Common health concerns and bodily changes can occur at any stage of pregnancy, but may be commoner in a particular trimester – or even before the pregnancy starts. Here we consider some of the questions customers may ask pharmacy teams in everyday practice scenarios:
Ideally, pregnant women should attempt to quit smoking without NRT, but if they are struggling to do so, they should seek advice from their GP first. Using NRT is still safer than smoking.
“Oral products, such as gum and lozenges, should probably be recommended to pregnant smokers first, because they provide intermittent nicotine rather than the constant flow released by patches,” says Sultan (Sid) Dajani, independent community pharmacist and member of the RPS English Pharmacy Board.
“However, feelings of nausea may make oral NRT products difficult to tolerate. If using nicotine patches, pregnant women should remove them at night and use a 16-hour patch. Zyban and Champix cannot be prescribed to pregnant women, who should also avoid liquorice-flavoured NRT.”
Only a third of British women take 400mcg folic acid before becoming pregnant and until week 12 of pregnancy, even though this is a key recommendation by the Department of Health. Some women need to be prescribed a higher dose of folic acid (5mg) e.g. if they have had a previous pregnancy affected by spina bifida, or if they are taking certain anticonvulsants or have conditions such as coeliac disease, diabetes or sickle-cell anaemia.
“Pregnant and lactating women are also advised to take 10mcg of vitamin D each day,” says Dr Carrie Ruxton of the Health Supplements Information Service. “Vitamin D is vital for normal immune function in babies. Other key nutrients to consider before conceiving are omega-3 fatty acids to supply the right balance of fats for foetal brain development.”
Dietitian Judy More, who specialises in children’s nutrition, recommends that pharmacists tell customers about the Healthy Start scheme. “Pharmacists should bring it up with all families with children under five and also with new mothers,” she says. “Pregnant women might take a pregnancy multivitamin containing the recommended 10mcg dose of vitamin D, but not everyone can afford this and single vitamin D supplements are often cheaper.”
According to new guidance issued by the Department of Health earlier this year, women should not drink any alcohol during pregnancy or when they are trying to conceive. Drinking in pregnancy can lead to long-term damage to the baby, although the risk is low if only small amounts of alcohol are drunk.
Pregnant women need to avoid or limit certain foods before and during pregnancy. “Avoid liver and liver-containing products, which contain high levels of vitamin A, and avoid some types of soft and blue cheeses, raw and undercooked meat, shellfish and eggs,” says London GP Dr Philippa Kaye, author of The First Five Years. “Also avoid shark, marlin and swordfish, and limit tuna to twice a week for fresh tuna steak and four times a week for tinned tuna, due to its high mercury content.”
Many women feel tired in the early weeks of pregnancy due to hormonal changes. Women should try to nap during the day and eat little and often. If the tiredness persists or is accompanied by pallor, palpitations or breathlessness, they should consult their GP. They may need to have their iron levels tested for signs of anaemia.
One in three pregnant women experience morning sickness, according to the British Pregnancy Advisory Service/Pregnancy Sickness Support report in April 2015. Morning sickness can often be managed with some simple measures.
“Try eating little and often, as getting hungry can trigger nausea. Eating a plain biscuit or cracker before getting out of bed can help,” says Dr Kaye. “Foods or drinks containing ginger or peppermint may also be helpful. If women aren’t managing with their nausea or vomiting, they should see their doctor, as various pregnancy-safe anti-sickness medicines can be prescribed.”
Most women gain around 10-13kg during pregnancy. “It is a myth that women need more calories during pregnancy,” says Dr Ruxton. “Most women don’t as they can cope with the extra 100 to 200 calories per day that a healthy pregnancy demands. That is equivalent to one piece of toast.”
Women may notice that their gums become sore, swollen and prone to bleeding during pregnancy. It is important that they practise good dental hygiene and see their dentist regularly. If they are vomiting with morning sickness, they should rinse their mouth out afterwards as the acid in the vomit can affect their teeth.
Headaches can get worse in the first few weeks of pregnancy, but they usually improve or stop completely during the last six months. “Women can get headaches in pregnancy for many reasons, including hormone changes,” says Dr Kaye.
Paracetamol is safe to take during pregnancy but ibuprofen is not recommended. “If women suddenly start developing headaches, especially in the third trimester, they should see their doctor as this could be a symptom of pre-eclampsia,” she adds.
Most women experience indigestion and/or heartburn at some point in pregnancy. Symptoms may be aggravated by certain foods, including spicy foods, oily foods, pickles and citrus, and alcohol. “Eat little and often and try to avoid eating late at night or lying down after eating. Sleeping on a few pillows can help,” says Dr Kaye.
“If these measures aren’t enough, women can try an OTC antacid/alginate combination product, as long as it is safe to take in pregnancy. If the symptoms are severe, customers should be advised to see their doctor or midwife, as there are prescribed medications that can be used to ease heartburn in pregnancy.”
Itching is common in pregnancy as the skin stretches over the abdomen. Applying a non-perfumed moisturiser may help to ease this. If the itching is severe, however, women should see their GP, as it could be a sign of a pregnancy-related liver disease called obstetric cholestasis.
Coping with a baby’s health problems can be daunting for new parents. Rather than wait for a GP appointment, they may find it easier to visit their local pharmacy for help and advice.
Nutritionally, breast milk is the best choice for babies, but some women can’t or don’t want to breastfeed. Pharmacy staff are ideally placed to offer advice on baby milks, specialist milks and common feeding problems, such as mastitis, colic, reflux and other minor feeding issues.
Research suggests that around 30 per cent of infants are affected by reflux and regurgitation, which can be distressing for parents. Indeed, gastro-oesophageal reflux is the most common functional gastrointestinal disorder (FGID) in infancy. Early life nutrition company Nutricia recommends managing reflux by avoiding overfeeding; burping the baby before, during and after feeding; avoiding exposure to tobacco; and, in bottle-fed babies, ensuring that the hole in the teat is not too large.
According to the company, various clinical studies have shown that a thickened or ‘antireflux’ formula can effectively manage reflux in bottle-fed infants. (For more information on infant nutrition and FGIDs, see the new CPD booklet from Nutricia inside the February issue of Pharmacy Magazine.)
Colic affects one in five babies, yet is still a poorly understood condition. It is characterised by excessive crying for extended or repeated periods in babies who are otherwise healthy and continue to gain weight. The babies tend to clench their fists, draw their knees up to their tummy and arch their back. The symptoms occur mainly in the late afternoon or evening.
It is thought that colic may be related to digestive problems or taking in too much air while feeding. There’s no proven treatment, but some babies benefit from tummy massage or cycling their legs in the air. Other options include using simeticone drops (to break down the trapped air), removing cow’s milk from the baby’s diet (on the advice of a health visitor) or using lactase drops to help babies digest milk sugars.
Most babies start teething at around six months. Sometimes the teeth will push through the gums with no pain or discomfort but, for many, gums will be sore and red where the tooth is coming through. The baby may dribble, gnaw and chew a lot, and cheeks may look flushed. Teething babies often benefit from gnawing on a hard toy or a teething ring (especially one kept cold in a fridge). Parents can also buy sugar-free OTC teething gels or granules.
All babies are prone to nappy rash, especially between nine and 12 months. They may have red inflamed skin where it has been in prolonged contact with a wet or soiled nappy. If it isn’t treated, nappy rash can develop into a yeast or bacterial infection. Signs include a persistent bright red, moist rash with white or red pimples spreading into the folds of the skin.
To prevent and treat nappy rash, parents should keep their baby clean and dry by changing wet or soiled nappies regularly. They should apply a thin layer of barrier cream or ointment before putting on a clean nappy (even when the skin is clear), although too much barrier cream will stop the nappies being so absorbent. If a baby is prone to nappy rash, suggest some nappy-free time every day to air the area.
Cradle cap usually appears in babies within their first two months and tends to clear up by the time the baby is one year old. The large greasy, yellow scales on the baby’s scalp often look unsightly but don’t cause any discomfort. Most cases clear up on their own. Parents can use some olive oil to loosen the scales and then brush them out. Baby shampoo or specialist cradle cap shampoos may also help.
Chickenpox doesn’t usually need any specific treatment, other than symptom relief. If a baby is in pain or has a fever, parents can give them paracetamol (ibuprofen may cause an adverse skin reaction if it is given for chickenpox). Babies and children should drink plenty of water to avoid dehydration. Sucking sugar-free ice lollies can help to soothe a sore mouth with chickenpox spots inside it.
Chickenpox can be very itchy, so babies’ fingernails should be kept clean and short to reduce the risk of infections and scarring. Using baby mittens may stop them scratching during the night. If the baby’s skin is very itchy or sore, parents can try aloe vera or calamine lotion, or cooling gels specifically developed for chickenpox. In severe cases an antihistamine may be prescribed.
Parents should be encouraged to take their baby for childhood vaccinations when these are due, but may need to delay the vaccinations if their baby has a temperature or is very unwell. Vaccinations shouldn’t hurt, but parents can give their baby an appropriate dose of paracetamol before or just after the vaccination.
In September 2015 a new meningitis B vaccine was added to the childhood immunisation programme (at ages two, four and 12 months). Babies receiving this vaccine are at risk of a fever that could last for a few days, so Public Health England advises that parents should give paracetamol following each dose as a prophylactic measure.
Pregnancy relaxes a woman’s ligaments. This can put a strain on the joints of her lower back and pelvis, which can cause backache. “Try to keep active, avoid lifting heavy weights and wear flat shoes,” says Dr Kaye. “Exercises on the NHS Choices website may be helpful. Women can use paracetamol but not ibuprofen to relieve the pain.”
Constipation can be an early sign of pregnancy, but may also occur as the uterus enlarges and presses on the bowel. It can be prevented with healthy eating, drinking plenty of water and keeping active. If the constipation persists, women should speak to a healthcare professional about taking a short course of laxatives (suitable for pregnancy). If the constant straining causes haemorrhoids, they should try to treat any underlying constipation. The mother-to-be may be prescribed a suitable haemorrhoid ointment.
Ankles, feet and fingers often swell a little in pregnancy as the body retains more water than usual. Pregnant women should put their feet up as much as possible, avoid standing for long periods, do some foot exercises and wear comfortable shoes. “A small amount of swelling is normal in pregnancy but if women suddenly become swollen, they should see their doctor urgently as this could be a sign of pre-eclampsia,” says Dr Kaye.
Light bladder weakness is common during pregnancy and after childbirth due to physical and hormonal changes. Recent research from lights by TENA has revealed that nearly half of women (48 per cent) are currently using unsuitable sanitary protection for light bladder weakness, often because they aren’t aware of the benefits of purpose-made products.
One of the best ways to prevent bladder weakness is to keep the pelvic floor muscles as strong and toned as possible. “Women should keep doing pelvic floor exercises,” says Dr Kaye. “It can be hard work but they do make a difference.”
To support women through their pelvic floor training, lights by TENA has developed the ‘My PFF’ (my pelvic floor fitness) mobile app. If women still experience problems with urine leakage, they should see their GP.
This could be a sign of varicose veins of the vagina and vulva. Other symptoms include stress incontinence, irritable bowel syndrome and discomfort around the bladder/rectum caused by the distended veins pushing against them.
“If left untreated, this can lead to uncomfortable and often painful consequences,” says Professor Mark Whiteley, consultant vascular surgeon at The Whiteley Clinic in London. “Women often find that the troublesome veins disappear following the birth, but they don’t realise that the veins are likely to come back with a vengeance during any further pregnancy. It is therefore much better to get checked out early by a specialist to avoid any future problems.”
Coping with babies’ health problems can be daunting for parents
A lot of women notice that their hair looks and feels thicker towards the middle and end of pregnancy, as their hair remains in its growth phase for longer. After pregnancy, many women notice some of their hair falls out, but this is only excess hair and the effect should be temporary. Treatment isn’t usually necessary unless the hair loss continues six months after the pregnancy.
Stretch marks usually appear on a woman’s abdomen, but sometimes on her upper thighs and breasts as well as her pregnancy progresses. These narrow pink or purplish streak-like lines are more likely to appear if women put on more weight than average. Unfortunately, once stretch marks appear, it is difficult to get rid of them.
There are lots of creams available that claim to prevent and reduce stretch marks and some evidence suggests that massaging the skin can also help.
Only a third of British women take 400mcg folic acid before becoming pregnant and until week 12 of pregnancy