POTS and the First Trimester of Pregnancy

Navigating the first trimester of pregnancy can be challenging for many women, but for those with POTS, it brings unique challenges and specific considerations that require special attention.

As I write this, I’m almost 18 weeks pregnant, and while the second trimester has introduced its own set of challenges with POTS, this post focuses on the first trimester. I'll share insights from my personal experience alongside scientific information to help guide you through the early stages of pregnancy with POTS.

Increased Blood Volume

During the first trimester, maternal blood volume increases up to 45% higher than normal. When blood volume increases, so does heart rate and overall cardiac output. This is a really important physiological change during early pregnancy as the increased blood volume supports the growing fetus. However, when you have POTS you already likely have a heart rate that at baseline is too high, resulting in POTS symptoms. During this time, it’s common to experience exacerbations of POTS symptoms such as palpitations, dizziness, fatigue, nausea and gastrointestinal discomfort.

Medication Management

During the first trimester, it is also common for patients with POTS to cease their usual medications that help lower the increased heart rate due to safety risk to the fetus. It’s important that before you begin trying to get prgenant, that you have converstaions with your healthcare providers - both doctors and allied health workers, to ensure you have a plan regarding your medication and supplement management during conception and pregnancy. If pregnancy comes as a surprise to you, please contact your healthcare providers as soon as possible to discuss medication management during pregnancy.

Often after the first trimester, you may be able to return to medications you have ceased or trial new ones that are known to be safe in pregnancy. Keep your healthcare providers up to date with how you are experiencing pregnancy so that they can provide you with relevant and individualised advice regarding medication and supplement management during various times in your pregnancy.

Prenatal Vitamins

Prior to conception and during pregnancy, it’s paramount to be taking prenatal vitamins to encourage optimal development of your baby. People with POTS often have co-existing conditions, some of which can include symptoms of sensitvity or allergic reactions to ingredients in supplements. If you are choosing prenatal vitamins and you also experience sensitivity/allergy, please trial supplements under the supervision of your healthcare provider, whether that be Naturopath, Nutritionist, Dietitian or Medical Practitioner.

Pacing and Fatigue

Pacing is a crucial strategy for managing POTS during the first trimester of pregnancy, as the body's energy demands and symptoms can fluctuate dramatically. Pregnancy itself can amplify fatigue, dizziness, and blood pressure fluctuations, common in POTS. For those in the first trimester—already dealing with nausea, exhaustion, and hormonal changes—learning to pace activities becomes essential. By breaking tasks into smaller, manageable parts, resting frequently, and listening to your body's signals, you can reduce symptom flare-ups and prevent overexertion. This gentle, balanced approach helps protect both your health and your baby’s development during this critical time.

pacing strategies for managing POTS during the first trimesteR:

1. Prioritise Rest: Ensure you’re getting enough rest throughout the day. Take frequent breaks between tasks, especially when feeling lightheaded or fatigued. Listening to your body’s signals is key.

2. Break Tasks Into Smaller Steps: Instead of tackling a large chore all at once, break it down into smaller, manageable steps. For example, if cleaning the Kitchen, break it up in to several steps with breaks between. Empty the dishwasher, take a break. Load the dishwasher, take a break. Wipe down the benches, take a break.

3. Alternate Rest and Activity: Use an "activity-rest" cycle. After 15-30 minutes of activity, take a 10-15 minute break.

5. Use Mobility Aids if Needed: For some, sitting while doing tasks like cooking or using a shower chair can conserve energy and reduce dizziness. Don’t be afriad to use mobility aids, even if you have never used them before. Mobility aids are there to support your needs. You do not need to meet any sort of criteria to “need one”. You do not need to justify your use of mobility aids to anyone but yourself. If a mobility aid can support you with your health needs, even if temporary - use them.

6. Set Realistic Expectations: Be gentle with yourself and adjust your daily goals to account for the increased physical demands of pregnancy. It’s okay to delegate tasks, ask for help and take sick days.

7. Track Symptoms and Patterns: Keeping a symptom journal can help identify triggers and patterns in fatigue or dizziness, allowing you to adjust your routine and pacing accordingly. You can do this simply with pen & paper or utilise a symptom tracker app like Guava Health (not sponsored - just a fan!)

Nausea:

Nausea is a common experience during the first trimester of pregnancy and it’s also a common experience for those with POTS. People with POTS who are also in their first trimester may have difficulty with managing this symptom. There is lots you can try to do before you reach for pharmaceutical medication, however, if you are finding it difficult to stay hydrated and keep food down frequently, medication may be required and that’s okay!

From Ginger, Vitamin B6, Acupressure, Probiotics, Dietary tips & more… there are lots of tools you can try to support you during this time.

I recommend reading this blog post by Nutritionist Court Garfoot titled “Easing the Waves of Nausea & Vomiting in Pregnancy”.

The most important thing to do to manage your POTS influenced nausea, is support your reduction in POTS symptoms by supporting your body with the strategies mentioned earlier in this post. The tools mentioned above can be helpful for managing symptoms.

THE POTS TRIAD OF TREATMENT

I refer to the POTS “triad of treatment” often as there are three things that are really important for managing POTS symptoms, pregnant or not. However, during pregnancy - you may need to modify some of these treatments.

SALT & WATER:

It’s recommended that patients with POTS consume at least 2-3L of water daily, along with 3-10grams of sodium (dependent on individual needs and should be determined by your practitioner) (Vernino et al., 2021). When pregnant, a daily intake of a minimum of 2.5 litres of fluids and around 7g of sodium daily is recommended (Morgan et al., 2022) but this should be discussed with your practitioner to find a dosage range that works for you. To put this in perspective, one teaspoon of salt contains approximately 2.3 grams of sodium. Some patients find it helpful to drink two cups of fluid before getting out of bed in the morning to manage symptoms. You can add sodium in to your diet in a variety of ways from adding table salt to your food, salt tablets and electrolytes. Most of my clients find that salt tablets cause gastrointestinal upset, therefore they rely on a combination of electrolytes and adding salt to food. My go-to electrolyte supplement is SODII Hydration. Use code “HYPERMOBILENAT” for 15% off.

COMPRESSION:
Consider using compression garments such as compression socks/stockings, shorts, abdominal binders, or gloves with a pressure rating of at least 20-30 mm Hg to support blood flow back to the heart. Recent studies indicate that compression garments targeting the thighs, buttocks, and abdomen (such as bike shorts) offer the most effective benefits. For pregnant individuals with POTS, maternity waist-high compression stockings are particularly recommended to enhance venous return to the heart (Morgan et al., 2022).

EXERCISE:
Swimming and using a recumbent bike are great ways to maintain blood plasma volume, muscle mass, and cardiovascular fitness during pregnancy (Morgan et al., 2022). The modified exercise protocol from the Children's Hospital of Philadelphia includes helpful isometric, aerobic, and resistance exercises for POTS, but it's important not to overexert yourself while pregnant. As you enter the second and third trimesters, it's best to avoid exercises done while lying on your back, as the weight of the growing fetus can compress the aorta and inferior vena cava (Morgan et al., 2022). Instead, focus on exercises performed while seated or lying on your left side for safer positioning. It’s also important to note that exercise with POTS looks different for everyone. I highly recommend working with an exercise physiologist or physiotherapist to determine a plan that is right for you.

My own reflections on my first trimester:

My first trimester was rough. I have had very managable POTS symptoms for a long time now, with little flare ups. As soon as I got pregnant, I noticed a difference in my symptoms. Fatigue, heat intolerance, exercise intolerance, dizziness, palpitations and nausea were all frequent occurrences. Really going back to the basics of rest, pacing, hydration, salt, compression and a few supplements and medications made all the difference, along with incorporating some mobility aids like a shower chair. I also have had wonderful support in my partner during this time and relied on his help lots to change positions safely due to my dizziness. When my second trimester began, I discussed medication management options with my healthcare team and that has really helped too. The best advice I can give for someone who is going through the first trimester with POTS is to just take it one day at a time, lean on the supports you have available, go back to basics with POTS management and ask for help when you need it.

References:
https://www.dinet.org/info/pots/considerations-of-pregnancy-in-patients-with-pots-r219/

Morgan, K., Smith, A., & Blitshteyn, S. (2022). POTS and Pregnancy: A Review of Literature and Recommendations for Evaluation and Treatment. International Journal of Women’s Health, 14, 1831–1847. https://doi.org/10.2147/IJWH.S366667

Kimpinski, K., Iodice, V., Sandroni, P., & Low, P. A. (2010). Effect of pregnancy on postural tachycardia syndrome. Mayo Clinic proceedings, 85(7), 639–644. https://doi.org/10.4065/mcp.2009.0672

https://www.standinguptopots.org/POTSiepregnancy#:~:text=POTS%20and%20Pregnancy%201%20Normal%20Physiological%20Changes%20that,during%20Pregnancy%20...%204%20Labor%20and%20Delivery%20

Vernino, S., Bourne, K. M., Stiles, L. E., Grubb, B. P., Fedorowski, A., Stewart, J. M., Arnold, A. C., Pace, L. A., Axelsson, J., Boris, J. R., Moak, J. P., Goodman, B. P., Chémali, K. R., Chung, T. H., Goldstein, D. S., Diedrich, A., Miglis, M. G., Cortez, M. M., Miller, A. J., Freeman, R., … Raj, S. R. (2021). Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting - Part 1. Autonomic neuroscience : basic & clinical, 235, 102828. https://doi.org/10.1016/j.autneu.2021.102828