“I’m 30 weeks pregnant and every evening my legs feel crawly and I have to move them — it’s ruining my sleep”

RESTLESS LEGS SYNDROME (RLS) is recognised by four core features: an URGE to move the legs (often with an unpleasant crawling/uncomfortable sensation), worse at REST, relieved by MOVEMENT, and worse in the EVENING/at night. It commonly first occurs or worsens in PREGNANCY (up to about 1 in 5, especially the third trimester) and usually resolves after delivery. Exclude mimics, especially a unilateral swollen painful calf (DVT — same-day assessment in a prothrombotic pregnancy). The key, easily-missed step is to check for and treat IRON DEFICIENCY, a common treatable secondary cause/contributor particularly relevant in pregnancy — check ferritin, FBC and folate, as low or even low-normal iron stores contribute (IRLSSG, international: oral iron when ferritin is below 75 µg/L; BSH 2020 for pregnancy thresholds) and iron and folate replacement often improves RLS. Screen other contributors (thyroid and renal function; medications that can worsen RLS — sedating antihistamines including over-the-counter sleep aids, some antidepressants such as SSRIs/mirtazapine, dopamine-antagonist antiemetics; caffeine) and ask about perinatal mood (NICE NG201) and address modifiable ones. Manage conservatively first — especially important in pregnancy — with sleep hygiene, gentle exercise/stretching/walking, leg massage, warmth/heat, reducing caffeine and evening triggers, and treating iron deficiency, because the usual RLS medications — dopamine agonists and alpha-2-delta ligands — are avoided in pregnancy (owner’s Medwise-reviewed protocol; AASM 2024, international) and should not be reached for. Reassure that pregnancy-related RLS is common and usually resolves after delivery and that conservative measures plus iron are the mainstay, and for severe/refractory symptoms seek advice from the obstetric team on safe specialist options rather than prescribing standard RLS drugs unsafely. The skill is recognising RLS, checking/treating iron deficiency, conservative pregnancy-safe management, reassurance about post-delivery resolution, and caution with medication.