrimazole, vaginal miconazole

For refractory cases: other vaginal azoles

Avoid oral fluconazole (Diflucan) in a dosage of 400 to 800 mg per day; caution also advised for low-dose oral fluconazole

If no clear diagnosis and UA findings are abnormal: vaginal examination with wet mount and urinary gonorrhea/chlamydia testing, empiric antibiotics for urinary tract infection pending urine culture results

For pyelonephritis

Intravenous antibiotics

For stones: hydration, pain management, urology consultation

If history of asymptomatic bacteriuria or one urinary tract infection: consider prophylactic nitrofurantoin until pregnancy is at term30,31

If costovertebral angle tenderness or fever: CBC, renal ultrasonography, intravenous antibiotics

Occurs at more than 20 weeks estimated gestational age: consultation with primary maternity care clinician to monitor for preterm labor and fetal well-being

If colicky flank pain or gross hematuria: renal ultrasonography, urology consultation

Low back pain

If there are urologic red flags (Table 1): UA with culture, consider renal ultrasonography and urology consultation

For musculoskeletal low back pain: low back stretching exercises, water exercises, physical therapy, job and activity modification, warm baths, lumbar traction, supportive devices (prenatal cradles, sacroiliac joint belts), acetaminophen, acupuncture36,37

If there are neurologic red flags (Table 1): neurosurgical consultation, magnetic resonance imaging of spine

If refractory and no red flags: consider epidural steroids36,37

If there are obstetric red flags: consultation with primary maternity care clinician

Headache

For all: blood pressure, UA, neurologic examination, funduscopy, nasal examination38

For sinusitis: amoxicillin

If headache not relieved with acetaminophen and rest, or there is scotomata, elevated blood pressure, or proteinuria: CBC, LFTs, consultation with primary maternity care clinician

For suspected meningitis: third-generation cephalosporins; consider vancomycin, acyclovir, dexamethasone3941

If focal neurologic signs or symptoms: shielded noncontrast head CT, neurology consultation; if CT is negative, consider magnetic resonance venography or angiography3941

For migraine

Lowest-risk therapy: acetaminophen; antiemetic; rest in a dark, quiet environment42

For severe or refractory migraines significantly affecting nutrition, hydration, or functioning (use these medications with caution, and explain potential risks to patients): sumatriptan (Imitrex), dexamethasone (brief, isolated use; avoid during first trimester), ketorolac (second trimester only)3941

Dihydroergotamine is contraindicated in pregnancy

If meningitis or subarachnoid hemorrhage is suspected: shielded noncontrast CT; consider lumbar puncture if CT results are normal3941


Information from references 5 through 42.

TABLE 3

Evaluation and Treatment of Common Symptoms in Pregnancy

Common symptomEvaluationTreatment

Nausea and vomiting

For all: weight, blood pressure, pulse, assessment of oral mucous membranes, orthostatic blood pressure measurement, abdominal examination

For nausea and vomiting of pregnancy

Lifestyle modifications: frequent small meals; avoidance of high-protein or fatty foods and foods with intense tastes or smells; P6 acupressure7,8

Medications: vitamin B6 (pyridoxine), over-the-counter antihistamines (doxylamine), natural ginger (less than 1,500 mg per day)710; antiemetics such as metoclopramide (Reglan) and trimethobenzamide (Tigan) can be used for severe or refractory cases,9,10 although there are concerns about the use of promethazine near term or during delivery and the use of ondansetron (Zofran) in the first trimester911; intravenous hydration as needed

If abdominal pain or tenderness: CBC; consider ultrasonography of gallbladder or appendix

If severe, refractory, begins before four weeks, or persists after 12 weeks estimated gestational age5,6: comprehensive metabolic panel; thyroid-stimulating hormone and beta human chorionic gonadotropin levels; transabdominal ultrasonography; consultation with primary maternity care clinician if evidence of dehydration, poor weight gain, molar pregnancy, or thyroid dysfunction

Epigastric pain/gastroesophageal reflux

For all: temperature, blood pressure, pulse, weight, assessment of oral mucous membranes, UA to check for protein

For gastroesophageal reflux of pregnancy

Initial therapy: frequent small meals; avoidance of smoking, caffeine, peppermint, and chocolate13

Next choices: over-the-counter antacids that do not contain salicylates (found in bismuth combination products); over-the-counter cimetidine (Tagamet), famotidine (Pepcid), and ranitidine (Zantac)1416

If fever or abdominal pain: CBC, LFTs12

For severe or refractory cases: proton pump inhibitors, only in consultation with primary maternity care clinician1416

If nausea, vomiting, colicky pain, positive Murphy sign, or fever: CBC for white blood cell count, lipase, bilirubin, LFTs, right upper quadrant ultrasonography12

If blood in the stool, emesis, or melena: CBC for hemoglobin and hematocrit, fecal occult blood test12

If begins after 20 weeks estimated gestational age and there are headaches, vision changes, abdominal pain, high blood pressure, or proteinuria: CBC for platelets, LFTs, consultation with primary maternity care clinician12

Cough

For all: vital signs with pulse oximetry; ears, nose, throat, and lung examination17

Prevention: hand/cough hygiene, hydration, inactivated influenza and Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccines18,19

If wheezing, fever, hypoxemia, shortness of breath, hemoptysis: consider chest radiography, CBC17

For specific causes

Physiologic rhinitis: nasal saline sprays, nasal opening strips20,21

Asthma: albuterol, inhaled corticosteroids, oral steroids for exacerbations

Allergic rhinitis: antihistamines, nasal steroids20,21

Influenza: administer oseltamivir (Tamiflu) as soon as possible

Pneumonia: antibiotics as indicated

Pertussis: azithromycin (Zithromax)

If myalgia or fever, or it is influenza season: consider empiric influenza therapy, hospitalization, and consultation with primary maternity care clinician17

Rash

For all: full examination of rash; note distribution, appearance, associated symptoms, and timing

Prevention: preconception varicella vaccine (contraindicated during pregnancy)

Based on characteristics

Blisters: consider Tzanck test or herpes simplex virus polymerase chain reaction testing, consultation with primary maternity care clinician

Suspected chickenpox: consider varicella-zoster immune globulin, consultation with primary maternity care clinician

Itching but no rash: LFTs, serum bile acids, consultation with primary maternity care clinician

Scaly: consider potassium hydroxide skin scraping test

Pustular: consider culturing pus

Continue most therapies for chronic conditions,2227 except for methotrexate and retinoids (contraindicated in pregnancy)

If diagnosis still unclear: consider biopsy

Selective use of acute therapy: topical steroids, antihistamines, topical antifungals, antibiotics

Consultation with primary maternity care clinician when considering antivirals for varicella or herpes, or ursodiol (Actigall) for intrahepatic cholestasis of pregnancy28,29

Dysuria

For all: vital signs, assessment of mucous membranes, examination for abdominal/costovertebral angle tenderness, vulvar inspection, UA with microscopy, urine culture30,31

For cystitis/asymptomatic bacteriuria

Initial choice for most: first-generation cephalosporins, nitrofurantoin (avoid at term), penicillins, erythromycins35

Consider if initial choices fail: amoxicillin/clavulanate (Augmentin)35

If UA results show a substantial number of epithelial cells, physiologic leukorrhea contamination should be suspected unless culture shows more than 100,000 colony-forming units of one organism3234

For vulvovaginal candidiasis

Routine, low-risk therapy: oral nystatin, vaginal clotrimazole, vaginal miconazole

For refractory cases: other vaginal azoles

Avoid oral fluconazole (Diflucan) in a dosage of 400 to 800 mg per day; caution also advised for low-dose oral fluconazole

If no clear diagnosis and UA findings are abnormal: vaginal examination with wet mount and urinary gonorrhea/chlamydia testing, empiric antibiotics for urinary tract infection pending urine culture results

For pyelonephritis

Intravenous antibiotics

For stones: hydration, pain management, urology consultation

If history of asymptomatic bacteriuria or one urinary tract infection: consider prophylactic nitrofurantoin until pregnancy is at term30,31

If costovertebral angle tenderness or fever: CBC, renal ultrasonography, intravenous antibiotics

Occurs at more than 20 weeks estimated gestational age: consultation with primary maternity care clinician to monitor for preterm labor and fetal well-being

If colicky flank pain or gross hematuria: renal ultrasonography, urology consultation

Low back pain

If there are urologic red flags (Table 1): UA with culture, consider renal ultrasonography and urology consultation

For musculoskeletal low back pain: low back stretching exercises, water exercises, physical therapy, job and activity modification, warm baths, lumbar traction, supportive devices (prenatal cradles, sacroiliac joint belts), acetaminophen, acupuncture36,37

If there are neurologic red flags (Table 1): neurosurgical consultation, magnetic resonance imaging of spine

If refractory and no red flags: consider epidural steroids36,37

If there are obstetric red flags: consultation with primary maternity care clinician

Headache

For all: blood pressure, UA, neurologic examination, funduscopy, nasal examination38

For sinusitis: amoxicillin

If headache not relieved with acetaminophen and rest, or there is scotomata, elevated blood pressure, or proteinuria: CBC, LFTs, consultation with primary maternity care clinician

For suspected meningitis: third-generation cephalosporins; consider vancomycin, acyclovir, dexamethasone3941

If focal neurologic signs or symptoms: shielded noncontrast head CT, neurology consultation; if CT is negative, consider magnetic resonance venography or angiography3941

For migraine

Lowest-risk therapy: acetaminophen; antiemetic; rest in a dark, quiet environment42

For severe or refractory migraines significantly affecting nutrition, hydration, or functioning (use these medications with caution, and explain potential risks to patients): sumatriptan (Imitrex), dexamethasone (brief, isolated use; avoid during first trimester), ketorolac (second trimester only)3941

Dihydroergotamine is contraindicated in pregnancy

If meningitis or subarachnoid hemorrhage is suspected: shielded noncontrast CT; consider lumbar puncture if CT results are normal3941


Information from references 5 through 42.

Common Symptoms During Pregnancy

NAUSEA AND VOMITING

About one-half of pregnant women have nausea and vomiting during pregnancy.43 Nausea and vomiting in pregnancy increases the risk of dehydration, poor function, poor weight gain, and, if severe, acute renal failure and impaired fetal growth. Benign nausea and vomiting of pregnancy is the most common obstetric cause and tends to begin by four weeks estimated gestational age and resolve by the end of 12 weeks estimated gestational age.5 If it begins or ends outside of these intervals or is severe or refractory, less common obstetric causes (e.g., multiple gestation, molar pregnancy) and nonobstetric causes (e.g., gallbladder problems, thyroid disease) should be considered.6

Despite increased availability of prescription therapies for nausea in pregnancy, not all women require prescription antiemetics, and the safety of these therapies is not as clear as conservative treatments.7,8 First-line treatments include low-risk lifestyle modifications, such as eating frequent small meals throughout the day to keep the stomach from becoming too empty or full, and avoiding foods that further slow gastric emptying (high-protein or fatty foods) or have intense smells or tastes.7,8 If these conservative approaches are ineffective, other therapies, including vitamin B6 (pyridoxine), over-the-counter antihistamines such as doxylamine, and natural ginger (less than 1,500 mg per day), can be added in a stepwise fashion.7,9,10 There is weak evidence that P6 acupressure can also be a treatment option7 (a video of this therapy is available at https://www.mskcc.org/cancer-care/patient-education/acupressure-nausea-and-vomiting). [corrected]

Combination doxylamine 10 mg/pyridoxine 10 mg (Diclegis) is approved by the U.S. Food and Drug Administration for the prevention of nausea and vomiting in pregnancy. The combination may improve compliance because it includes fewer pills but can also be much more expensive than each medication alone.

Prescribed antiemetics such as metoclopramide (Reglan) and trimethobenzamide (Tigan) are reserved for severe or refractory cases.9,10 However, there are safety concerns with some prescribed antiemetics, such as promethazine, which has a risk of neonatal respiratory depression near term or during labor, and ondansetron (Zofran), which physicians should consider avoiding in the first trimester because of conflicting data on the risk of teratogenicity.911

EPIGASTRIC PAIN/GASTROESOPHAGEAL REFLUX

Gastroesophageal reflux disease is common in pregnancy and is attributed to progesterone-mediated relaxation of the lower esophageal sphincter, which increases the frequency and severity of gastric reflux. Other conditions that present as heartburn-like discomfort during pregnancy include peptic ulcer disease, preeclampsia (i.e., HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome),12 cholecystitis, and acute fatty liver of pregnancy.

If the discomfort is atypical for reflux, persistent, or severe, or if it begins after 20 weeks estimated gestational age in combination with other concerning symptoms (Table 3542), the patient should be evaluated for conditions other than reflux.

An elevated alkaline phosphatase level is normal during pregnancy. However, an elevated lipase, bilirubin, or transaminase level requires ultrasound evaluation for cholecystitis, especially in the presence of severe colicky abdominal pain or other suggestive findings (e.g., positive Murphy sign, leukocytosis, fever). Peptic ulcer disease should be considered if results of laboratory tests such as complete blood count, liver panel, and lipase level are normal and reflux therapies are ineffective.

No one therapy for gastroesophageal reflux has been proven superior; therefore, prioritizing therapy depends on relative risks and adverse effects.13 Initial therapies for gastroesophageal reflux of pregnancy include low-risk lifestyle interventions such as eating frequent small meals and avoiding smoking, caffeine, peppermint, and chocolate. Next choices generally include over-the-counter antacids that do not contain salicylates (found in bismuth combination products) and over-the-counter cimetidine (Tagamet), famotidine (Pepcid), or ranitidine (Zantac). Proton pump inhibitors are reserved for severe or refractory cases because of cautions advised during pregnancy and should be considered only in consultation with a primary maternity care clinician.1416 Whatever the suspected cause, an esophagogastroduodenoscopy should be performed only for serious indications, such as significant gastrointestinal bleeding, and is safer in the second trimester compared with the first.44

COUGH

Apart from physiologic rhinitis of pregnancy, upper respiratory tract conditions are not usually caused by the normal hormonal, anatomic, and circulatory effects of pregnancy.45 In patients with preexisting chronic conditions, such as asthma, management of the condition is similar during pregnancy, although therapies can be adjusted based on safety data.46,47 Evaluation of acute cough should consider acute asthma exacerbation, allergic reaction, and viral and bacterial infections.17 Although cough alone is not indicative of pulmonary embolism, because of the increased risk of pulmonary embolism in pregnancy, the condition should be considered whenever cough is associated with chest pain or shortness of breath.

Common symptoms associated with cough include nasal congestion, rhinorrhea, pharyngitis, shortness of breath, and chest discomfort. In the absence of a concerning diagnosis, the symptoms can be treated with the usual prescription and over-the-counter therapies.20,21 Prevention of upper respiratory tract illnesses through hand/cough hygiene and the inactivated influenza and Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccines is essential. Although a case-control study found a possible relationship between the influenza vaccine and miscarriage in a subset of patients, current evidence supports the safety of the vaccine in pregnancy.18,19

RASH

Skin conditions that arise or worsen during pregnancy can be due to hormonal and other physiologic changes of pregnancy.48,49 Most of these conditions do not impact pregnancy outcomes.50,51 Benign skin conditions of pregnancy include melasma (eFigure A) and striae gravidarum (eFigure B). Signs and symptoms of dermatoses in pregnancy include pruritus, papules, and plaques. Notably, pruritic urticarial papules and plaques of pregnancy spare the umbilicus (eFigure C). Treatment of skin conditions in pregnancy typically involves antihistamines, topical steroids, or oral steroid tapers.2227

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eFIGURE A

Melasma.

Image used with permission from VisualDx.


eFIGURE A

Melasma.

Image used with permission from VisualDx.

 Enlarge     Print

eFIGURE B

Striae gravidarum (stretch marks).

Reprinted with permission from Tunzi M, Gray GR. Common skin conditions during pregnancy. Am Fam Physician. 2007;75(2):215.


eFIGURE B

Striae gravidarum (stretch marks).

Reprinted with permission from Tunzi M, Gray GR. Common skin conditions during pregnancy. Am Fam Physician. 2007;75(2):215.

 Enlarge     Print

eFIGURE C

Pruritic urticarial papules and plaques of pregnancy. The rash presentation can vary; two examples are shown.

Reprinted with permission from Tunzi M, Gray GR. Common skin conditions during pregnancy. Am Fam Physician. 2007;75(2):212.


eFIGURE C

Pruritic urticarial papules and plaques of pregnancy. The rash presentation can vary; two examples are shown.

Reprinted with permission from Tunzi M, Gray GR. Common skin conditions during pregnancy. Am Fam Physician. 2007;75(2):212.

Intrahepatic cholestasis of pregnancy, which causes pruritus without a rash, has been associated with increased fetal mortality, warranting antenatal surveillance in consultation with a primary maternity care clinician. Intrahepatic cholestasis of pregnancy is treated with ursodiol (Actigall) in consultation with a primary maternity care clinician, although the therapy leads to only slightly better fetal and maternal outcomes than placebo. Cholestyramine (Questran) has been used, but it only reduces pruritus.28 Delivery by 35 to 37 weeks estimated gestational age may be warranted if bile acid levels are more than 16.3 mcg per mL (40 μmol per L).29

DYSURIA

Although frequency and urgency are normal as the uterus enlarges in the later stages of pregnancy, dysuria may be a result of cystitis, pyelonephritis, or sexually transmitted infections, which can lead to maternal and fetal morbidity.30,31 In pregnant women who have more than 100,000 colony-forming units of one bacterial species on urine culture, starting antibiotics early is necessary to reduce the risk of pyelonephritis, even in those who are asymptomatic.3234

The choice of an appropriate oral antibiotic (e.g., penicillins, such as amoxicillin; first-generation cephalosporins; erythromycin; nitrofurantoin) is based on known drug risks during pregnancy, patient drug allergies, and bacterial resistance patterns.35 Nitrofurantoin is not used at term because of the risk of severe hemolytic anemia following birth. Trimethoprim/sulfamethoxazole is generally not recommended for use in pregnancy because of risks of neural tube defects in early pregnancy, as well as kernicterus in the newborn and permanent neonatal neurologic damage. [corrected] A systematic review found that of the nonantibiotic measures taken to prevent urinary tract infections during pregnancy, only genital hygiene can be recommended in practice.52

Because bacteriuria increases the risk of preterm labor, urinary cultures should be checked after treatment for asymptomatic bacteriuria, cystitis, or pyelonephritis to ensure bacteriuria resolves and does not recur. A follow-up urinary culture should be performed for test of cure. It is prudent to repeat follow-up cultures periodically.

LOW BACK PAIN

Low back pain often occurs during pregnancy because of musculoskeletal strain from increased lordosis and soft tissue laxity. However, urologic and neurologic red flags (Table 1) should be identified and treated. Acute low back pain should be more rigorously evaluated when associated with a history of trauma, vaginal bleeding, severe abdominal pain, loss of fluid, uterine contractions, uterine tenderness, change in fetal movement, or urinary tract symptoms. This evaluation (in consultation with a primary maternity care clinician) should be focused on ruling out obstetric complications of trauma, such as abruption, combined with systematic monitoring for uterine contractions and fetal heart rate, and possibly fetal ultrasonography.36

Treatment of back pain in pregnant women targets alleviating musculoskeletal strain with exercises and physical therapy. Additional therapy such as acetaminophen, acupuncture, support devices, warm baths, or epidural steroids may be needed.36,37 A systematic review found that osteopathic manipulative treatment may improve function and reduce pelvic girdle and low back pain during and after pregnancy.53

HEADACHES

New-onset headaches or a new type of headache in pregnancy warrants further evaluation to distinguish urgent or emergent causes (e.g., meningitis, subarachnoid hemorrhage) from common preexisting conditions (e.g., sinusitis, tension or migraine headaches).38,40,42 Preeclampsia must be ruled out in all pregnant women with headache who are more than 20 weeks' gestation by monitoring serial blood pressures and assessing urine for protein in consultation with a primary maternity care clinician.40,42

Tension and migraine headaches can lead to significant morbidity.42 Acetaminophen is an initial, low-risk therapy. Other drugs such as sumatriptan (Imitrex), dexamethasone (brief, isolated use; avoid during the first trimester), and ketorolac (second trimester only) can be used with caution, after the potential risks are explained to the patient, for severe or refractory headaches that significantly affect the patient's nutrition, hydration, or functioning. When headaches are associated with sudden onset, focal neurologic symptoms and findings, fever, or neck stiffness, further emergent workup, initially with shielded head computed tomography and possibly lumbar puncture, is warranted.3941

Data Sources: The authors searched the Cochrane database, National Guideline Clearinghouse, UpToDate, and Ovid/PubMed, as well as references within these sources. Key words included pregnancy, rash, skin, asthma, upper respiratory infection, infection, nonobstetric complaints, nausea, dyspepsia, heartburn, low back pain, headache, urinary tract infection, back pain, and lumbar pain. Search dates: March 1 to November 7, 2016, and June 19 to July 3, 2018.

The Authors

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DAVID S. GREGORY, MD, is program director of the Centra Lynchburg (Va.) Family Medicine Residency. He is also an associate clinical/adjunct professor at the University of Virginia School of Medicine in Charlottesville, Virginia Commonwealth University School of Medicine in Richmond, and Liberty University College of Osteopathic Medicine in Lynchburg....

VELYN WU, MD, is assistant director of sports medicine at the Centra Lynchburg Family Medicine Residency. She is also an assistant clinical professor in the Department of Family Medicine at the University of Virginia School of Medicine and the Virginia Commonwealth University.

PREYASHA TULADHAR, MD, is a third-year resident at the Centra Lynchburg Family Medicine Residency.

Address correspondence to David S. Gregory, MD, Centra Health, 2323 Memorial Ave. 8, Ste. 10, Lynchburg, VA 24501 (e-mail: runfamdoc@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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1. Coco A. How often do physicians address other medical problems while providing prenatal care? Ann Fam Med. 2009;7(2):134–138....

2. Mitchell AA, Gilboa SM, Werler MM, et al. Medication use during pregnancy, with particular focus on prescription drugs: 1976–2008. Am J Obstet Gynecol. 2011;205(1):51.e1–51.e8.

3. Briggs GG, Freeman RK. Drugs in Pregnancy and Lactation. 11th ed. Philadelphia, Pa.: Lippincott Williams and Wilkins; 2017.

4. U.S. Department of Health and Human Services. Pregnancy, lactation, and reproductive potential: labeling for human prescription drug and biological products—content and format. Guidance for industry. June 2015. https://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM450636.pdf. Accessed May 22, 2018.

5. Gadsby R, Barnie-Adshead AM, Jagger C. A prospective study of nausea and vomiting during pregnancy [published correction appears in Br J Gen Pract. 1993;43(373):325]. Br J Gen Pract. 1993;43(371):245–248.

6. Zielinski R, Searing K, Deibel M. Gastrointestinal distress in pregnancy. J Perinat Neonatal Nurs. 2015;29(1):23–31.

7. Matthews A, et al. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. 2015;(9):CD007575.

8. Boelig RC, Barton SJ, Saccone G, et al. Interventions for treating hyper-emesis gravidarum. Cochrane Database Syst Rev. 2016;(5):CD010607.

9. Herrell HE. Nausea and vomiting of pregnancy. Am Fam Physician. 2014;89(12):965–970.

10. McParlin C, O'Donnell A, Robson SC, et al. Treatments for hyperemesis gravidarum and nausea and vomiting in pregnancy. JAMA. 2016;316(13):1392–1401.

11. Lavecchia M, Chari R, et al. Ondansetron in pregnancy and the risk of congenital malformations. J Obstet Gynaecol Can. 2018;40(7):910–918.

12. American College of Obstetricians and Gynecologists. Hypertension in pregnancy. Obstet Gynecol. 2013;122(5):1122–1131.

13. Phupong V, Hanprasertpong T. Interventions for heartburn in pregnancy. Cochrane Database Syst Rev. 2015;(9):CD011379.

14. Pasternak B, Hviid A. Use of proton-pump inhibitors in early pregnancy and the risk of birth defects. N Engl J Med. 2010;363(22):2114–2123.

15. Gerson LB. Treatment of gastroesophageal reflux disease during pregnancy. Gastroenterol Hepatol (N.Y.). 2012;8(11):763–764.

16. Gill SK, O'Brien L, et al. The safety of proton pump inhibitors (PPIs) in pregnancy: a meta-analysis. Am J Gastroenterol. 2009;104(6):1541–1545.

17. Hameed AB. Cardiac and pulmonary disorders in pregnancy. In: DeCherney AH, ed. Current Diagnosis and Treatment: Obstetrics and Gynecology. 11th ed. New York, NY: McGraw-Hill/Medical; 2013.

18. Donahue JG, Kieke BA, King JP, et al. Association of spontaneous abortion with receipt of inactivated influenza vaccine containing H1N1pdm09 in 2010–11 and 2011–12. Vaccine. 2017;35(40):5314–5322.

19. Meijer WJ, van Noortwijk AG, Bruinse HW, et al. Influenza virus infection in pregnancy. Acta Obstet Gynecol Scand. 2015;94(8):797–819.

20. Laibl V, Sheffield J. The management of respiratory infections during pregnancy. Immunol Allergy Clin North Am. 2006;26(1):155–172.

21. Servey J, Chang J. Over-the-counter medications in pregnancy [published correction appears in Am Fam Physician. 2015;92(5):332]. Am Fam Physician. 2014;90(8):548–555.

22. Tunzi M, Gray GR. Common skin conditions during pregnancy. Am Fam Physician. 2007;75(2):211–218.

23. Stephenson-Famy A, Gardella C. Herpes simplex virus infection during pregnancy. Obstet Gynecol Clin North Am. 2014;41(4):601–614.

24. DiCarlo A, Amon E, et al. Eczema herpeticum in pregnancy and neonatal herpes infection. Obstet Gynecol. 2008;112(2 pt 2):455–457.

25. Müllegger RR, Häring NS, Glatz M. Skin infections in pregnancy. Clin Dermatol. 2016;34(3):368–377.

26. Tyler KH. Dermatologic therapy in pregnancy. Clin Obstet Gynecol. 2015;58(1):112–118.

27. Danesh M, Pomeranz MK, McMeniman E, Murase JE. Dermatoses of pregnancy. Clin Dermatol. 2016;34(3):314–319.

28. Reyes H, Sjövall J. Bile acids and progesterone metabolites in intrahepatic cholestasis of pregnancy. Ann Med. 2000;32(2):94–106.

29. Geenes V, Chappell LC, Seed PT, et al. Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy outcomes. Hepatology. 2014;59(4):1482–1491.

30. Smaill FM, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev. 2015;(8):CD000490.

31. Mittendorf R, Williams MA, Kass EH. Prevention of preterm delivery and low birth weight associated with asymptomatic bacteriuria. Clin Infect Dis. 1992;14(4):927–932.

32. Widmer M, Lopez I, et al. Duration of treatment for asymptomatic bacteriuria during pregnancy. Cochrane Database Syst Rev. 2015;(11):CD000491.

33. Vazquez JC, Abalos E. Treatments for symptomatic urinary tract infections during pregnancy. Cochrane Database Syst Rev. 2011;(1):CD002256.

34. Schneeberger C, Geerlings SE, Middleton P, Crowther CA. Interventions for preventing recurrent urinary tract infection during pregnancy. Cochrane Database Syst Rev. 2015;(7):CD009279.

35. Delzell JE Jr, LeFevre ML. Urinary tract infections during pregnancy [published correction appears in Am Fam Physician. 2000;61(12): 3567]. Am Fam Physician. 2000;61(3):713–721.

36. Sabino J, Grauer JN. Pregnancy and low back pain. Curr Rev Musculoskelet Med. 2008;1(2):137–141.

37. Liddle S, et al. Interventions for preventing and treating low-back and pelvic pain during pregnancy. Cochrane Database Syst Rev. 2015;(9):CD001139.

38. Sperling J, Dahlke JD, Huber WJ, Sibai BM. The role of headache in the classification and management of hypertensive disorders in pregnancy. Obstet Gynecol. 2015;126(2):297–302.

39. Schoen JC, Campbell RL, Sadosty AT. Headache in pregnancy. West J Emerg Med. 2015;16(2):291–301.

40. Ramchandren S, Cross BJ, Liebeskind DS. Emergent headaches during pregnancy: correlation between neurologic examination and neuroimaging. AJNR Am J Neuroradiol. 2007;28(6):1085–1087.

41. Raffaelli B, Siebert E, Körner J, et al. Characteristics and diagnoses of acute headache in pregnant women. J Headache Pain. 2017;18(1):114.

42. Robbins M, Farmakidis C, Dayal AK, Lipton RB. Acute headache diagnosis in pregnant women. Neurology. 2015;85(12):1024–1030.

43. ACOG. Practice bulletin 189. Nausea and vomiting of pregnancy. 2018.

44. Shergill AK, Ben-Menachem T, et al. Guidelines for endoscopy in pregnant and lactating women [published correction appears in Gastrointest Endosc. 2013;77(5):833]. Gastrointest Endosc. 2012;76(1):18–24.

45. Hegewald MJ, Crapo RO. Respiratory physiology in pregnancy. Clin Chest Med. 2011;32(1):1–13.

46. Kelly W, Massoumi A, Lazarus A. Asthma in pregnancy: physiology, diagnosis, and management. Postgrad Med. 2015;127(4):349–358.

47. Vanders RL, Murphy VE. Maternal complications and the management of asthma in pregnancy. Womens Health (Lond). 2015;11(2):183–191.

48. Vora RV, Gupta R, Mehta MJ, et al. Pregnancy and skin. J Family Med Prim Care. 2014;3(4):318–324.

49. Winkel AF. Dermatologic disorders in pregnancy. In: DeCherney AH, ed. Current Diagnosis and Treatment: Obstetrics and Gynecology. 11th ed. New York, NY: McGraw-Hill/Medical; 2013.

50. Elston CA, Elston DM. Treatment of common skin infections and infestations during pregnancy. Dermatol Ther. 2013;26(4):312–320.

51. Adler H, Lambert JS. Clinical focus: infections in pregnancy. Hosp Pract (1995). 2014;42(2):108–124.

52. Ghouri F, Hollywood A, Ryan K. A systematic review of non-antibiotic measures for the prevention of urinary tract infections in pregnancy. BMC Pregnancy Childbirth. 2018;18(1):99.

53. Franke H, Franke JD, et al. Osteopathic manipulative treatment for low back and pelvic girdle pain during and after pregnancy. J Bodyw Mov Ther. 2017;21(4):752–762.

 

 

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