gynecology and obstetrics
Lower Extremity Edema During Late Pregnancy
Evaluation
Evaluation of patients with lower-extremity edema during late pregnancy aims to exclude deep venous thrombosis (DVT), preeclampsia, peripartum cardiomyopathy, and other pathologic causes of edema. Physiologic edema is a diagnosis of exclusion. History of present illnessshould include the estimated due date (and whether this is based on last menstrual period or ultrasonography), any risk factors for obstetric complications, and prior testing or complications during the current pregnancy. It should include symptom onset and duration, exacerbating and relieving factors (physiologic edema is reduced by lying in the left lateral decubitus position), and risk factors for DVT, preeclampsia, and peripartum cardiomyopathy. High-risk factors for preeclampsiainclude Previous pregnancy with Preeclampsia and Eclampsia None Multifetal Pregnancy None Chronic Hypertension None Type 1 or type 2 Diabetes Mellitus (DM) None Kidney disorders Autoimmune Disorders in Pregnancy None Gestational Trophoblastic Disease None Moderate-risk factors for preeclampsiainclude First pregnancy Obesity (body mass index > 30) Family history of preeclampsia African descent Lower income Age≥35 In vitro fertilization Personal history factors (eg, previous infants with low birth weight or small for gestational age, previous adverse pregnancy outcome, > 10-year pregnancy interval) Risk factors for DVTinclude Venous insufficiency Trauma Hypercoagulability disorder Thrombotic disorders Cigarette smoking Immobility Cancer Obesity None Risk factors for peripartum cardiomyopathyinclude Age > 30 History of cardiomyopathy African descent Multifetal Pregnancy None History of Hypertension and/or Review of symptomsshould seek symptoms of possible causes, including the following: High blood pressure, nausea, and vomiting: Preeclampsia and Eclampsia None Pain, redness, or warmth in an extremity: Deep Venous Thrombosis (DVT) or Dyspnea: Pulmonary edema, peripartum cardiomyopathy, or preeclampsia Sudden increase in weight or edema of the hands and face: Preeclampsia Headache, confusion, mental status changes, blurry vision, right upper quadrant pain, or seizures: Preeclampsia should include history of DVT, Pulmonary Embolism (PE) , cardiac disease, preeclampsia, and hypertension. Examination begins with review of vital signs, particularly blood pressure. Areas of edema are evaluated for distribution (ie, whether bilateral and symmetric or unilateral) and presence of redness, warmth, and tenderness. General examination focuses on systems that may show findings of preeclampsia. Eye examination includes testing visual fields for deficits, and funduscopic examination should check for papilledema. Cardiovascular examination includes auscultation of the heart and lungs for evidence of fluid overload (eg, audible S3 or S4 heart sounds, tachypnea, rales, crackles) and inspection of neck veins for jugular venous distention. The abdomen should be palpated for tenderness, especially in the epigastric or right upper quadrant region. Neurologic examination should assess mental status for confusion and seek focal neurologic deficits. The following findings are of particular concern: Blood pressure≥140/90 mm Hg Unilateral leg or calf warmth, redness, or tenderness, with or without fever Systemic symptoms or signs of preeclampsia, particularly mental status changes Symptoms or signs of pulmonary edema Although edema is common during pregnancy, considering and ruling out the most dangerous causes (preeclampsia, peripartum cardiomyopathy, and DVT) are important: If blood pressure is>140/90 mm Hg, preeclampsia should be considered. If edema involves only one leg, particularly when redness, warmth, and tenderness are present, DVT and cellulitis should be considered. Bilateral leg edema suggests a physiologic process, preeclampsia, or peripartum cardiomyopathy as the cause. Symptoms or signs of pulmonary edema, particularly in patients who have preeclampsia (or other risk factors), suggest peripartum cardiomyopathy. Clinical findings help suggest a cause (see table). Additional findings may suggest preeclampsia (see table). If preeclampsia is suspected, urine protein is measured, and a complete blood count, electrolytes, bloodureanitrogen, glucose, creatinine, and liver tests are obtained; new-onset hypertension plus proteinuria indicates preeclampsia. Urine dipstick testing may be used. Many laboratories can more rapidly assess urine protein by measuring and calculating the urine protein:urine creatinine ratio. If the diagnosis is unclear, urine protein may be measured in a 24-hour collection. Proteinuria is no longer required to diagnose preeclampsia; abnormal laboratory or clinical findings of preeclampsia in patients with hypertension may also confirm preeclampsia. If DVT is suspected, lower-extremity duplex ultrasonography is done. If peripartum cardiomyopathy is suspected, ECG, chest X-ray, and echocardiography are done. BNP (brain [B-type] natriuretic peptide) or NT-proBNP (N-terminal pro b-type natriuretic peptide) is measured. 