A 31-year-old woman, gravida 1 para 0, at 32 weeks gestation comes to the office for a routine prenatal visit. The patient reports normal fetal movements and has had no abdominal pain or vaginal bleeding. Over the past 2 weeks, she has had intermittent uncomfortable sensations in her legs, especially at bedtime and when she sits for prolonged durations like watching a movie. The patient reports no leg pain or pins and needles sensation, and the symptoms improve once she gets up and moves around. Her husband states that she frequently gets in and out of bed. Medical history is significant for depression and anxiety during adolescence after her parents' divorce. Vital signs are within normal limits. Prepregnancy BMI was 30 kg/m², and she has gained 6.8 kg (15 lb) during this pregnancy. Physical examination shows trace lower extremity edema, but no other abnormalities are present. Which of the following is the most likely cause of this patient's current symptoms?

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11ec25c8_d980_b3e6_bc81_65ded2e87364_MD0003_00 This pregnant patient with an uncomfortable feeling in her legs temporarily alleviated by movement most likely has restless legs syndrome (RLS), a neurologic condition common in pregnancy that can interfere with duration and quality of sleep. RLS is characterized by dysesthesia (eg, crawling and itching feelings) and an irresistible urge to move the legs when at rest. Symptoms occur primarily in the evenings and at night; they are partially relieved by movement and recur when movement ceases. Symptoms of RLS that appear during pregnancy typically worsen throughout gestation and improve or resolve after delivery. However, women who have RLS symptoms during pregnancy are at increased risk of developing primary (idiopathic) RLS in the future. As in other patients with RLS, serum iron studies should be obtained. Patients with iron deficiency, or even low-normal ferritin levels (≤75 µg/L), should take supplemental iron, which often improves symptoms. Improvement in sleep hygiene and gentle exercise should also be recommended as well as reassurance of the likely temporary nature of symptoms. Other agents typically used in RLS (eg, dopamine agonists, alpha-2-delta calcium channel ligand) should be avoided in pregnancy. (Choice A) Compressive neuropathy (eg, meralgia paresthetica, sciatica) is also common in pregnancy. Although compressive neuropathy can present with abnormal sensations, neuropathic pain is typically described as burning or shock-like rather than the vague discomfort seen in RLS. Unlike RLS, compressive neuropathy is typically associated with numbness and may be accompanied by motor weakness. In addition, pain due to compressive neuropathy would not immediately be relieved with movement. (Choice B) Positional leg discomfort is very common in pregnancy. It is relieved with position change but does not require continuous movement to maintain the relief. It is also not associated with specific times (eg, evenings, bedtime). (Choice C) Leg cramps are also common in pregnancy and can interfere with sleep. However, they present with sudden, painful tightness of the calf muscles with obvious hardening of the muscle. In addition, relief typically requires stretching of the specific muscle affected rather than continuous movement. (Choice D) Patients with RLS often have comorbid psychiatric disorders that can interfere with sleep. However, anxiety disorders do not cause leg discomfort relieved by walking. Educational objective: Restless legs syndrome can occur during pregnancy and is characterized by an urge to move the legs accompanied by dysesthesia that is worsened by inactivity and improved with movement. Symptoms are worse in the evening or at night and may impair sleep.

A 31-Year-Old Woman, Gravida 1 Para 0, at 32 Weeks