Common symptom	Evaluation	Treatment
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 acupressure^7,8 Medications: vitamin B₆ (pyridoxine), over-the-counter antihistamines (doxylamine), natural ginger (less than 1,500 mg per day)^7–10; 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 trimester^9–11; 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 age^5,6: 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)^14–16
	If fever or abdominal pain: CBC, LFTs¹²	For severe or refractory cases: proton pump inhibitors, only in consultation with primary maternity care clinician^14–16
	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) vaccines^18,19
	If wheezing, fever, hypoxemia, shortness of breath, hemoptysis: consider chest radiography, CBC¹⁷	For specific causes Physiologic rhinitis: nasal saline sprays, nasal opening strips^20,21 Asthma: albuterol, inhaled corticosteroids, oral steroids for exacerbations Allergic rhinitis: antihistamines, nasal steroids^20,21 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,^22–27 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
	If diagnosis still unclear: consider biopsy	Consultation with primary maternity care clinician when considering antivirals for varicella or herpes, or ursodiol (Actigall) for intrahepatic cholestasis of pregnancy^28,29
Dysuria	For all: vital signs, assessment of mucous membranes, examination for abdominal/costovertebral angle tenderness, vulvar inspection, UA with microscopy, urine culture^30,31	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 organism^32–34	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 term^30,31
	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, acupuncture^36,37
	If there are neurologic red flags (Table 1): neurosurgical consultation, magnetic resonance imaging of spine	If refractory and no red flags: consider epidural steroids^36,37
	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, dexamethasone^39–41
	If focal neurologic signs or symptoms: shielded noncontrast head CT, neurology consultation; if CT is negative, consider magnetic resonance venography or angiography^39–41	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)^39–41 Dihydroergotamine is contraindicated in pregnancy
	If meningitis or subarachnoid hemorrhage is suspected: shielded noncontrast CT; consider lumbar puncture if CT results are normal^39–41