Maintaining a healthy diet during pregnancy
Healthy eating and keeping physically active during pregnancy is recommended for women to stay healthy and to prevent excessive weight gain. A healthy diet is particularly important during pregnancy to support the health of both mother and baby. Pregnant women do not need to go on a special diet but should be reminded it is important to eat a variety of different foods every day to get the right balance of nutrients for themselves and their baby.(1)
There is no need to 'eat for two', even though women might find that they are hungrier than usual.(1) Where appropriate, advice should include eating five portions of fruit and vegetables a day and one portion of oily fish (eg mackerel, sardines, pilchards, herring, trout or salmon) a week. The importance of washing fresh fruit and vegetables should also be reiterated.(2)
Most foods are safe for consumption in pregnancy, but there are some that should be avoided. Pregnant women should be advised on how to reduce the risk of food-acquired infections such as listeriosis. Pregnant women should be advised that:(1)
- only pasteurised milk should be consumed
- ripened soft cheeses such as brie should be avoided
- pâté of any sort should not be consumed
- uncooked or undercooked ready prepared meals should be avoided
- raw or partially cooked eggs or foods that may contain them (eg mayonnaise) should be avoided
- British lion eggs (with a lion stamp on them) are safe for consumption
- raw or partially cooked meat should be avoided
- raw shellfish, as well as swordfish and marlin, should all be avoided to reduce the risk of food poisoning.
Caffeine can be consumed by pregnant women in moderation. The NHS advises reducing caffeine intake to no more than 200mg a day. This is equivalent to one cup of coffee a day or two or three cups of tea.(3) The NHS recommends that if you are pregnant or planning to become pregnant, the safest approach is to avoid alcohol completely to keep risks to the baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby. It can be helpful to inform pregnant women that the risk of harm to their baby is likely to be low if they have consumed only small amounts of alcohol before knowing they were pregnant or during pregnancy.(4)
Those who are pregnant or intending to get pregnant should take a folic acid supplement, because it can be difficult to get the amount of folate recommended for a healthy pregnancy from food alone. It is recommended for women to take 400 micrograms of folic acid each day, starting before pregnancy occurs, until they are 12 weeks pregnant. Taking folic acid can help prevent birth defects known as neural tube defects, including spina bifida. Those at higher risk of pregnancy being affected by neural tube defects may be asked to take 5mg of folic acid.(1)
Pregnant women with low iron levels may experience tiredness and suffer from anaemia. However, iron supplementation should not be routinely offered to all pregnant women. It is recommended that pregnant women eat foods rich in iron such as lean meat, green leafy vegetables, dried fruit and nuts. Those with low iron levels may be advised by their GP or midwife to take iron supplements.(1,5)
Pregnant women should not take vitamin A supplements (above 700 micrograms) as this can be teratogenic. Women should be informed that liver and liver products may contain high levels of vitamin A, and therefore consumption should be avoided.(5)
All pregnant women should be advised to consider taking a vitamin D supplement between the months of September and March, at a recommended dose of 10 micrograms daily. Vitamin D is important in maintaining the health of bones, teeth and muscles. It can be found in some foods including oily fish, eggs and red meat. Those at particular risk of not having enough vitamin D include those with darker skin and those who do not often expose their skin to the sun. These groups may wish to consider taking a daily supplement of vitamin D all year round.(1)
Pregnant women should be informed that beginning or continuing with a moderate course of exercise during pregnancy is not associated with adverse outcomes.(5) Exercise in pregnancy can help with labour. Advice includes continuing with normal daily activity for as long as is comfortable. Tips for remaining active safely during pregnancy include staying hydrated and always warming up and cooling down.(6)
Women should be informed of the potential dangers of certain activities during pregnancy, for example contact sports, high‑impact sports and vigorous racket sports that may involve the risk of abdominal trauma, falls or excessive joint stress, and scuba diving, which may result in foetal birth defects and foetal decompression disease.(5)
Nausea and vomiting in pregnancy
Nausea and vomiting are the most common symptoms of pregnancy. As a result, the pharmacy team should be familiar with giving advice to patients, including non-pharmacological treatment options and self-help advice.(5) Nausea and vomiting affects up to 80% of pregnant women and in about 35% of these women, symptoms are of clinical relevance.(7) Although it is usually referred to as “morning sickness”, symptoms persist over the whole day for many women, with a broad spectrum of severity ranging from occasional nausea to severe and continuous vomiting.
Nausea and vomiting begin in the first trimester, typically between four to seven weeks gestation, typically peaking at about nine weeks gestation and settling by about 12 weeks.(7) Most symptoms will resolve spontaneously within 16 to 20 weeks of pregnancy.(1) Adequate oral hydration and avoidance of dietary triggers are often sufficient, but a proportion of women with severe and protracted nausea and vomiting will need antiemetic treatment in the form of antihistamines. A severe form of nausea and vomiting in pregnancy, known as hyperemesis gravidarum, affects 0.3-3.6% of pregnancies.(7)
What are the causes?
Nausea and vomiting in pregnancy are mediated by placentally derived human chorionic gonadotrophin (HCG) and symptoms typically begin when concentrations are at their highest – at around nine weeks’ gestation. Hyperemesis gravidarum is reported more often in women with high concentrations of HCG (for example, those with multiple and molar pregnancies). Thyroid function may be physiologically altered during pregnancy because the structural homology between HCG, thyroid stimulating hormone and their receptors facilitates cross-reactivity between these two hormones. One prospective study found evidence of transient hyperthyroidism in 60% of women with hyperemesis gravidarum. The degree of HCG concentrations correlates with the severity of vomiting. Higher concentrations of progesterone, adrenocorticotrophic hormone and leptin have also been associated with hyperemesis gravidarum.(8)
Non-pharmacological management is usually a sufficient treatment option to elevate symptoms of morning sickness. Therefore, counselling offered by pharmacy teams is vitally important in improving patient outcomes.
These are some helpful tips for patients, including complementary treatments:(7)
- Reassure the woman that nausea and vomiting is a normal part of pregnancy that usually resolves by 16 to 20 weeks of gestation, and that pregnancy outcomes are generally better for women who have nausea and vomiting in early pregnancy.
- Advise rest.
- Advise avoiding any foods or smells that trigger symptoms (for example spicy or fatty foods). Cold meals may be more easily tolerated if nausea is smell-related.
- Advise eating plain biscuits or crackers in the morning before getting up.
- Advise eating bland, small, frequent meals that are low in carbohydrate and fat but high in protein.
- Advise drinking little and often rather than large amounts, as this may help to prevent vomiting.
- Suggest that ginger can be helpful.
- Acupressure is an option.
- Consider advising avoiding or changing iron-containing preparations if they make symptoms worse.
When to seek medical help
Advise all women with nausea and vomiting in pregnancy to seek medical help if they experience:(7)
- very dark urine or no urination for more than eight hours
- abdominal pain or fever
- severe weakness or feeling faint
- vomiting blood
- repeated, unstoppable vomiting
- inability to keep down food or fluids for 24 hours
- severe headache, visual problems, severe pain below the ribs, sudden swelling of the face, hands, or feet (symptoms of pre-eclampsia).
How to spot danger signs of serious conditions in pregnancy
Pre-eclampsia is a combination of hypertension (raised blood pressure) and proteinuria in pregnancy (the presence of protein in your urine). Pre-eclampsia usually comes on some time after the 20th week of pregnancy and resolves within six weeks of giving birth. Although most cases of pre-eclampsia cause no problems and improve soon after the baby is delivered, there is a risk of serious complications that can affect both the mother and her baby. Mild pre-eclampsia affects up to 6% of pregnancies, and severe cases develop in about 1 to 2% of pregnancies.
If the patient has a persistent severe headache, abdominal pain, visual disturbance, heartburn that does not improve with antacids or rapidly increasing swelling of the face, hands or feet, then it is important for them to go see their doctor or contact their antenatal clinic because these could be signs of pre-eclampsia.(9)
A miscarriage is the loss of a pregnancy during the first 23 weeks.(10) Any loss from 24 weeks onwards is referred to as a stillbirth.(11) It is estimated that about one in eight pregnancies will end in miscarriage among women who know they are pregnant. Losing three or more pregnancies in a row (recurrent miscarriages) is uncommon and only affects around 1 in 100 women.(10) Most miscarriages cannot be prevented.
Causes can include:(11)
- blood clotting problems
The most common early signs and symptoms of a miscarriage are:(10)
- vaginal bleeding that can be anything from light spotting to a heavy bleed, perhaps with some blood clots
- strong period-type cramping pains
- any discharge of fluid or tissue from the vagina
- lack or loss of pregnancy symptoms can sometimes be a sign of miscarriage, but that does not necessarily mean there is a problem.
If a pregnant woman presents in the pharmacy with any of these symptoms, they should be referred to their midwife or doctor immediately. However, it is important to reassure those affected that light vaginal bleeding is relatively common during the first trimester of pregnancy and does not necessarily indicate a miscarriage.(10) Pharmacists should be mindful of the emotional impact miscarriage can have on women and their partners. Signposting to organisations such as the Miscarriage Association for support can be helpful.
Deep Vein Prophylaxis (DVT)
DVT is not common in pregnancy but pregnant women at any stage of pregnancy, and up to six weeks after birth, are five to 10 times more likely to develop DVT than non-pregnant women.(12) The most common symptoms are swelling, pain or tenderness in one of the legs, warm skin in the affected area or red skin at the back of the leg. If DVT is suspected then patients should see their doctor or midwife as soon as possible. Risk factors can include being aged over 35 years, obesity, carrying multiple babies and smoking.
Advice that can provided to reduce the risk of DVT includes:(13)
- staying active
- wearing graduated elastic compression stockings
- keeping hydrated by drinking normal amounts of fluids
- stopping smoking
- losing weight before pregnancy if overweight.
Other Common health issues in pregnant women
Fainting in pregnancy can occur due to hypotension, due to the circulation expanding and hormonal changes causing the blood vessels to dilate. To reduce symptoms, pregnant women can be advised to get up slowly from sitting or standing, to sit down quickly if feeling faint and avoid lying on their back after 28 weeks gestation. Swelling can occur due to increased blood volume and water retention. Swelling of gradual onset is not usually harmful but a sudden increase in swelling can be a sign of pre-eclampsia.(14) All pregnant women will be screened for anaemia and offered treatment if appropriate. Blood pressure is also monitored regularly throughout pregnancy. Those at risk will receive appropriate advice and care from their midwife.(15)
Back pain is a common symptom in pregnancy. This is caused by the hormone relaxin causing ligaments to stretch and soften around the body and the mother carrying extra weight and having an altered posture.(16,17). Advice to reduce symptoms includes remaining active, warm baths and paracetamol.(17)
Pelvic ligament pain and girdle pain are other common symptoms of pregnancy. These are caused by the softening and stretching of ligaments combined with pressure of a growing womb. Women can discuss these symptoms with their midwife, who can provide advice on exercise and physiotherapy.(17)
Frequent urination can occur due to increased pressure on the bladder from the growing uterus and baby and the relaxed pelvic floor muscles. In this case, it is useful to reduce fluids at night and refer to the patient to their doctor or midwife if there is any blood or pain associated. Any pain while passing urine or blood in in urine could indicate a urinary tract infection, warranting referral to a doctor or midwife.
Pregnant women are at increased risk of vaginal thrush. Those affected should seek treatment from their doctor or midwife. Oral treatment with fluconazole is contra-indicated in pregnancy, although treatment with clotrimazole as a cream or pessary is appropriate under the supervision of a doctor or midwife.(14) Pessaries should be inserted without using an applicator in pregnancy.(15)
Tiredness is a common symptom of pregnancy. In the first trimester, this is thought to be caused by hormonal changes. In the third trimester, this is exacerbated by the extra weight being carried by the mother. In addition, sleep problems can be amplified by frequent urination and discomfort when lying down. Women should be reminded to rest when they can and to look after their physical health.(19)
Gestational diabetes may develop during the second or third trimester of pregnancy and usually disappears after giving birth, although it does not usually cause any symptoms. Some women may develop symptoms such as increased thirst, frequent urination, a dry mouth or tiredness. Although these are not necessarily indicative of gestational diabetes in pregnancy, those worried about their symptoms can raise concerns with their doctor or midwife.(20)
Constipation is very common in pregnancy. Hormonal changes combined with the growing size of the uterus putting pressure on the bowel results in reduced gastric motility. Good fluid hydration is important, as are remaining active and consuming adequate amounts of fibre. Haemorrhoids can be a common complaint caused by hormonal relaxation of veins and exacerbated by constipation. Often, increased fibre intake, not standing for long periods and regular exercise can help to alleviate symptoms. It is best to refer those seeking further treatment to their doctor or midwife.(21)
Heartburn can occur because progesterone relaxes the oesophageal sphincter. This is compounded by the growing pressure of the baby on the mothers’ stomach. Controlling symptoms can involve eating smaller meals more often, avoiding spicy or fatty foods, sitting upright after eating and avoiding alcohol and smoking. Antacids and alginates provide a safe treatment option for those affected. If symptoms do not improve, ranitidine or omeprazole may be prescribed by the woman's doctor, which are known to be safe in pregnancy.(22)
Itching is very common in pregnancy due to skin dryness and stretching of the skin. Advice includes trying not to scratch and using moisturiser regularly. Severe itch developed in the later weeks of pregnancy with no skin rash could indicate obstetric cholestasis requiring further investigation from a doctor or midwife.(23)
Pregnant women should be encouraged to look after their mental health. Self help advice can include:(24)
- talking to family or friends about how they are feeling
- physical activity
- eating a healthy diet
- attending antenatal classes.
Pharmacists can signpost women to organisations such as NCT, a charity that provides support to new parents for the first 1,000 days after birth.
Pregnancy and COVID-19
Expectant mothers may have concerns regarding COVID-19. Pharmacists should be mindful of the vast amount of information available in the media surrounding COVID-19 and how this may heighten anxiety felt by pregnant women. In addition, it is important to note that each region of the UK adheres to region specific guidance on COVID-19 and pregnancy and that this guidance is being updated on a regular basis and women should be referred to Gov.UK for the latest recommendations.
Pregnant women can be reassured that there is no evidence they are more likely to get seriously ill from COVID-19 than other people. There is also no evidence to suggest that being infected with COVID-19 causes miscarriage or interferes with the baby’s development. In the UK, pregnant women are in the moderate risk (clinically vulnerable) group as a precaution. While it is possible for a mother to pass COVID-19 to their baby before delivery, these babies normally recover well.(25)
Pregnant women should be advised to adhere to all public health guidelines including:(24)
- washing hands regularly
- wearing a face covering or mask
- social distancing
- staying away from those with symptoms of COVID-19
They should also be advised to inform their midwife or doctor immediately if they experience symptoms of COVID-19.
Pregnant women may have questions surrounding COVID-19 vaccination. The Royal College of Obstetricians and Gynaecologists alongside the Royal College of Midwives have released a statement in January 2021 on COVID-19 vaccination in pregnancy. They said, “…the decision whether to have the vaccination is your choice. You can either have the vaccine or wait for more information about the vaccine.” They encourage women to discuss any concerns they have with their midwife or a healthcare professional. It has produced this useful information sheet summarising advice for pregnant women on the matter of vaccination.(26)
- NHS (2020) Vitamins, supplements and nutrition in pregnancy
- National Institute for health and Care Excellence (2015) Public health guideline: Maternal and child nutrition
- NHS (2020) Foods to avoid in pregnancy
- UK Chief medical Officers’ Guideline (2016) Low risk drinking guidelines
- National Institute for health and Care Excellence (2019) Clinical guideline: Antenatal care for uncomplicated pregnancies
- NHS (2020) Exercise in pregnancy
- National Institute for health and Care Excellence (2020) Clinical Knowledge Summaries: Nausea/vomiting in pregnancy
- Jarvis S, Nelson-Piercy C (2011) Management of nausea and vomiting in pregnancy. BMJ 342
- NHS (2018) Pre-eclampsia
- NHS (2018) Miscarriage
- Miscarriage Association (2021) What is a miscarriage?
- Royal College of Obstetricians and Gynaecologists (2015) Reducing the risk of venous thromboembolism during pregnancy and the puerperium
- NHS (2018) Deep vein thrombosis in pregnancy
- NHS (2018) Common health problems in pregnancy
- eMC (2018) Canesten 100mg Pessary
- National Institute for health and Care Excellence (2019) Clinical guideline: Hypertension in pregnancy: diagnosis and management
- Goldsmith L, Weiss G (2009) Relaxin in Human Pregnancy. Ann N Y Acad Sci 1160
- Patient.info (2017) Common problems in pregnancy
- NHS (2021) Tiredness and sleep problems
- NHS (2019) Overview: Gestational diabetes
- NHS (2020) Piles in pregnancy
- NHS (2020) Indigestion and heartburn in pregnancy
- Royal College of Obstetricians and Gynaecologists (2012) Obstetric cholestasis
- NHS (2021) Mental health in pregnancy
- NHS (2021) Pregnancy and coronavirus
- Royal College of Obstetricians and Gynaecologists (2021) The RCOG and the RCM respond to misinformation around COVID-19 vaccine and fertility