A 32-year-old primigravida at 24 weeks gestation is evaluated for excessive tiredness. The patient feels sleepy throughout the day and keeps dozing off at work. Her overnight sleep is poor and she does not feel refreshed on awakening in the morning. She also reports occasional morning headaches. The patient had mild nausea during the first trimester but her pregnancy has otherwise been uneventful. She has no known medical issues and her only medication is prenatal vitamins. The patient drinks alcohol occasionally but stopped after conception and does not use tobacco or illicit drugs.
Blood pressure is 142/90 mm Hg, pulse is 98/min, respirations are 18/min, and SaO₂ is 96% on room air. The patient's pre-pregnancy weight was 76 kg (167.6 lb) with BMI of 28 kg/m²; she has gained 7 kg (15.4 lb) during the pregnancy. Examination shows normal thyroid gland, prominent jugular venous pulse estimated at 2 cm above the sternal angle, clear lungs, grade 2/6 systolic ejection murmur, and gravid uterus appropriate for gestation. There is mild ankle edema. Fetal heart rate is within normal limits.
Laboratory studies are significant for hemoglobin of 11.4 g/dL and trace protein in urine.
Which of the following is the most appropriate next step in management of this patient?

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Quizplus · Accepted Answer

Physiologic changes of pregnancy, including weight gain, nasopharyngeal mucosal edema, and upward displacement of the diaphragm, may predispose to snoring and sleep-disordered breathing. Symptoms of obstructive sleep apnea (OSA) in pregnancy are similar to those in nonpregnant patients. However, OSA is likely underdiagnosed in pregnant patients due to disrupted sleep and fatigue being attributed to normal pregnancy. Similar to nonpregnant patients, obese pregnant patients with excessive fatigue, snoring, and daytime somnolence should be evaluated with overnight polysomnography. OSA has also been linked to gestational diabetes, gestational hypertension, and preeclampsia. This patient with preeclampsia (mild hypertension and proteinuria), excessive fatigue, and daytime somnolence should be evaluated for OSA. (Choice A) Current guidelines do not recommend treatment for mild hypertension (blood pressure ≤150/100 mm Hg) in preeclampsia. When needed, first-line antihypertensives in pregnancy include hydralazine and labetalol. Calcium channel blockers (eg, diltiazem, verapamil, nifedipine) are usually second-line agents. (Choice B) Anemia during pregnancy is defined as hemoglobin <10.5 g/dL during the second trimester and <11 g/dL during the first and third trimesters. This patient is not anemic, making iron deficiency an unlikely cause of her symptoms. (Choice D) Echocardiogram is appropriate to evaluate for peripartum cardiomyopathy; however, this usually presents after 36 weeks gestation. In addition, this patient's mild ankle edema and prominent but not elevated jugular venous pulse are explained by normal cardiovascular changes of pregnancy. jugular venous pulse (Choice E) Reassurance without evaluating for OSA would be inappropriate in this patient with excessive fatigue, daytime somnolence, and preeclampsia. Educational objective: Obstructive sleep apnea (OSA) in pregnancy is associated with gestational diabetes, gestational hypertension, and preeclampsia. Presenting symptoms of OSA are similar to those in nonpregnant patients (eg, snoring, excessive fatigue, daytime somnolence), and patients with such symptoms should be evaluated with overnight polysomnography. __________ References: Maternal sleep-disordered breathing and adverse pregnancy outcomes: a systematic review and metaanalysis. (http://www.ncbi.nlm.nih.gov/pubmed/23911687)

A 32-Year-Old Primigravida at 24 Weeks Gestation Is Evaluated for Excessive