What is the best approach to manage fatigue in a pregnant patient?

Personalized Care Plan for Pregnancy-Related Fatigue

Fatigue in pregnancy is a physiologic symptom driven by increased oxygen consumption, fetal growth demands, and cardiovascular adaptations, requiring a structured approach focused on activity-rest balance, sleep optimization, and screening for treatable contributing factors rather than pharmacologic intervention.

Initial Assessment and Monitoring

Screen fatigue severity at every prenatal visit using a 0-10 numeric rating scale, with scores ≥4 requiring comprehensive evaluation of physical, cognitive, and emotional impact on daily activities. 1

• Document fatigue patterns across trimesters, as severity typically peaks in the first trimester (mean score 23.53), increases through the second trimester (25.78), and reaches highest levels in the third trimester (26.46). 2
• Assess which trimester the patient is currently in, as 94.2% of pregnant women experience fatigue during pregnancy, with physiologic causes varying by gestational age. 3, 2

Rule Out Treatable Contributing Factors

Systematically evaluate and treat medical conditions that compound pregnancy fatigue before implementing symptom management strategies:

• Check complete blood count and ferritin levels, as iron deficiency (even with normal hemoglobin) significantly contributes to fatigue and should be treated with oral iron supplementation targeting ferritin >50-70 ng/mL. 4
• Verify thyroid function with TSH ideally between 0.5-2.5 mIU/L, as subclinical hypothyroidism presents with fatigue and is readily treatable. 4, 1
• Screen for depression using validated tools, as inadequately treated depression is a major contributor to fatigue and requires treatment with pregnancy-safe antidepressants if indicated. 4, 1
• Assess vitamin D, vitamin B12, and magnesium levels, repleting deficiencies as these commonly contribute to fatigue. 4

Sleep Quality Optimization

Address sleep disturbances aggressively, as there is significant inverse correlation between sleep quality and fatigue severity in pregnancy (p=0.031). 2

• Establish consistent sleep and wake times, eliminate electronic devices before bedtime, and avoid caffeine in the evening. 5
• Screen for obstructive sleep apnea if the patient has elevated BMI or snoring, as this is a primary driver of fatigue. 4
• Implement cognitive behavioral therapy for insomnia (CBT-I), which has Category 1 evidence for reducing fatigue. 4, 5
• Limit daytime naps to less than 1 hour to avoid disrupting nighttime sleep quality. 5

Activity-Rest Program Development

Create a structured activity-rest schedule based on the patient's energy patterns, as this is the cornerstone of managing first-trimester fatigue. 3

• Have the patient maintain a daily fatigue diary to identify peak energy periods and schedule essential activities during these times. 4, 5
• Teach energy conservation strategies: prioritize essential activities, delegate nonessential tasks, use labor-saving techniques (rolling carts, reachers, wearing bathrobe instead of toweling off). 5
• Plan rest periods throughout the day without excessive daytime sleeping that disrupts nighttime rest. 3

Physical Activity Prescription

Prescribe tailored moderate-intensity physical activity as the most strongly evidence-based intervention for fatigue, starting at low intensity and gradually increasing based on tolerance. 1

• Recommend moderate aerobic exercise such as walking, swimming, or cycling 3-5 times weekly, tailored to functional status and gestational age. 1
• Consider gentler alternatives like prenatal yoga, tai chi, or qigong, which show significant improvements in fatigue, quality of life, and sleep quality. 1
• Adjust exercise intensity based on trimester and any pregnancy complications, avoiding overexertion. 1

Psychoeducational Interventions

Provide comprehensive education about the physiologic basis of pregnancy fatigue to reduce distress and improve coping:

• Explain that fatigue results from energy depletion due to increased oxygen consumption, fetal growth demands, and cardiovascular, respiratory, metabolic, and psychological adaptations occurring during pregnancy. 3
• Reassure the patient that fatigue is a normal pregnancy symptom, not a sign of inadequate coping or underlying pathology. 3, 6
• Discuss how fatigue patterns typically evolve across trimesters so the patient can anticipate changes. 2

Psychosocial Support and Stress Management

Address psychological stresses and ensure adequate social support, as stress and fatigue are closely linked in pregnancy. 3

• Assess partner support and relationship quality, as paternal support during pregnancy predicts maternal distress levels. 7
• Consider referral for cognitive behavioral therapy (CBT) if fatigue persists despite addressing physiologic factors, as CBT demonstrates moderate improvements in fatigue and mental health functioning. 1
• Offer mindfulness-based stress reduction programs, which show moderate effect sizes for enhancing quality of life. 1

Nutritional Optimization

Refer to a registered dietitian for structured nutritional counseling to address both fatigue and overall pregnancy nutrition. 4

• Ensure adequate caloric intake to meet increased metabolic demands of pregnancy. 3
• Optimize protein, complex carbohydrate, and healthy fat intake to maintain stable energy levels throughout the day. 4

Workplace and Environmental Modifications

Recognize that adverse working conditions and occupational stress increase fatigue and potentially impact pregnancy outcomes. 6

• Discuss workplace accommodations such as more frequent breaks, reduced standing time, or modified duties if occupational fatigue is significant. 6
• Address home environment stressors and help the patient identify ways to reduce unnecessary demands. 6

Monitoring and Reassessment

Reassess fatigue levels at every prenatal visit using the same 0-10 numeric scale to track response to interventions. 1

• Reevaluate at 4-6 weeks after initiating iron supplementation or other medical treatments. 4
• Modify management strategies based on response, changes in gestational age, and evolving clinical status. 1
• If fatigue remains severe despite comprehensive management, consider referral to maternal-fetal medicine or supportive care specialists. 1

Critical Pitfalls to Avoid

Do not prescribe sedating medications (antihistamines, benzodiazepines) that compound fatigue. 4

• Avoid attributing all fatigue to normal pregnancy without screening for treatable causes like anemia or thyroid dysfunction. 4
• Do not recommend complete bed rest or activity restriction unless medically indicated, as this worsens deconditioning and fatigue. 1
• Recognize that increased severity of fatigue during pregnancy can increase risk of preterm labor, prolonged labor, cesarean section, and postpartum depression, making proactive management essential. 2