a) Nausea and vomiting (morning sickness): some degree of nausea and vomiting during the first trimester, in particular between the first and the second missed periods, is a very common complaint. It usually continues until about the fourteen weeks of gestation. They can appear at any time of the day but is worse in the morning. Thus they are given the name morning sickness. This condition is believed to be caused by the high or rapidly rising level of human chorionic gonadotrophic hormone (HCG) and oestrogen. It is worse in multiple pregnancies and some other conditions. Psychological problems like anxiety can aggravate the situation. The remedy is eating little food at more frequent intervals and avoiding food items whose smell precipitate or exacerbate the symptoms. If available, anti-emetics can be helpful.

b) Heartburn: heartburn (epigastric burning sensation), is one of the most common complaints of pregnant women especially during late pregnancy. The symptom is usually mild. It is caused by reflux of gastric content into the lower oesophagus due to upward displacement and compression of the stomach by the enlarging uterus and progesterone induced relaxation of the lower oesophagal sphincter.It is relieved by having smaller meals, avoiding bending over or lying flat. Anti-acid preparation (aluminium hydroxide or magnesium trisilicate alone or in combination). In severe cases, refer the woman for other investigation or medications

c) Pica (abnormal craving): pica, craving of a pregnant woman for items of little nutritional value like ice or clay can occur. No known cause has been identified but it is known to be common in patients with iron deficiency anaemia. In these cases, it is relieved by correction of anaemia. Some pregnant women may have the symptom without anaemia. Educating the woman is all that is advisable.

d) Ptyalism: ptyalism, excessive salivation, not related to increased saliva production is common. It is the result of reduced swallowing because of nausea. Simple explanations will suffice.

e) Constipation: progesterone-induced relaxation of smooth muscles and pressure by the uterus in the later part of pregnancy result in a common complaint of constipation. This is a decrease in the frequency of bowel movements. The condition can be treated with high fibre diet and increasing fluid intake. Sometimes bulk forming laxatives may be needed.

f) Haemorrhoids (piles): haemorrhoids, varicosities of the rectal veins, may first appear during pregnancy. More often pregnancy causes exacerbation or recurrence of previous haemorrhoids due to increased pressure in the rectal veins caused by obstruction of venous return by the large uterus.Constipation during pregnancy also contributes to development of haemorrhoids.Haemorrhoids can be asymptomatic or present with rectal bleeding, rectal pain or as a prolapsed mass through the anal orifice. Treatment includes topically applied anaesthetic and anti-inflammatory agents for pain and swelling, warm soaks (sits bath), laxatives and modification of bowel habits.

g) Urinary frequency: increased glomerular filtration rate and in the latter part of pregnancy pressure by the enlarging uterus explain the common complaint of the frequency of urination. Urinary tract infection is also common as the result of incomplete emptying of the bladder and stasis of urine. Microscopic examination of urine must be done in all cases. Once UTI is ruled out simple explanation is enough.

h) Vaginal discharge: pregnant women typically develop increased vaginal discharge in many instances. It is clear, whitish and odourless. This is the result of oestrogen mediated increased mucus secretion by the cervical glands. Reassurance is usually sufficient. If it is a cause of concern vaginal douche with water mildly acidified with vinegar can be used. Other vaginal infections like trichomoniasis and candidiasis should be ruled out in every patient with this symptom.

i) Low Back and pelvic pain: exaggerated lordosis and relaxation of the lumbar ligaments cause the common complaint of low back pain. Minor degrees of pain may follow excessive strain or fatigue, bending, lifting or walking. Its severity increases with the duration of pregnancy. Low back pain can be reduced by having the woman squat rather than bending over when reaching down, providing back support with a pillow when sitting down, and avoiding high heeled shoes.Severe back pain with localised spinal tenderness should not be attributed solely to pregnancy and further evaluation is needed.

j) Varicose veins: varicose veins, dilatation of the superficial veins of the lower extremities, could develop in predisposed women. It becomes more prominent as pregnancy advances, weight increases and the length of time spent upright position is prolonged. It is due to progesterone mediated smooth muscle relaxation of the blood vessels and increased venous pressure in the femoral veins due to compression by the enlarging uterus.In most cases, it is asymptomatic. The only concern in these women is cosmetic. In fewer cases it, causes discomfort of variable degree.The treatment is periodic rest with elevation of legs and use of elastic stocking or both.

k) Dependent edema: edema of the lower extremities is common. It is as the result of increased venous pressure of the lower extremities. It appears near the end of the day and disappears after a period of rest. It is important to rule out preeclampsia (which you will learn later in this session) especially in those with persistent dependent edema.

l) Other complaints:

• Fatigue is the other common complaint during early pregnancy. The woman will have a desire for excessive sleep. This symptom remits spontaneously by the fourth month of the pregnancy and has no special significance.

• Chloasma (mask of pregnancy) and striae are other sources of concern for which no treatment is required. These often regress but may not totally resolve after delivery. Occasionally women complain about leg cramps. It is believed to be the result of phosphorous deficiency and is relieved by dietary adjustment.
  
• Hyperemesis gravidarum: severe nausea and repeated vomiting that precludes oral intake and leads to dehydration and ketoacidosis are termed as hyperemesis gravidarum (which is not minor complication).The cause is unknown but high levels of oestrogen and HCG, Vitamin B 6 deficiency and psychologic factors are implicated. It is common in multiple pregnancies and those with family or past history of this condition. Inadequate fluid intake results in dehydration, and weight also reduced urine output may be seen. The presence of exaggerated nausea, excessive vomiting, weight loss and signs of dehydration like fatigue, dry oral mucosa, weak pulse, low blood pressure and reduced urine are hallmarks of this condition. Once the diagnosis is confirmed, the woman needs to be admitted; you should refer her after counselling her partner.