What are the best management strategies for a 36-week pregnant woman experiencing severe lower back pain, heartburn, and respiratory distress when supine?

Management of Late Pregnancy Musculoskeletal and Respiratory Symptoms

For this 36-week pregnant woman with severe lower back pain, heartburn, and supine respiratory distress, the primary management strategy is strict avoidance of supine positioning (left lateral positioning instead), lifestyle modifications for reflux, and conservative non-pharmacological interventions for musculoskeletal pain—all symptoms are physiologically normal for this gestational age and require reassurance plus supportive care rather than aggressive intervention. 1, 2, 3

Immediate Positioning Management

The respiratory distress when supine is supine hypotension syndrome caused by aortocaval compression by the gravid uterus, which decreases cardiac output by up to 24% at 32 weeks gestation. 2

• After 20 weeks gestation, patients must avoid prolonged supine positioning during sleep, procedures, or rest 1, 2
• Left lateral position or left pelvic tilt should be maintained to prevent inferior vena cava compression and restore venous return 1, 2
• The immediate improvement when sitting up or changing position confirms this diagnosis, as it relieves the compression 2
• This positioning strategy is critical during labor and delivery as well 1

Respiratory Symptom Management

The dyspnea is physiologically expected at 36 weeks and requires only reassurance given the normal physical examination. 4

• Functional residual capacity decreases by 10-25% as the uterus elevates the diaphragm, reducing oxygen reserves 4
• Oxygen consumption rises 20-33% above baseline by third trimester due to fetal and placental metabolic demands 4
• Mild exertional dyspnea with normal examination requires only reassurance, and patients should maintain moderate-vigorous physical activity 4

Red Flags Requiring Urgent Evaluation:

• Severe dyspnea at rest, chest pain, syncope, hemoptysis, or palpitations mandate urgent workup 4
• Oxygen desaturation, tachypnea at rest, persistent tachycardia, abnormal lung sounds, or unilateral leg swelling require investigation to exclude pulmonary embolism 4

Heartburn Management

Heartburn in late pregnancy results from progesterone-induced lower esophageal sphincter relaxation and is managed primarily through dietary and lifestyle modifications. 1

First-Line Non-Pharmacological Interventions:

• Reduce spicy, fatty, acidic, and fried foods 1
• Eat small, frequent, bland meals (BRAT diet: bananas, rice, applesauce, toast) 1
• High-protein and low-fat meals are helpful 1
• Sleep propped up on multiple pillows (which this patient is already doing appropriately) 1
• Avoid eating close to bedtime 1

Pharmacological Options if Lifestyle Modifications Fail:

• H2-receptor antagonists are considered safe first-line pharmacologic therapy 1
• Antacids can be used as needed 1

Lower Back Pain Management

The severe lower back pain with sacroiliac joint tenderness, positive Patrick's test, and pronounced lumbar lordosis represents typical pregnancy-related musculoskeletal changes that should be managed conservatively with non-pharmacological interventions. 3, 5

Conservative Treatment Approach:

Exercise-based interventions are the foundation of treatment and are not contraindicated in pregnancy. 3, 6

• Physical therapy with targeted exercises has rare side effects and benefits far outweigh risks 3
• Multimodal intervention combining exercise and education has proven effective 6
• Water-based exercises are particularly beneficial 6
• Proper postural hygiene education is essential 6

Alternative Modalities:

• Osteopathic manipulation has demonstrated effectiveness 6
• Acupuncture may be considered 6
• Pelvic support belts can help with sacroiliac joint pain 3

Medication Considerations:

• Pregnant women should avoid treating musculoskeletal pain with medication when possible and choose alternative methods 3
• Acetaminophen is the safest analgesic option if pharmacological intervention becomes necessary 3
• NSAIDs should be avoided, especially in third trimester 3

Pelvic Floor and Positioning for Airway Clearance

Upright sitting with neutral lumbar spine is the most comfortable position for any breathing exercises or airway clearance during late pregnancy. 1

• Left and right side lying (horizontal or head up) may be effective alternatives 1
• Avoid supine horizontal position, especially during second and third trimesters, to minimize inferior vena cava compression 1
• The growing fetus creates upward pressure on the diaphragm and downward pressure on the pelvic floor 1

Prognosis and Reassurance

Low back pain associated with pregnancy generally resolves postpartum. 5, 7

• Multiple factors contribute including pelvic changes and alterations to loading 5
• The anatomical changes (lumbar lordosis, anterior pelvic tilt, widened gait) are normal adaptations to the gravid uterus 3
• Symptoms typically improve significantly within weeks to months after delivery 7

Common Pitfalls to Avoid

• Do not allow prolonged supine positioning during sleep or rest—this is the critical intervention for respiratory symptoms 1, 2
• Do not dismiss symptoms without ruling out red flags (pulmonary embolism, preeclampsia, preterm labor) 4
• Do not rush to pharmacological management for musculoskeletal pain when conservative measures are safer and effective 3
• Do not restrict physical activity based on mild dyspnea alone—exercise should be maintained 4
• Ensure compression stockings and early ambulation to prevent venous stasis and potential paradoxical embolism 1