Pregnancy disorders

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Chapter 32 Pregnancy disorders

Introduction

Pregnancy is a special time in a woman’s life that should be enjoyed with good health. Due to a surge of hormones and rapid physical changes by the body, a number of distressing symptoms may arise, especially if the woman is unprepared. Many women conceive without planning a pregnancy, so it is not always possible to be prepared for a pregnancy. Hence it is vital that women optimise their health as soon as they make the decision to plan a pregnancy.

Complementary and alternative medicines (CAMs) are frequently used in pregnancy, more than prescription medicines, according to Australian research.¹ These CAMs include massage (49%), vitamin and mineral supplements (30%) and yoga (18.4%) which are not likely to be harmful in pregnancy. The study highlighted more than three-quarters had used at least 1 complementary therapy 8 weeks prior to the study; one-third had used complementary medicine to alleviate a physical symptom such as headache, cough or cold with a 95% positive response to treatment compared with 6.8% of women on prescription medicine to treat a complaint.

Studies in the Netherlands found up to 36% of women were using herbs in pregnancy and up to 43% during breastfeeding.² The most commonly used herbs in pregnancy include red raspberry leaf, ginger, chamomile³ and also echinacea and cranberry.² Less commonly used supplements were fish oil, herbal teas, blue cohosh, acidophilus, ombeshi plums, homeopathic drops, peppermint and St John’s wort.

Symptoms of pregnancy

A number of problems can develop during pregnancy, including the following:⁴

• psychosocial and emotional stress

• high body temperature

• morning sickness [nausea and vomiting >50% of women]

• breasts changes

– nipples may be tender and sensitive

– some women describe their nipples to be irritatingly sensitive

– breast may be sore and/or lumpy

– nipples may deepen in colour

– veins may become more noticeable and enlarged in the breast area

– aereolas may darken

– Montgomery’s tubercles may increase

• increased cervical mucus

• fatigue

• frequent urination

• cramping

• spotting [in early pregnancy = 10% of normal pregnancies]

• constipation and wind

• changes in sense of smell

• nasal stuffiness/colds

• pimples/acne

• cravings/changes in taste

• dental problems can worsen

• stretch marks and pigmentation of skin.

Lifestyle

Simple lifestyle strategies are not only useful for a pregnancy but also to optimise wellbeing for life. These include: rest, stress management, exercise, adequate sleep, fresh air, plenty of adequate sunshine and good dietary habits. Also, pregnant women should avoid illicit drugs, smoking, exposure to chemicals and alcohol.

Mind–body medicine

Sleep

A good nights sleep of up to 8 hours a night is essential in pregnancy and post-partum to help reduce fatigue, depression, mood disturbances and exhaustion. Recent evidence also suggests that a good nights sleep also contributes to shorter labour and an easier delivery.⁵ Women who slept for less than 4–5 hours per night were more likely to have caesarean deliveries and experience longer labour times compared with women who were well rested.⁵

Psychosocial and psychological factors

Many women experience anxiety during pregnancy and fear of pain, especially with a vaginal delivery. Studies suggest that personality factors such as general anxiety, neuroticism, low self-esteem and vulnerability, and dissatisfaction with their partners, violence in the relationship, lack of social support and unemployment will contribute and amplify pregnancy related anxiety.^6,⁷ Strategies such as increasing supports, meditation, counselling and cognitive behaviour therapy (CBT) should be aimed at reducing maternal anxiety and addressing issues with the partner. Even a telephone-based peer support line can make a significant difference in preventing postnatal depression among women at high risk.⁸

Duration between births

Women should be advised to avoid conceiving too quickly after giving birth to avoid subsequent birth complications. A large scale study of 89 000 women found shorter intervals between births (i.e. of less than 6 months between first and second pregnancy) was an independent risk factor for pre-term birth and neonatal death in the second pregnancy.⁹

Physical activity/exercise

It is clear that daily exercise benefits pregnant women both physically and emotionally but what is not certain is the level of intensity that is safe for pregnancy. A prospective study of 148 pregnant women examined whether vigorous exercise undertaken by recreational exercisers had any impact on infant birth weight and gestational age at birth.¹⁰ The researchers found there were no differences between the different exercise groups in pregnancy outcome, and duration or frequency of vigorous exercise was not associated with any adverse outcome for the infant, such as mean birth weight.

Regular exercise maintains and improves fitness during pregnancy, including aerobic exercise. However, larger and better trials are needed before confident recommendations can be made about the benefits and risks, such as pre-term birth, of more vigorous exercise in pregnancy.¹¹

Environmental factors

Pollution

Pollution is a public health issue and can cause adverse health outcomes in pregnancy. A large Australian study of 28 000 births recorded during the study period found exposure to low levels of air pollution from vehicle exhausts, particularly in the 1st trimester, resulted in more premature births before 37 weeks gestation, the risk increasing by 15–26%.¹² This association was strongest in winter and less in autumn compared with summer.

Smoking

Smoking should be completely avoided in pregnancy for its known adverse pregnancy outcomes that include intrauterine growth retardation, failure to thrive, low birth weight, premature death, fetal anomalies, and predisposition to asthma (maternal and child). Giving up smoking prior to pregnancy is preferred, although even ceasing early in the pregnancy (before 15 weeks gestation) can also be of benefit and reduce the risk of spontaneous pre-term birth and infants who are small for gestational age, according to a prospective cohort study.¹³

Smokers demonstrate lower levels of folate compared with non-smokers with similar dietary folate intake which may explain some of the negative pregnancy outcomes.¹⁴ Passive smoking is also harmful.

Recent evidence suggests smoking during pregnancy also increased the risk of children developing behavioural problems and hyperkinetic disorder by threefold compared with non-smokers.¹⁵

Alcohol

The Australian new-draft alcohol guidelines state that for pregnant women and women planning pregnancy no drinking is the safest option.¹⁶ A British study examining the effects of low–moderate prenatal alcohol exposure on pregnancy outcome found no convincing evidence of adverse effects.¹⁷ Similar findings have been found by a Western Australian group, however, alcohol intake at higher levels, particularly heavy and binge drinking patterns, was associated with increased risk of pre-term birth even when drinking was ceased before the 2nd trimester.¹⁸ Adverse effects of alcohol exposure on the fetus include fetal alcohol syndrome (1–3 % of live births), birth defects, neurodevelopmental disorders, miscarriage, still births, pre-term births and low birth weight.

Fetal alcohol exposure can be minimised through abstaining or reducing alcohol consumption or increasing effective contraception in females who engage in risk drinking.¹⁹

Animal studies suggest dietary zinc supplementation may play a role in preventing fetal alcohol syndrome due to prenatal ethanol exposure, although more studies are required.²⁰

Maternal obesity

It is natural for a woman to gain on average up to 18kg during pregnancy without risking complications, although the recommended weight range is from 11.5 to 16kg.²¹ The optimal birth weight for the infant is 3500–4500g. Women gaining weight at the lower end of the recommended range had a higher chance of low birth weight newborns weighing less than 3500g.

A study of 100 pregnant women were randomised to a program of dietary and lifestyle counselling that helped reduce excessive weight gain during pregnancy compared with the routine prenatal care group, who also had significantly more caesarean deliveries by 58.6% due to failure to progress (compared with lifestyle counselling group 25.0%, P = .02).²²

Obesity is an independent risk factor for negative, adverse pregnancy outcome. It contributes to infertility, miscarriage, hypertension, increased deep vein thrombosis and pulmonary embolisms, pre-eclampsia, gestational diabetes, prematurity, congenital anomalies, fetal distress, still birth, longer labour, caesarean delivery, subsequent post-operative complications, and cardiovascular risk factors.²³^–²⁶

A large scale cohort study of 54 000 pregnant women found the risk of fetal death (stillbirth) for obese women (Body Mass Index [BMI] >30) doubled by week 28 of gestation and quadrupled by week 40 compared to normal weight women.²⁷ They found that obesity was associated with placental dysfunction.

Nutritional influences

Diet

A number of studies have evaluated the role of diet in the prevention of gestational diabetes and pre-eclampsia. It is essential women maintain a healthy diet as nutritional needs are increased substantially during this time. Substantial epidemiological evidence documents diverse health benefits associated with diets high in fibre, fish and low in glycaemic index (GI).

Health benefits of fish may counterbalance any adverse effects of mercury exposure on the developing nervous system.³² All fish contains some mercury in their flesh, mostly in the form of organic methyl mercury (MeHg), a known neurotoxin which can cause developmental delay, neurological problems and damage to the developing central nervous system (CNS). The quantity of MeHg present in fish varies depending on the dietary habits and age of the fish, and is particularly concentrated in the larger predatory fish at the top of the food chain.

Foods Standards Australia New Zealand (FSANZ) has useful advice on mercury in fish.³³ FSANZ found that most fish is safe for all population groups to eat 2–3 serves per week and recommends that pregnant women, women planning pregnancy and young children continue to consume a variety of fish as part of a healthy diet, but limit their consumption of the larger predatory fish such as shark, marlin, broadbill and swordfish (containing highest levels of MeHg) to no more than 1 serve per fortnight with no other fish to be consumed during that fortnight. For orange roughy (also sold as sea perch) and catfish, the FSANZ advice is to consume no more than 1 serve per week, with no other fish being consumed during that week.³³

The FSANZ ‘Advice on Fish Consumption’ has been specifically developed for the Australian population and suggests that women in other countries check with their local authorities as mercury content of fish varies from country to country depending on the environmental exposure, patterns of fish consumption in the community and other food sources consumed containing mercury.

Nutritional risk factors in pregnancy

The increased needs during pregnancy can vary from 12% for dietary fibre, 14% for vitamin A, 46% for vitamin B6, 50% for folate, 37% for zinc, 50% for iron, 46% for iodine, 30% for protein and 25% for essential fatty acids.^34,³⁵

Teenage pregnancy requires special needs as a mother’s body is still growing in many instances. The ideal weight gain for teenage pregnancy is 10kg; lower weight gain can lead to lower birth weight which can be associated with greater risk of developing type 2 diabetes and hypertension later in life, as well as a weight problem.²⁷

Routine supplementation with iron, vitamin A, C and E are not recommended in pregnancy. ³⁶

Vegetarian mothers are at risk of deficiencies in protein, iron, vitamin B12, folate, calcium and zinc and should be screened early in pregnancy, if not beforehand, to minimise complications. Untreated vitamin B12 deficiency may lead to serious neurological consequences especially in exclusively breastfed babies. Vegan sources of omega-3 foods include soybeans, beans, linseed, walnuts, pecans and soy.

Vitamin D deficiency is common in dark skinned, veiled women and their breastfed offspring should also be screened with consideration to supplement with vitamin D.

Nutritional supplements

Fish oil for pregnancy and breastfeeding

Fish oils play an important role in pregnancy and in the development of the fetus and newborn. Pregnant women should be encouraged to eat at least 3 deep sea fish a week although there are real concerns with heavy metal toxicity in the larger predator fish (see section titled ‘Fish and heavy metals’).³⁷ A number of studies demonstrate fish oils can significantly reduce the risk of atopy, asthma (see Chapter 5 for asthma information) and other immune-mediated diseases by positively modulating inflammation and prostaglandin effects on the newborn child. In addition, the benefits of fish oils are carried through to breastfed babies. In bottle-fed babies, the benefits are through formulas enriched with fish oils.³⁸^–⁴²

For instance, a population-based study of 533 pregnant women from 30 weeks gestation to birth were randomly assigned to receive 4 x 1g gelatin capsules/day of fish oil (2.7g n-3 PUFAs) or 4 x 1g similar-looking capsules/day with olive oil, or no oil capsules.⁴³ Over a 16-year follow-up of offspring, the risk of asthma was reduced by 63% and of allergic asthma by 87% in those pregnancies treated with fish oil compared with the olive oil group. This study supports a potential prophylactic role of fish oils late in pregnancy, reducing risk of asthma in the newborn.⁴³

Women consuming fish oil supplements compared with olive oil capsules were also less likely to experience pre-term delivery and more likely to reach full term without any complications.⁴⁴ The high intake of fish oils might prolong pregnancy by shifting the balance of production of prostaglandins in parturition.

Fish oils play an important role in the development of the nervous system and augments cognitive function, IQ, vision and behaviour in offspring to mothers supplemented with fish oils during pregnancy and breastfeeding.⁴⁵^–⁶⁰

However, a double-blind study randomised pregnant mothers to take 10ml of either cod-liver oil or corn oil from 18 weeks gestation until 3 months after delivery.⁶¹ At 7 years of age, children were assessed and the researchers found higher maternal plasma phospholipid concentrations of alpha-linolenic acid (18:3n-3) and docosahexaenoic acid during pregnancy were correlated with enhanced cognitive function, such as sequential processing, but no significant effect was observed on global IQs or on BMI in the children.

Multi-nutrients and pregnancy

Micronutrients such as vitamins and minerals are necessary for the growing demands experienced by the pregnant mother and for the normal functioning, growth and development of the fetus. A Cochrane review of 9 trials including 15 378 women demonstrated multi-nutrient supplementation reduced the number of low birth weight and small-for-gestational-age babies and maternal anaemia, but close analyses of the data revealed no added benefit compared with iron/folic acid supplementation alone.⁶² Further research is required to confirm the benefits of taking multi-nutrients during pregnancy.

A systematic review and meta-analysis of the use of prenatal supplementation with multivitamins found that they decreased the risk for paediatric brain tumour, neuroblastoma and leukaemia.⁶³

Vitamin A deficiency

Vitamin A deficiency is common in developing countries such as Indonesia and Nepal due to poor nutritional intake where daily or weekly supplementation may be necessary as deficiency of vitamin A causes night-blindness, anaemia and other problems.⁶⁴ However, in women with adequate nutritional intake, vitamin A supplementation can cause toxicity, especially doses >10 000IU/day, and should be avoided. Toxic levels can cause miscarriage and birth defects. Note: beta-carotene intake is very safe.

Vitamin C deficiency

It is not clear if taking vitamin C supplementation in pregnancy is safe, because a Cochrane review found in a trial that vitamin C supplementation was linked with a moderate risk of pre-term birth, although more studies are required to confirm this adverse effect.⁶⁵ Vitamin C deficiency is linked with complications in pregnancy such as pre-eclampsia, anaemia and intrauterine growth retardation, and so women should be encouraged to eat foods rich in vitamin C such as fruit.

Vitamin D deficiency

Severe vitamin D deficiency can cause maternal osteomalacia and lead to significant morbidity in the mother and fetus. The prevalence of vitamin D deficiency in pregnant women is high and this can have serious health ramifications in the mother and child.^66,⁶⁷ Pregnant women who are deficient in vitamin D can lead to reduced weight gain and pelvic deformities that prevent normal delivery. For the fetus, vitamin D deficiency is linked with poor fetal growth, low birth weight, neonatal hypocalcemia with and without convulsions, neonatal rickets, defective tooth enamel, and pre-disposition to childhood rickets, particularly in breastfed, dark skinned children.^68,^{69, 70} Deficiency is common in populations residing in geographically prone areas such as southern Australia (e.g. Melbourne) and in some high-risk communities such as migrants, women wearing veiled clothing, and people who spend more time indoors.⁷¹ Ninety percent of the body’s vitamin D is produced by the skin from sunlight (ultraviolet B light) exposure of non-covered skin without sunscreen, with only 10% coming from dietary sources. It is essential to restore vitamin D deficiency in mothers by advising safe sun exposure which is dependent on geographical areas and pigmentation of the skin (the darker the skin the more sun that is required), and supplement with cholecalciferol if needed, but this needs to be done cautiously to avoid vitamin D toxicity. Excessive vitamin D may cause hypercalcemia and fetal harm. Doses within RDI are safe. According to a Cochrane review of the literature, there is not enough evidence to date to evaluate the effects of vitamin D supplementation in pregnancy.⁷² Vitamin D is excreted in milk in limited amounts, and with excessive use can cause toxicity in infants. If pharmacological supplementation is required, it is essential to monitor calcium levels in the infant and get maternal vitamin D checked regularly.

Folate deficiency

Folate is one of the most important nutrients for healthy fetal development. Pregnant women and the growing embryo require higher levels of folate for cell replication and growth. Rapidly dividing cells in the embryo fail to produce healthy DNA if folate levels are low. The recommended daily intake for folate is increased significantly by 50% in pregnancy. It is recommended that every woman planning a pregnancy should take 500mcg folate a few months prior to pregnancy and in the 1st trimester although recent studies indicate that folate supplementation in the 2nd trimester may help prevent pre-eclampsia.⁷³ Low folate levels are associated with increased risk of spontaneous abortion, anaemia, low birth weight and congenital malformations such as neural tube defects (NTD), oral clefts and cleft palate, and cardiovascular and urinary tract malformations.^74,⁷⁵ Overall, nutritional deficiency in the pregnant woman (not just folate deficiency) can increase the risk of orofacial cleft. Increasing intakes of vegetables, protein, fibre, fruit, ascorbic acid, iron, vitamin Bs and magnesium also reduce the risk of orofacial cleft.^76,⁷⁷

Folate is essential for fetal brain and spinal cord development. A Cochrane review evaluated 4 trials of folate supplementation involving 6425 women. Peri-conceptional folate supplementation significantly reduced the incidence of NTD (relative risk 0.28, 95% confidence interval 0.13 to 0.58) without significant harmful effects such as miscarriage, ectopic pregnancy or stillbirth. The authors also found multivitamins were not associated with any additional beneficial preventative effects of NTDs even when given with folate.⁷⁸

Medications interfering with folate

Maternal exposure to folate antagonist medication such as sulfamethoxazole-trimethoprim and anti-epileptic medication such as phenobarbital and sodium valproate may contribute to adverse pregnancy outcomes by affecting placental function, although more studies are required to confirm this finding and one needs to weigh the benefit to any potential risk.^79,⁸⁰ It is important to avoid any medication and herbal medicines that may harm the fetus in pregnancy unless there is a clear risk to the mother.

Anti-epileptic medication and folate

Pregnant women who require anti-epileptic medication, many of which antagonise folate action, are at increased risk of fetal abnormalities and birth defects such as NTDs.⁸¹ Epileptic women in reproductive years should be advised to take folate peri-conceptually if on anti-epileptic medication that interferes with folate, although it is not clear what this dosage should be.

Women of child-bearing age prescribed, for example, sodium valproate should be warned about the potential risks of the drug, including teratogenesis, and should be strongly advised to ensure adequate contraception whilst taking this drug.^82,⁸³

Minerals

Iron deficiency

The recommended daily intake for iron is increased significantly, by 50%, in pregnancy. Iron deficiency is linked with infertility, anaemia, increased risk of infection, fatigue, and behavioural and cognitive development problems.^84,^{85, 86} It is possible that fetal oxygenation is compromised with iron deficiency.⁸⁵ While the benefits are clear for iron supplementation, if the mother demonstrates serum iron deficiency with or without anaemia, at this stage, there is not enough evidence to recommend routine iron supplementation in all pregnant women.⁸⁷

Zinc deficiency

Zinc is an essential trace element and plays an important role in normal growth and development, protein synthesis and cellular integrity. Zinc deficiency can adversely effect pregnancy outcome, such as pre-term birth, intrauterine growth retardation, poor fetal bone growth and prolong labour.^88,⁸⁹ Zinc deficiency is common in low socioeconomic groups with poor nutritional intake and in third world countries. A trial of zinc supplements in HIV pregnant women improved infant mortality, birth weight and duration of pregnancy.⁹⁰ Its benefit was related to improving immune status.

Foods rich in zinc are found in pecans, wholegrains, lima beans, almonds, walnuts, hazelnuts, sardines and chicken. A Cochrane review of 17 randomised controlled trials (RCTs) involving over 9000 women and their babies demonstrated zinc supplementation resulted in a significant reduction in pre-term birth by 14%, reduced need for caesarean section and in 1 trial demonstrated reduced need for induction of labour, but did not reduce the risk of babies with low birth weight.⁹¹ In a study held in Bangladesh, babies of women who took 30mg/day of elemental zinc during pregnancy were less likely to develop acute diarrhoea by 16%, dysentery by 64% and impetigo by 47%, compared with mothers on placebo.⁹²

Iodine deficiency

Iodine is an essential trace element for the production of thyroid hormones T3 and T4. Studies indicate mild deficiency of iodine is common in pregnant women.⁹³ Sources of iodine include ocean fish, spinach, seaweed (such as kelp), garlic, watercress, citrus fruit, cereals, nuts (cashews), egg yolk and iodised salt. Researchers suggest pregnant women need to increase their intake of iodine and, if deficient, should consider supplementation from 100–200mcg/day.

A high frequency of iodine deficiency is known to occur in Australia, with almost 20% of pregnant women having a moderate to severe iodine deficiency. Mild deficiency occurred in almost 30% of women.⁹⁴

Maternal iodine deficiency is known to cause neonatal cretinism. A suboptimal iodine intake by pregnant females without overt deficiency may compromise fetal development, even in the absence of cretinism, leading to developmental delays in the infant.⁹⁵

It is possible to prevent cretinism with iodine supplementation pre-conception, and also if supplementation is given before the end of the 2nd trimester.⁹⁶

Medical conditions associated with pregnancy or a complication of pregnancy

Gestational diabetes mellitus (GDM)

Between 1 to 14% of women develop GDM during pregnancy. Dietary advice is essential to help reduce the incidence of diabetes in pregnancy and subsequently in life. GDM can cause significant health problems, such as a very large baby, and increase the risk of negative and adverse pregnancy outcomes, such as an increased risk of induced birth and caesarean section, prematurity and increased infant morbidity and mortality. GDM is also associated with an increased risk of diabetes for mother and child later in life.

Depression as a risk factor for GDM

Among low-income pregnant women, those with diabetes (pre-existing of gestational) were twice as likely to suffer peri-natal depression and more likely to have post-partum depression after adjustment for other confounding factors, according to a retrospective cohort study.⁹⁷

Lifestyle and GDM

Lifestyle risk factors play a role in the development of diabetes in any person and these include stress management, sunshine for vitamin D, dietary factors, exercise and sleep strategies. (See Chapter 13 for diabetes and Chapter 22 for sleep.)

Exercise and GDM

An analysis of 21 765 women as part of the Nurses Health study II found that women who perform regular exercise, especially brisk walking 30 minutes daily, before pregnancy have a significantly reduced risk of developing GDM, by up to 34%, when compared with women who did the least amount of exercise.⁹⁸

Diet and GDM

Diet factors play a significant role in the control of diabetes, with wholegrain carbohydrates and low GI diets being particularly helpful.

Low GI diet and GDM

A low GI diet can effectively halve the need to use insulin compared with a high GI diet, according to a recent randomised study.⁹⁹

A Cochrane review identified 3 trials including 107 women.¹⁰⁰ Two trials assessed low versus high GI diets for pregnant women. Women on low GI diets, had less large-for-gestational-age infants and lower maternal fasting glucose levels. The other trial assessed high fibre versus control diet but the trial did not report on the outcomes. The reviewers concluded based on these findings that whilst ‘a low glycaemic index diet was seen to be beneficial for some outcomes for both mother and child, results from the review were inconclusive’.¹⁰⁰

Weight gain and GDM

Women of reproductive age should be encouraged to maintain a normal healthy weight as weight gain and maternal obesity is associated with increased risk for diabetes, adverse pregnancy and neonatal outcome.¹⁰¹ See the maternal obesity section earlier in this chapter.

Cinnamon and GDM

Cinnamon has been reported to enhance insulin sensitivity. (See Chapter 13 for diabetes information.)

Nutrients and GDM

Nutrients in GDM may be of some help, such as fish oil and chromium supplementation, to improve insulin sensitivity, although great care is required, especially with high doses, as there are no adequate studies in pregnancy. (See Chapter 13 for diabetes information.)

Pre-eclampsia (PE)

PE is a serious condition affecting pregnant women and occurs in about 2–8% of women, characterised by high blood pressure, with or without proteinuria.

Exploring diet and lifestyle are essential to lower the risk of developing PE, particularly increasing nutrient rich foods for antioxidants, vitamin E, calcium and magnesium as deficiency of these nutrients can predispose to PE. This is commonly seen in under-nourished, low socio-economic communities. A diet high in sugar and fat, cigarette smoking and low physical activity are known risk factors for PE. Stress is a contributor to PE-like hypertension. It is likely other lifestyle risk factors may also play a role in PE and strategies such as stress management, dietary changes (increasing vegetables, high fish intake), exercise and sleep restoration should assist in the management of PE (see Chapter 19 on hypertension). Calcium and magnesium appear to be particularly effective and may play an important role as therapeutic agents for PE. PE can cause serious morbidity and can lead to death in pregnant women, who should be monitored closely, including for onset and progression of chronic kidney disease.¹⁰²

Stress and PE

Work stress is a significant predictor and risk factor for developing PE.¹⁰³ In a trial on pregnant normotensive women, heart rate increased and mean arterial blood pressure rose by more than 2.9mmHg, and in some up to 10mmHg on work days.¹⁰⁴ Higher blood pressures occurred in women experiencing greater job stress.

Fibre and PE

High dietary fibre plays an important role in the prevention of PE. A study of over 1500 pregnant women found that women consuming more than 21.2g/day of fibre were associated with reduced risk of PE by up to 70% and mean concentrations of triglycerides was higher and high density lipoprotein (HDL) cholesterol was lower compared with women consuming less than 11.9g of fibre daily.¹⁰⁵

Salt and PE

Whilst a low salt diet is recommended for the prevention of hypertension, there is currently insufficient evidence to advise reduction of dietary salt during pregnancy for the prevention of PE and its complications.¹⁰⁶

Antioxidants and PE

Findings from a Cochrane review could not recommend the use of antioxidants for the prevention of PE ¹⁰⁷ although another Cochrane review found women taking vitamin supplements ‘may be less likely to develop pre-eclampsia and more likely to have a multiple pregnancy’.¹⁰⁸

Vitamins C and E and PE

Inadequate dietary intake of vitamin E during pregnancy is associated with PE and low birth weight. A Cochrane review found in trials that pregnant women supplemented with vitamin E in combination with other supplements compared with placebo were at reduced risk of developing clinical PE, however, the data was too few to recommend supplementation in pregnancy at this stage.¹⁰⁹

One double-blind RCT of 283 women at risk of PE (previous history of PE or placental blood flow abnormalities) were assigned to 1000mg/day of vitamin C and 400IU/day of vitamin E or placebo at 16-22 weeks gestation.¹¹⁰ Vitamin supplementation correlated with a significant 21% reduction in plasma markers reflecting endothelial and placental function. Plasma ascorbic acid increased 32% on average, and the α-tocopherol level increased by 54%. PE developed in 17% of placebo recipients but in only 8% of women given vitamins. Furthermore, small-for-gestational-age infants were less frequent, although less significant in the vitamin-supplemented group. Subsequent research demonstrated similar findings.^111,¹¹²

Another study found 1000mg of vitamin C or 400IU of vitamin E did not reduce the risk of PE compared with placebo, however, the synthetic form of vitamin E was used in this study.¹¹³ Women should be encouraged to eat foods high in vitamin E found in vegetable oils, nuts, cereals and some leafy green vegetables.

However, a recent study warns against peri-conception use of vitamin E supplements with high dietary vitamin E intake above 14.9mg/day as it increased the risk of congenital heart defects (CHDs) in offspring by nine fold.¹¹⁴

Folate and PE

A prospective cohort study of 2951 women at 12–20 weeks gestation found supplementation with multivitamins containing folic acid in the 2nd trimester reduced the risk of developing PE.⁷³

Mineral supplementation for PE

Calcium and PE

In a review of the literature of RCTs found calcium supplementation to play an important role in the prevention of PE and pre-term delivery more than any other supplement.¹¹⁵

A randomised placebo-controlled study of 524 healthy first-time pregnant women whose mean dietary calcium was less than RDI, found 2g of elemental calcium supplementation daily during pregnancy was associated with a significant reduced risk of PE by 69% and pre-term delivery by 49% compared with placebo.^116,¹¹⁷

Furthermore, a Cochrane review of the literature of 12 good quality trials supports the findings that calcium may play an important role in the prevention of PE, the authors concluding that calcium supplementation could ‘almost halve the risk of PE, and reduce the rare occurrence of the composite outcome death or serious morbidity’.¹¹⁸

Magnesium and PE

According to a Cochrane review magnesium supplementation during pregnancy may be able to reduce PE and fetal growth retardation.¹¹⁹ In a large scale international trial from 33 different countries 10 141 pregnant women were randomised to magnesium sulfate or placebo. The trial was cut short due to the positive conclusive findings demonstrating magnesium sulfate led to a significant 58% reduction of PE and 45% reduction in maternal death compared with placebo.¹²⁰

Herbs for PE

Garlic and PE

Meta-analyses have demonstrated that garlic is a valid therapeutic treatment for hypertension, but its role in PE is not so clear. (See Chapter 19 for hypertension information.) A Cochrane review identified 1 study of 100 pregnant women that showed dried garlic capsules did not prevent PE compared with placebo and demonstrated no significant differences in side-effects except women on garlic reported odour.¹²¹

Hyperemesis gravidarum (HG)

Nausea and vomiting

Nausea and vomiting may occur in the early stages of pregnancy and can be quite intense and disabling for the mother. In some mothers, nausea and vomiting persist throughout the whole pregnancy. HG occurs in 0.5–2% of pregnant women, although up to 85% of women will experience some level of nausea. When symptoms are severe, some women require hospitalisation and intravenous fluid therapy to avoid dehydration.

Many trials have compared the use of vitamin B6 and ginger with anti-emetic medication. A Cochrane review of the literature found anti-emetic medication to reduce the frequency of nausea but there is little research that explores adverse fetal outcome from this medication and it can cause side-effects such as drowsiness in the mother. The reviewers found evidence for ginger, acupressure (of pericardium P6) and vitamin B6 in reducing severity of nausea and vomiting.¹²²

Vitamin B6 and nausea

Vitamin B6 needs to be used with caution as high doses (more than 50mgs/day) and prolonged use have been associated with neurotoxicity such as peripheral neuropathy (e.g. tingling, burning and numbness of limbs), and should be stopped immediately should these symptoms develop.^123,¹²⁴ Vitamin B6 should be used cautiously for therapeutic purposes and not used routinely, although a trial did suggest it may protect against tooth decay in pregnant women.^125,¹²⁶

Ginger (zingiber officinale) and nausea

Ginger is a popular remedy used by pregnant women for the treatment of nausea in pregnancy. A Cochrane review of 6 RCTs involving 675 pregnant women assessed the evidence for efficacy and safety of ginger therapy for nausea and vomiting in early pregnancy.¹²⁷ The authors concluded that ginger may be an effective treatment choice for nausea and vomiting associated with early pregnancy but further studies with larger numbers of women are required to confirm the promising preliminary data for the safety of this therapy. Four of the 6 RCTs showed superiority of ginger over placebo and 2 of them showed equivalence to vitamin B6 in relieving the severity and episodes of nausea and vomiting.¹²⁸

Acupuncture, acupressure and nausea

A Cochrane review identified 26 trials of 3347 participants suffering nausea and vomiting and found significant reduction in the risk of nausea and need for anti-emetic medication with acupuncture point stimulation (pericardium 6) compared with sham acupuncture.¹²⁹ There were minimal side-effects with this method. This treatment should be considered for pregnant women suffering severe nausea.

Gingivitis

Topical or systemic folate may play a role in relieving gingivitis in pregnancy.¹³⁰

Cramps

Calcium and magnesium can provide effective treatment for pregnancy-induced leg cramps.^131,^{132, 133}

Ectopic pregnancy

Ectopic pregnancy occurs in 1–2% of pregnancies and is a leading cause of pregnancy-related deaths in the 1st trimester. Whilst traditional Chinese herbal medicines are used in China to treat ectopic pregnancy, most of the trials are of poor quality.¹³⁴ Surgery is highly recommended for the treatment of any ectopic pregnancy, and to exclude any predisposing factors to ectopic pregnancy, such as fallopian tube disorders.

Miscarriage

Lifestyle and miscarriage

A large UK population case-control study identified risk factors for 1st trimester miscarriage and found lifestyle factors and stress play an important role in increasing the risk of miscarriage.¹³⁵ The findings of this case-control population-based study are summarised in Table 32.1.^18,¹³⁵

Table 32.1 Lifestyle and behavioural risk and protective factors for miscarriage

Increase risk of miscarriage	Protective factors for miscarriage	No association with miscarriage
High maternal age Previous miscarriage Termination and infertility assisted conception Low pre-pregnancy Body Mass Index Regular or high alcohol consumption Feeling stressed (including trend with number of stressful or traumatic events) High paternal age Changing partner Nutrient deficiencies (e.g. iodine,folate) Poor diet Illness (e.g. coeliac disease)

Previous live birth

Nausea

Vitamin supplementation

Eating fresh fruits and vegetables daily

Low caffeine consumption (1 cup daily)

Smoking

Moderate or occasional alcohol consumption

Educational level

Socioeconomic circumstances

Working during pregnancy

(Source: Maconochie N, Doyle P, Prior S, Simmons R. Risk factors for first trimester miscarriage — results from a UK-population-based case-control study. BJOG 2007;114(2))

Stress and miscarriage

Stress is a risk factor for miscarriage, particularly with stressful and traumatic events. Stress may contribute to hormonal imbalance such as lowered progesterone and raised cortisol levels through neuroendocrine pathways.

Caffeine and miscarriage

Furthermore, a recent study suggests caffeine consumption of at least 2 cups daily (200mg or more) increases the risk of miscarriage by up to 40% compared with women with no intake of caffeine.¹³⁶

Nutritional factors and miscarriage

A Cochrane review of the literature found research to date indicates that pregnant women taking a daily multivitamin supplementation prior to or early in pregnancy does not reduce the risk of miscarriage or stillbirth.¹³⁷ It is likely that supplements used did not contain enough of the nutrients that can be protective. The quality of the nutrients is also important. The amount of nutrients and the type of nutrient, especially whether they were synthetic or natural, may have been an important factor in this study, which could explain this unexpected result.

Despite these findings, numerous studies have demonstrated the association between increased homocysteine and spontaneous miscarriage.^138,¹³⁹ Folic acid and vitamin B6 and B12 take part in the metabolism of homocysteine.

Coeliac disease is associated with damaged intestinal mucosa leading to a malnourished state caused by the malabsorption of macro and micronutrients. Miscarriages are more frequently observed in those with coeliac disease.¹⁴⁰ Therefore coeliac disease must be considered in the pre-conceptional screening and treatment of patients with reproductive disorders.

Iodine deficiency is a risk factor for growth and development of up to 800 million people living in iodine deficient environments throughout the world. The effects on growth and development, called the Iodine Deficiency Disorders, includes miscarriages.^94,^{95, 96} Poor diet or diets that are vitamin deficient such as folate have been associated with an increased risk of women losing their baby early in pregnancy.¹⁴¹

Sperm and miscarriage

Older sperm are also risk factors for miscarriage. ¹⁴³

Congenital heart defect (CHD) in newborn

Saturated fats, riboflavin and nicotinamide and newborn CHD

Fatty acids play an important role in embryonic development, and B-vitamins riboflavin and nicotinamide play a role as co-enzymes in lipid metabolism. Vitamin B deficiency is linked with increased incidence of CHD.¹⁴⁴ A study demonstrated that maternal diets low in dietary riboflavin (<1.20mg/d) and nicotinamide (<13.5mg/d) increased the risk of a child with CHDs by twofold, especially in mothers who did not take multivitamins, and particularly those on high saturated fatty diets.¹⁴⁵ These findings were independent of dietary folate intake.

Vitamin E increases risk of newborn CHD

High vitamin E dietary intake and supplements have been associated with CHD in offspring (see under heading above, ‘Vitamins C and E and PE’).¹¹⁴

Pre-term birth, low birth weight, fetal failure to thrive

Stress and pre-term birth (PTB)

Epidemiological evidence suggests that maternal psychosocial stress, strenuous physical activity and fasting are independent risk factors for PTB and low birth weight.¹⁴⁶

Depression, anxiety, stress and PTB

Depression and anxiety are risk factors for pre-term labour. Screening of pregnant women for depression may be useful as antenatal depression is significantly associated with almost twice the risk of pre-term delivery (before 37 weeks) compared with non-depressed women, according to a cohort study of 791 women assessed at 10 weeks gestation and followed up during pregnancy.¹⁴⁷ Severe depression increased the risk by up to 2.2 times compared with women not suffering antenatal depression. The authors concluded that their findings show that pregnant women with depressive symptoms are a risk factor for PTB and exacerbated by stressful events, low educational level, and a history of fertility and obesity. It is likely excess cortisol produced in response to stress may play a role, although other factors may also contribute.

A study of 634 pregnant women revealed that depression was positively associated with underweight women (pre-pregnancy BMI below 19) and together with anxiety correlated with a higher incidence of pre-term delivery.¹⁴⁸ Anxiety also correlated with vaginal bleeding. These findings indicate that depression and anxiety are associated with spontaneous pre-term labour.

Yoga reduces risk of PTB, PE, intrauterine growth retardation

A study demonstrated yoga consisting of gentle, daily physical postures, meditation and breathing improves pregnancy outcome, significantly reduces risk of PE, intrauterine growth retardation, pre-term labour and low birth weight newborns.¹⁴⁹ No significant adverse events were reported in the yoga group. Yoga helps with relaxation, postural and stretching exercise so may have benefits in other areas of pregnancy, such as anxiety, headaches and back pain.

Sex in pregnancy

Exercise reduces risk of PTB

Vigorous exercise in pregnancy, such as swimming, cycling and aerobics, reduces risk of pre-term birth by 20% when engaged in the 1st trimester and by 50% in the 2nd trimester.¹⁵⁰

Poor dental hygiene and PTB

A meta-analysis of RCTs concluded periodontal disease treatment with scaling and/or root planning during pregnancy may significantly reduce PTB or low birth weight infant incidence, but not spontaneous abortion or stillbirth.¹⁵¹

Maternal periodontitis and PTB

It is known that a number of diseases including cardiovascular diseases, respiratory diseases, diabetes mellitus and osteoporosis are linked to periodontitis. A number of studies have found that maternal periodontitis can lead to adverse pregnancy outcomes including pre-term, low birth weight or small-for-gestational-age babies.^152,¹⁵³

It is important that a thorough dental examination is carried out either prior to pregnancy or once pregnancy has been confirmed.

Smoking and PTB

Numerous studies have investigated the influence of smoking on the outcome of pregnancy. A large US study found that small fetal size at 10–19 weeks is associated with tobacco use in pregnancy, early pre-term births and low birth weight plus poor fetal growth.¹⁵⁴ This finding is supported by another study.¹⁵⁵

An Australian study concluded that smoking by indigenous and non-indigenous mothers led to growth restriction in full-term births.¹⁵⁶

Mothers who are able to quit smoking early in pregnancy reduced the risk of having a pre-term or low birth weight baby to nearly that of mothers who did not smoke.¹⁵⁷

A systematic review and meta-analysis investigated the role of environmental tobacco smoke and has shown that this too can lead to fetal failure to thrive.¹⁵⁸

There is a clear dose-related impact of smoking on risk of spontaneous pre-term labour and should be avoided in pregnancy.¹⁵⁹ The highest risk occurred in women who smoked more than 10 cigarettes daily.

Diet and PTB

Fish reduces risk of PTB

A study of over 8700 pregnant women demonstrated that eating as little as 15g/day of fish significantly reduced the risk of pre-term delivery or having a low birth weight baby compared with women not eating any fish.¹⁶⁰ Pregnant women who did not eat fish increased their risk of pre-term delivery or having a low birth weight baby by up to 3.5 times compared with fish eaters.

In another study researchers found a significant reduction of 90% of pre-term delivery among healthy women on fruit, vegetables, wholegrains and low cholesterol diet substituted with fatty fish, vegetable oils, nuts and nut butter in place of meat, butter, cream and fatty dairy foods.¹⁶¹ This has enormous health implications and reinforces the important role of women of child-bearing age to be on a healthy low cholesterol diet.

Caffeine effects and PTB

Studies consistently demonstrate the adverse effects of maternal caffeine consumption on fetal development.¹⁶²^–¹⁶⁵ A large prospective observational study of over 2600 low-risk pregnant women showed maternal consumption of caffeine from 100mg/day to over 300mg/day (1–3 cups/day) at any stage throughout the pregnancy was associated with a significant risk of fetal growth restriction.¹⁶⁶ An intake of 200mg/day of caffeine was associated with a significant reduction of birth weight by 60–70g, and consumption of caffeine >100mg/day with each trimester led to drops in birth weight by 34–59g in the 1st trimester, 24–74g in the 2nd and 66–89g in the 3rd trimester. Caffeine is rapidly absorbed and crosses the placenta freely. Cytochrome P450 1A2, the principal enzyme involved in caffeine metabolism, is absent in the placenta and the fetus.

A recent study confirms these findings and demonstrated that the equivalent of only 1 dose of caffeine (just 2 cups of coffee) ingested during pregnancy may be enough to affect fetal heart development.¹⁶⁷ The authors strongly advise pregnant women should not consume coffee.

Another study found that coffee consumption during pregnancy was associated with miscarriage, in particular if more than 3 cups of coffee were consumed per day.¹⁶⁸

Fish oil supplements protect against PTB

Long chain polyunsaturated fatty acids are essential for infant growth and development. Maternal intake of 500mg DHA-rich tuna fish oil supplements taken daily during lactation improved cognitive development and reduced risk of developmental delay in pre-term babies when assessed at 18 months.¹⁶⁹ The main side-effect was a ‘fishy burp taste’.

Magnesium protective for PTB

Magnesium is a promising nutrient not only for PE treatment but also in the prevention of pre-term labour and birth. An analysis of trials involving over 2600 pregnant women found oral magnesium treatment in early pregnancy was associated with reduced risk of pre-term birth, a lower frequency of low birth weight and less small-for-gestational age infants compared with placebo.¹⁷⁰ Furthermore, the women treated with magnesium required less hospitalisation during pregnancy and less risk of antepartum haemorrhage compared with placebo treated women. However, the Cochrane review noted the poor quality trials are likely to have resulted in a biasness favouring magnesium supplementation and concluded at this stage that there is ‘not enough high quality evidence to show that dietary magnesium supplementation during pregnancy is beneficial’.¹⁷⁰

A recent Cochrane review of 5 trials involving 6145 babies demonstrated giving intravenous magnesium sulfate to women at risk of pre-term birth significantly reduced the risk of cerebral palsy and the overall mortality of the infant.¹⁷¹ Side-effects included nausea, vomiting, headaches and palpitations. Epidemiological and scientific studies suggest that magnesium sulfate before birth may be neuroprotective for the fetus.

Placental disruption

Multivitamins and folate

A large population-based study of 280 127 deliveries recorded over a 5-year period demonstrated that women who took any supplement during pregnancy had a 26% reduced risk of developing placental disruption, folate supplement reduced the risk by 19% and a multivitamin supplement was associated with a 28% reduction compared with no supplementation.¹⁷² Combining folate with multivitamins reduced the risk of placental abruption by a further 32%.

Failure to thrive

Poor nutrition and failure to thrive

Birth weight is a key determinant of natal mortality, morbidity, subsequent growth and development, as well as early onset of adulthood diseases.¹⁷³

Poor nutrition is especially common in developing countries where fetal failure to thrive is a common problem. ^64,^{65, 66,} ¹⁷⁴ The role of diet and specific nutrients in avoiding failure to thrive are discussed earlier in this chapter.

Premature rupture of membranes (PROM)

Occupational fatigue and PROM

A large-scale study of 2929 pregnant women at 22 to 24 weeks gestation were enrolled in a multi-centre (10 sites) as part of the Pre-term Prediction Study, which identified a high volume of working hours and occupational fatigue as significant risk factors for PROM. This was particularly evident in nulliparous compared with multiparous women.¹⁷⁵

Frequency of meals and PROM

Poor nutritional status is a risk factor to developing PROM. Pregnant women who eat only once daily had a slightly increased risk of having a pre-term birth and a significant risk of developing PROM compared with women who ate 3 times daily.¹⁷⁶

Vitamin C and E and PROM

Vitamin C is required for the synthesis of collagen and plays an important role in the maintenance of chorioamniotic membranes. Low dietary vitamin C intake before conception and during 2nd trimester is a risk factor for PROM and pre-term delivery.¹⁷⁷

A randomised double-blind trial of 109 pregnant women found daily supplementation with 100mg of vitamin C reduced the risk of PROM up to 20 weeks gestation compared with placebo.¹⁷⁸ Pregnant women should be encouraged to ingest a diet high in vitamin C rich foods such as red sweet peppers, kale, parsley, fruit, and tomatoes. Where there is a strong history of recurring PROM, supplementation with vitamin C may be warranted.

Vitamin E is a lipid-soluble antioxidant that inhibits membrane-damaging effects of reactive oxygen species-induced lipid peroxidation. It is hypothesised that dietary vitamins C and E in low doses may prevent damage by reactive oxygen species that can impair fetal membrane integrity and reduce mid-gestation levels of vitamin C associated with PROM.¹⁷⁹

Fish oils and PROM

A randomised trial of fish oils in high-risk pregnancies found there may be a potential role for its use in the prevention of PROM although more studies are warranted.¹⁸⁰

Genital tract infections

Pre-term labour can be caused by maternal genital infection in 30–50% of cases and lead to serious complications in the newborn. Clearing infections in the vagina can reduce the rate of pre-term births. Studies explored the use of probiotics, such as Lactobacillus preparations and yoghurts containing live cultures, either orally or vaginally, by women diagnosed with bacterial vaginosis in early pregnancy. A Cochrane review concluded that whilst probiotics reduced risk of genital infection by 81%, there was insufficient data to firmly conclude in the few trials that probiotics can prevent pre-term labour or its complications.¹⁸¹ Another Cochrane review did find that probiotics are particularly useful for the prevention of severe necrotising enterocolitis in pre-term during enteral feeding by the infant.¹⁸²

Pelvic and back pain in pregnancy

Back and pelvic pain are common symptoms of pregnancy aggravated by the weight of the growing newborn and then carrying after the baby is born. Management strategies include: exercise, rest, heat or cooling compresses, a supportive belt, using pillows during sleep and sitting, massage, acupuncture, chiropractic, relaxation, yoga and Reiki, and if necessary the use of medication such as paracetamol.

A Cochrane review was undertaken of 8 studies (1305 participants) that examined the effects of adding various pregnancy-specific exercises, physiotherapy, acupuncture and pillows to usual prenatal care.¹⁸³ Women who were not instructed to do exercise, stretching or have acupuncture and just received usual prenatal care reported more use of analgesics, physical modalities and sacroiliac belts.

Exercise helps back pain

The abovementioned Cochrane review found strengthening exercises, stabilising exercises, sitting pelvic tilt exercises and water gymnastics reduced pain intensity and back pain-related sick leave in pregnant women more than usual prenatal care alone.¹⁸³

Acupuncture helps pelvic and back pain

The Cochrane reviewers found that acupuncture relieved pelvic pain, particularly relief from evening pain, more than exercises, and in 1 study was more effective than physiotherapy in reducing the intensity of pain. Acupuncture relieved intensity of pain by up to 60% compared to 14% of those receiving usual prenatal care.¹⁸³

A systematic review of the literature that included 3 RCTs found statistically significant reduction in pain using acupuncture compared with control, particularly the combination of acupuncture and standard treatment with physiotherapy, for women suffering mixed pelvic and back pain in pregnancy.¹⁸⁴ No serious adverse events were reported across all trials with only minor adverse events, such as local pain, bruising, sweating and nausea.¹⁸⁴

Stretching helps pelvic and back pain

According to the Cochrane review, stretching exercises resulted in total pain relief by up to 60% compared with usual care (11%).¹⁸³

Labour and labour pain

Mind–body factors and labour

Ten percent of women experience fear of labour. Feeling fear without counselling was associated with a negative birth experience.¹⁸⁵ Counselling helped women have a more positive experience with childbirth but, of interest, it was associated with a higher risk of having a caesarean section.

More research is required to explore non-drug and surgical interventions for the safe delivery of the newborn as interventions such as caesarean sections carry a high risk to both mothers and newborns and whilst epidurals are effective in reducing pain they come at a high risk, resulting in higher chances of instrumental delivery.¹⁸⁶

Music and labour

Music plays an important role in the management of anxiety (see Chapter 4 on anxiety) and for pain relief. A systematic review of the literature identified 51 studies involving 3663 patients experiencing acute or chronic pain (not pregnant) and found music reduced pain by up to 50%, and reduced the need for morphine-like analgesics.¹⁸⁷ It would appear calm, gentle, soothing music may play a role in helping reduce pain and anxiety during labour, as gentle music poses little risk or harm to the mother, although research is required to confirm this.

Yoga and labour

Practising regular yoga during pregnancy is associated with improved birth outcomes, improved maternal comfort and reduced labour pain.¹⁸⁸^–¹⁹¹ Also, yoga practise was associated with higher incidence of vaginal birth rate and less need for caesarean section.

Acupuncture, acupressure, hypnosis, massage, relaxation, aromatherapy and labour

A Cochrane literature review explored trials using non-drug approaches such as acupuncture, mind-body techniques, massage, reflexology, herbal medicines, homoeopathy, hypnosis and music for pain management during labour.¹⁹² They identified 14 trials including 1448 pregnant women:

• 3 trials acupuncture (n = 496)

• 2 acupressure (n = 172)

• 1 audio-analgesia (n = 24), ‘sea sounds’

• 1 aromatherapy (n = 22)

• 5 hypnosis (n = 729), including self-hypnosis

• 1 massage (n = 60)

• 1 relaxation (n = 34).

The authors concluded that acupuncture and self-hypnosis reduced the need for pain relief and led to women feeling more satisfied with their pain during labour compared with controls, plus requiring less analgesia and the need for an epidural. However, the other studies were of too poor a quality to comment.

Water births and labour

A Cochrane review of 8 trials including 2939 women found statistically significant reduction in pain and the use of epidural/spinal/paracervical analgesia/anaesthesia amongst women allocated to water immersion during the first stage of labour compared to those not allocated to water immersion.¹⁹³ Also, women were less likely to require analgesia and there were no adverse outcomes on labour duration, operative delivery or neonatal outcomes, although more research is still warranted.

Pelvic floor exercises and labour

A study of 120 healthy nulliparous women who engaged in a series of weekly pelvic floor training sessions over 12 weeks in the second half of the pregnancy, experienced better childbirth than women in the control group who experienced longer active pushing in the second stage of labour.¹⁹⁴

Moxibustion is a method used in Chinese medicine that involves the burning of a herb close to the skin. In breech, traditional Chinese medicine (TCM) practitioners apply moxibustion near the little toe. A Cochrane review identified 3 trials of 597 women, but only 1 trial reported relevant outcome measures.¹⁹⁸ This study demonstrated that moxibustion reduced the need for ECV or the use of oxytocin before and during labour for women who had vaginal deliveries. Whilst the authors concluded the research to date is not convincing, it would appear a very simple, non-harmful approach to trial if needed.

Labour pain

Perineal massage and labour

A Cochrane review of 3 good quality trials involving 2434 women comparing digital perineal massage with control demonstrated a clear benefit using perineal massage during pregnancy as little as once or twice weekly from 35 weeks gestation.¹⁹⁹ Antenatal perineal massage significantly reduced the incidence of perineal trauma requiring suturing (episiotomy) especially in women without previous vaginal birth. In women with a history of previous vaginal birth they reported significant reduction of pain at 3 months post-partum.¹⁹⁹ As such, women should be encouraged to undertake perineal massage, which can be done by the woman or her partner.

Perineal pain after labour

Cooling packs

Perineal tears following labour can cause much pain and discomfort for the mother and it is common practice after labour to apply ice or cold packs onto tears or cuts. ²⁰⁰ A review of the literature demonstrates that ice packs provide pain relief up to 72 hours following birth but women preferred gel pads (ease of use) when compared with ice packs or no treatment. There were no differences in level of bruising or oedema in each group.²⁰⁰

Ultrasound

There is little evidence to evaluate the use of ultrasound in treating perineal pain following childbirth.²⁰¹

Antenatal and postnatal depression

Antenatal depression (AND) is common, affecting from 7.4% in the 1st trimester up to 12.8% in the 2nd trimester. Psychosocial and psychological support is vital for the wellbeing of the mother and child during and following pregnancy, especially for the prevention of post-partum depression.

A Cochrane review found too few trials to confidently make any recommendations for other therapies, such as massage therapy or depression-specific acupuncture, for the treatment of antenatal depression.²⁰²

Postnatal depression (PND) affects up to 15% of mothers. It is vital that PND is detected and treated early. Mothers require guidance and emotional and physical support, especially in the first few months following birth. It is a time when they experience poor sleep, may experience pain, illness, problems with lactation, have difficulty cooking, lack exercise and sunshine and all these factors can contribute to fatigue, exhaustion and depression. There is a traditional North American Indian saying: ‘it takes a whole village to bring up a child’. The level of support in smaller communities, extended families, villages and so forth, can play a vital role in supporting the mother, especially a first-time mother who needs guidance and assistance within the first year following birth. There are many cultures where women become more supportive to new mothers and provide assistance with cooking and cleaning.

A meta-analyses of the literature identified 9 studies (n = 956) that found psychosocial interventions such as peer support or non-directive counselling, cognitive behavioural therapy (CBT), interpersonal psychotherapy, and psychodynamic therapy significantly reduced evidence of depression within the first year after delivery, compared to usual care in women with PND.²⁰³ Professional counselling reduced rates of PND by 40%, while support from other mothers reduced the risk by up to 50%. Research consistently supports the value of psychological and psychosocial support in reducing the incidence of PND.²⁰⁴

Infants of mothers with PND are more likely to experience cognitive and psychomotor developmental delays, although the mechanism is not clear.²⁰⁵

Lifestyle and AND/PND

There is clear evidence that lifestyle factors, such as diet, exercise, sunshine, sleep and stress management, play an important role in the management of depression. (See Chapter 12 for more information on depression.)

Psychosocial and psychological support and AND/PND

Antidepressant use in pregnancy should be avoided as much as possible, because of adverse effects on the fetus, and should be weighed against the risk and harm to the mother.²⁰⁶^–²⁰⁹ Counselling is not only recommended for treatment of depression but can help reduce risk of developing depression.

Sleep and PND

Two-thirds of clinically significant depression symptoms in pregnancy occur in mothers reporting an infant with a sleep problem. An Australian study of mothers with infants 6–12 months of age found that sleep deprivation was a factor in PND.²¹⁰ If the infant had a sleep problem, the mother was twice as likely to have PND. The same group showed that by improving the mother’s sleep, this improved the PND.²¹¹

In another study, this group is investigated for behavioural intervention for sleep problems on maternal depression.²¹² They concluded that sleep intervention in infancy resulted in sustained positive effects on maternal depression.

Fish oils and PND

It is well recognised that a diet high in fish and omega-3 supplementation may help with depression. (See Chapter 12 for more information on depression.) A small pilot study found omega-3 supplementation may help women with PND.²¹³ A review of the literature found 3 trials of omega-3 fatty acids versus placebo for perinatal depression show conflicting results.²¹⁴ It is likely women with lower levels of omega-3 fatty acids during pregnancy are more likely to develop depression than those with higher levels.