Examkin

Question

Difficulty: MediumNormal Pregnancy and Prenatal Care

An expectant mother at 22 weeks gestation is evaluated in the obstetric clinic. The 28-year-old nulliparous patient mentions newly noticed ankle swelling that worsens by the evening and feeling slightly winded when walking up the stairs to her apartment. She denies paroxysmal nocturnal dyspnea, chest pain, syncope, or palpitations. Her past medical history is unremarkable, and she takes only a daily prenatal vitamin. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 108/68 mm Hg, pulse of 86/min, and respirations of 16/min. Cardiac auscultation reveals a grade 2/6 early systolic ejection murmur heard best at the left upper sternal border and a distinct S3 gallop. Pulmonary auscultation is clear bilaterally. There is trace pitting edema of both ankles. Which of the following is the most appropriate next step in management?

  1. Reassurance and continuation of routine prenatal careAnswer
  2. B
    Transthoracic echocardiography
  3. C
    Prescription for oral furosemide
  4. D
    24-hour urine collection for total protein
  5. E
    Electrocardiography

Answer

Reassurance and continuation of routine prenatal care
The correct answer is reassurance and continuation of routine prenatal care. This patient's symptoms and physical examination findings are classic for the normal physiologic adaptations of pregnancy. During pregnancy, maternal plasma volume expands by up to 50%, leading to increased cardiac output and a hyperdynamic circulation. This high-flow state commonly produces a benign grade 1/6 to 2/6 early or mid-systolic ejection murmur and a third heart sound (S3). Progesterone also stimulates the medullary respiratory center, causing an increase in minute ventilation that many pregnant patients perceive as mild dyspnea, despite having clear lungs and normal oxygenation. Furthermore, the enlarging gravid uterus compresses the inferior vena cava, increasing venous hydrostatic pressure in the lower extremities and leading to trace-to-mild dependent pitting edema. Because all of these changes are expected and benign, no further workup is indicated.

Step-by-Step Solution

1
Analyze the patient's symptoms and vital signs.
The patient has mild exertional dyspnea and dependent edema with normal vital signs for pregnancy (mildly decreased BP is expected in the second trimester).
Establishing the clinical stability of the patient helps differentiate benign adaptations from pathologic states.
2
Interpret the physical examination findings.
The grade 2/6 systolic ejection murmur and S3 gallop in the setting of clear lungs indicate a high-flow state without heart failure.
Pregnancy induces a hyperdynamic circulation due to significantly increased plasma volume and cardiac output.
3
Determine the appropriate management.
Since all findings are part of normal pregnancy physiology, no diagnostic testing or pharmacologic intervention is required.
Medical interventions or extensive testing for benign physiologic changes can cause unnecessary anxiety and potential harm.

Key Concept

Normal cardiovascular and respiratory physiologic adaptations during pregnancy
Estimated Time:1m 15s
Rate this question

Topics

Normal Pregnancy and Prenatal Care

More questions from this topic