From the Guidelines
The most appropriate next step in management is to induce labor, as the patient is at 37 weeks gestation and her symptoms, although not indicative of preeclampsia, suggest significant discomfort that may be alleviated by delivery. The patient's vital signs are stable, with normal blood pressure and only trace proteinuria, which does not meet criteria for preeclampsia 1. The systolic ejection murmur is a common finding in pregnancy due to increased cardiac output. Her symptoms of bilateral leg cramps relieved by massage and stretching are consistent with benign nocturnal leg cramps rather than deep vein thrombosis.
Key Considerations
- The patient's gestational age of 37 weeks is a critical factor, as delivery at this stage is often recommended for women with preeclampsia without severe features, and may be considered for women with significant discomfort or other indications 1.
- The patient's symptoms, including peripheral edema, shortness of breath, and leg cramps, are consistent with normal physiologic changes of late pregnancy, but may also be indicative of underlying conditions that could be alleviated by delivery.
- Induction of labor without medical indication before 39 weeks gestation is associated with increased neonatal morbidity, including respiratory distress syndrome and NICU admission, but in this case, the patient's gestational age and symptoms may justify earlier delivery.
Management
- Education about normal pregnancy symptoms and reassurance about their benign nature
- Supportive measures such as leg elevation, proper hydration, and regular exercise to help alleviate her discomfort
- Consideration of induction of labor at 37 weeks gestation, given the patient's significant discomfort and gestational age
- Close monitoring of the patient's vital signs and symptoms, with prompt intervention if any concerning features develop, such as severe hypertension, proteinuria, or fetal distress 1.
From the Research
Assessment of Fetal Well-being
The patient is at 37 weeks gestation and requesting induction of labor due to discomfort. However, before proceeding with induction, it is essential to assess fetal well-being.
- The patient's symptoms of exhaustion, shortness of breath, and bilateral foot and ankle swelling are common in late pregnancy, but they do not necessarily indicate a need for immediate induction.
- The presence of a 2/6 systolic ejection murmur and symmetric, bilateral pitting edema of the calves, ankles, and feet are also observed.
- Urinalysis shows trace protein, which is not significantly abnormal.
Next Steps in Management
Given the patient's symptoms and physical examination findings, the most appropriate next step in management would be to assess fetal well-being using antenatal fetal assessment methods such as the nonstress test, contraction stress test, or biophysical profile 2, 3, 4.
- These tests can help evaluate fetal well-being and determine if induction of labor is necessary.
- The biophysical profile, in particular, allows for a more thorough evaluation of fetal well-being and can help reduce the false-positive rate of other tests 3.
- However, the provided studies do not directly address the patient's specific symptoms and physical examination findings, and therefore, the most appropriate next step in management is not clearly supported by the evidence.
Other Considerations
The patient's symptoms and physical examination findings are not directly related to the management of intracranial pressure 5 or infusion therapy 6, and therefore, these studies are not relevant to the patient's care.