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Difficulty: MediumNormal Pregnancy and Prenatal Care

During a routine third-trimester visit, a patient at 33 weeks gestation reports feeling increasingly winded after walking up the stairs at her home. She also notes that her shoes feel tight by the evening. The pregnancy has been uncomplicated thus far. Her current vital signs include a blood pressure of 112/68 mm Hg, a heart rate of 96/min, and a respiratory rate of 18/min. On physical examination, the physician notes a grade 2/6 systolic ejection murmur along the left sternal edge, accompanied by an early diastolic extra heart sound (S3). There is trace bilateral pitting edema of the ankles. Pulmonary auscultation reveals clear breath sounds in all fields, and the jugular venous pulse is not elevated. A rhythm strip demonstrates normal sinus rhythm with left axis deviation. What is the most appropriate action at this time?

  1. A
    Transthoracic echocardiogram
  2. B
    Initiation of oral furosemide
  3. Reassurance and continued routine prenatal careAnswer
  4. D
    Serum D-dimer testing
  5. E
    Urine protein-to-creatinine ratio

Answer

Reassurance and continued routine prenatal care
The correct action is reassurance. Normal maternal physiology undergoes profound changes to accommodate the developing fetus. The cardiovascular system exhibits increased cardiac output and plasma volume, frequently resulting in a hyperdynamic state. This commonly manifests as an S3 gallop and a soft (grade 1/6 or 2/6) systolic ejection murmur. The expanding uterus displaces the diaphragm upward, causing a left axis deviation on an electrocardiogram. Mechanical compression of the inferior vena cava by the uterus leads to decreased venous return from the lower extremities, resulting in benign, dependent pedal edema. Finally, progesterone drives an increase in minute ventilation, often perceived by the patient as exertional dyspnea. Because this patient has no signs of decompensation (clear lungs, normal jugular venous pressure, normal blood pressure), these findings are entirely physiologic and require only routine follow-up.

Step-by-Step Solution

1
Analyze the patient's vital signs and respiratory symptoms.
The patient has dyspnea on exertion, but vital signs show normal respiratory rate, normal blood pressure, and mild tachycardia typical for the third trimester.
To distinguish between physiologic dyspnea of pregnancy (progesterone-mediated) and a pathologic pulmonary process.
2
Evaluate the cardiovascular exam findings.
The grade 2/6 systolic ejection murmur, S3 gallop, left axis deviation, and dependent edema are identified in a patient with clear lungs and normal JVP.
To determine if the cardiac signs represent structural heart disease/failure or normal hyperdynamic circulation of pregnancy.
3
Determine the appropriate management.
All findings represent normal maternal adaptations to pregnancy; therefore, no diagnostic testing or pharmacologic intervention is required.
Intervening on physiologic changes can lead to unnecessary testing or iatrogenic harm.

Key Concept

Normal maternal cardiovascular adaptations to pregnancy include increased plasma volume, increased cardiac output, a benign systolic ejection murmur, an S3 gallop, dependent edema, and dyspnea on exertion.
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Topics

Normal Pregnancy and Prenatal Care

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