A 24-year-old woman, gravida 2, para 1, at 37 weeks gestation comes to the office requesting induction of labor. The patient says that the last few weeks of pregnancy have been "very uncomfortable" due to exhaustion and shortness of breath when walking. She has bilateral leg swelling and is unable to fit into her shoes. The patient has difficulty sleeping at night due to bilateral crampy pain in her calves that is relieved by massage and stretching, and because the baby moves frequently at night. Review of systems is negative for contractions, vaginal bleeding, and loss of fluid. Temperature is 36.8 C (98.2 F), blood pressure is 110/70 mm Hg, pulse is 110/min, and respiratory rate is 18/min. Urinalysis shows trace protein. Physical examination shows symmetrical, bilateral pitting edema of the calves, ankles, and feet. Cardiac auscultation shows a 2/6 systolic ejection murmur. Her lungs are clear to auscultation. Which of the following is the most appropriate next step in management?

Question

A 24-year-old woman, gravida 2, para 1, at 37 weeks gestation comes to the office requesting induction of labor.  The patient says that the last few weeks of pregnancy have been "very uncomfortable" due to exhaustion and shortness of breath when walking.  She has bilateral leg swelling and is unable to fit into her shoes.  The patient has difficulty sleeping at night due to bilateral crampy pain in her calves that is relieved by massage and stretching, and because the baby moves frequently at night.  Review of systems is negative for contractions, vaginal bleeding, and loss of fluid.  Temperature is 36.8 C (98.2 F), blood pressure is 110/70 mm Hg, pulse is 110/min, and respiratory rate is 18/min.  Urinalysis shows trace protein.  Physical examination shows symmetrical, bilateral pitting edema of the calves, ankles, and feet.  Cardiac auscultation shows a 2/6 systolic ejection murmur.  Her lungs are clear to auscultation.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec25c8_da53_1e8b_bc81_b75bffbe45cf_MD0003_00 Pregnancy causes maternal hemodynamic changes that include an increase in cardiac output and plasma volume as well as a decrease in systemic vascular resistance and blood pressure. The increased cardiac output results from an increase in stroke volume in early pregnancy and a faster heart rate in late pregnancy and is frequently accompanied by a systolic ejection murmur. The plasma volume expansion can cause peripheral edema. Dyspnea is also common due to respiratory adaptations to pregnancy. Progesterone induces increased minute ventilation through an increase in tidal volume, but the respiratory rate is unchanged. The enlarging uterus causes the diaphragm to be elevated, resulting in decreased functional residual capacity. Nocturnal leg pain is also common due to muscle cramping from lactic and pyruvic acid accumulation. Reassurance and routine prenatal care are indicated for this patient, who is experiencing normal manifestations of physiologic adaptations to pregnancy. (Choice A) A 24-hour urine collection for total protein is part of the evaluation for preeclampsia, the cardinal features of which include hypertension, edema, and pathologic proteinuria. This normotensive patient has trace protein on urinalysis, a normal finding in pregnancy due to increased urinary protein excretion. It results from an increase in the glomerular filtration rate and the permeability of the glomerular basement membrane. (Choice B) A chest x-ray would be helpful in the diagnosis of pulmonary edema, which typically presents with orthopnea, cough, and rales on pulmonary auscultation, none of which are present in this patient. (Choice C) CT pulmonary angiography is the gold standard for diagnosis of a pulmonary embolism (PE). Although pregnancy increases PE risk, the absence of tachypnea, pleuritic chest pain, cough, and calf tenderness makes evaluation for PE unnecessary. (Choice D) Doppler ultrasound is used to evaluate for deep venous thrombosis, which typically presents with unilateral calf or thigh pain, swelling, and redness. This patient's calf pain is bilateral and relieved by massage. (Choice E) An echocardiogram would be indicated to evaluate for peripartum cardiomyopathy, which may cause peripheral edema and dyspnea. However, the absence of cough, hemoptysis, and a holosystolic mitral regurgitation murmur makes further workup unnecessary. Educational objective: Maternal adaptations to pregnancy include increases in cardiac output, plasma volume, and tidal volume. A systolic ejection murmur, peripheral edema, and dyspnea are common but benign symptoms that result from these changes. References: Physiologic adaptations to pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/22840789)

A 24-Year-Old Woman, Gravida 2, Para 1, at 37 Weeks