I am 23 weeks pregnant and experiencing fatigue; how should I evaluate and manage it?

Fatigue at 23 Weeks Pregnancy: Evaluation and Management

At 23 weeks pregnancy, fatigue is a normal physiological response to pregnancy, but you should systematically screen for treatable contributing factors including anemia, thyroid dysfunction, sleep disturbances, and mood disorders before attributing symptoms solely to pregnancy itself.

Understanding Normal Pregnancy Fatigue

Fatigue affects over 94% of pregnant women and typically peaks in the first and third trimesters, though it commonly persists throughout pregnancy 1. At 23 weeks (second trimester), you're in a period where fatigue may be somewhat improved compared to early pregnancy, but it remains a significant concern 2. The fatigue results from:

• Increased oxygen consumption and metabolic demands from fetal growth 3
• Cardiovascular and respiratory system adaptations 3
• Psychological adjustments to pregnancy 3
• Sleep quality deterioration, which correlates directly with worsening fatigue 1

Systematic Evaluation Approach

Screen for these specific treatable causes using a structured assessment:

Primary Laboratory Evaluation

• Check complete blood count to identify anemia (hemoglobin, hematocrit, mean corpuscular volume) 4
• Measure thyroid function (TSH, free T4) as thyroid disorders commonly cause fatigue in pregnancy 5
• Assess iron stores (serum ferritin) even if hemoglobin is normal, as low iron without anemia causes fatigue 4
• Consider vitamin D and magnesium levels if fatigue is severe, as deficiencies contribute to muscle fatigue 6, 4

Clinical Assessment Components

• Quantify fatigue severity using a 0-10 numeric scale; scores ≥4 indicate moderate-to-severe fatigue requiring intervention 4
• Evaluate sleep patterns including total sleep time, nighttime awakenings, and sleep quality, as poor sleep directly correlates with increased fatigue 1, 2
• Screen for mood disorders including depression and anxiety, as avoidant coping styles and depressive symptoms worsen fatigue 7
• Assess pain and physical discomfort that may compound fatigue 6

Management Strategy

If Anemia is Identified

• Initiate iron supplementation immediately and reassess fatigue severity after 2 weeks of treatment 4
• Hemoglobin improvements should correlate with reduced fatigue; if not, investigate other causes 4
• If no improvement after 4 weeks, further evaluate with additional testing 4

Non-Pharmacologic Interventions (First-Line for All Patients)

Activity and Energy Management:

• Implement structured activity-rest programs with 20-30 minute naps maximum to avoid disrupting nighttime sleep 7
• Maintain a daily diary to identify peak energy periods and schedule important activities accordingly 7
• Practice energy conservation by prioritizing essential activities and delegating non-essential tasks 7
• Avoid complete inactivity; moderate walking programs can reduce fatigue if you're not significantly anemic 6, 4

Sleep Optimization:

• Establish structured daily routines to improve sleep quality 7
• Address specific sleep disturbances through cognitive-behavioral strategies 7
• Consider sleep medication consultation if non-pharmacologic approaches fail 7

Psychological Support:

• Provide reassurance that second-trimester fatigue, while common, warrants evaluation and is not simply "normal pregnancy" if severe 8
• Educate about realistic expectations regarding energy levels and the importance of rest 3
• Encourage supportive social engagement and distraction activities (music, reading, socializing) which may help manage fatigue perception 7

Critical Pitfalls to Avoid

• Do not assume fatigue is solely due to pregnancy without screening for treatable medical causes, as multiple overlapping factors commonly contribute 4, 5
• Do not recommend vigorous exercise if anemia is present, as this may worsen symptoms and exercise tolerance 4
• Do not dismiss persistent or worsening fatigue as "just pregnancy," particularly if accompanied by other symptoms suggesting thyroid disease, cardiac dysfunction, or mood disorders 6, 5
• Failing to reassess after treatment misses opportunities to identify additional treatable causes 6, 4

When to Refer or Escalate

• Persistent fatigue despite treatment of identified causes after 4 weeks warrants specialist evaluation 6
• Severe deconditioning or cardiopulmonary limitations require referral to physical medicine or supervised rehabilitation 4
• Scores ≥7 on fatigue scale correlate with marked functional impairment and require immediate comprehensive intervention 4
• New or worsening symptoms including chest pain, severe shortness of breath, or signs of depression necessitate urgent evaluation 6