What are the management options for a 36-week pregnant woman experiencing back pain, heartburn, breathing difficulties, frequent urination, constipation, and pelvic pressure?

Management of Late-Pregnancy Symptoms at 36 Weeks

For this 36-week pregnant woman with multiple physiologic complaints, implement a comprehensive symptom-based management strategy prioritizing positional modifications, dietary adjustments, and safe pharmacological interventions when needed, as these symptoms are expected physiologic changes that will resolve postpartum. 1

Breathing Difficulties

The uterine fundus at 36 weeks reaches the xiphoid process, causing 4 cm superior displacement of the diaphragm and reducing functional residual capacity. 1

Sleep in a semi-recumbent position with the upper body elevated at 30-45 degrees using multiple pillows to reduce upward pressure on the diaphragm and improve lung expansion. 1

• Avoid the supine horizontal position entirely during the third trimester because the gravid uterus compresses the inferior vena cava, decreasing venous return and cardiac output. 2, 1

• Use the left lateral decubitus position when lying down, as this minimizes vena cava compression while allowing better diaphragmatic movement. 1

• Upright sitting is often the most comfortable position for daily activities and can optimize breathing mechanics. 2

Heartburn Management

Implement dietary modifications as first-line therapy: consume 5-6 small, frequent meals daily rather than 3 large meals to reduce gastric distension and lower esophageal sphincter pressure. 1, 3

• Avoid spicy, fatty, acidic, and fried foods that exacerbate reflux symptoms. 1, 3

• Continue sleeping propped up on multiple pillows to prevent nocturnal reflux. 1

• Time meals at least 2-3 hours before lying down to allow gastric emptying. 1

If dietary modifications fail, antacids with or without alginates provide moderate-quality evidence for complete heartburn relief (RR 1.85 compared to placebo). 1, 3

Lower Back Pain and Sacroiliac Joint Pain

Maintain neutral lumbar spine positioning during all daily activities to optimize bladder control and prevent worsening back problems. 1

• Avoid prolonged standing or walking; alternate positions frequently to reduce sacroiliac joint stress. 1, 4

• Use pelvic support garments or maternity belts to reduce sacroiliac joint stress and improve stability. 1

• Back care advice and education provided early can significantly reduce the severity of low back pain during pregnancy. 5

• Exercise-based interventions are generally safe and effective conservative treatments for pregnancy-related low back pain. 4, 6

The positive Patrick's test and sacroiliac joint tenderness indicate typical pregnancy-related pelvic girdle pain, which generally resolves postpartum. 4

Constipation

Increase dietary fiber intake to approximately 30 g/day through fruits, vegetables, whole grains, and legumes as first-line therapy. 1, 3

• Ensure adequate fluid intake of 8-10 glasses of water daily to soften stools. 1, 3

If dietary measures fail, use bulk-forming laxatives (psyllium husk or methylcellulose) as safe first-line pharmacological options due to lack of systemic absorption. 1, 3

• Osmotic laxatives can be considered as second-line agents if bulk-forming laxatives are insufficient. 3

Frequent Urination

Frequent urination is an expected physiologic symptom at 36 weeks due to the uterine fundus at the xiphoid process level causing downward pressure on the bladder. 1

• This symptom requires no specific intervention beyond reassurance, as it will improve after delivery when the fetal head descends into the pelvis. 1

• Ensure symptoms are not accompanied by dysuria, fever, or suprapubic pain, which would suggest urinary tract infection requiring evaluation. 7

Pelvic Pressure

The pelvic pressure described is expected at 36 weeks with a vertex presentation and estimated fetal weight of 2800g. 1

• Pelvic support garments can help reduce this sensation by providing external support. 1

• The cervical length of 2.8 cm is normal and reassuring, indicating no cervical insufficiency. 1

Red Flags Requiring Immediate Evaluation

Instruct the patient to seek immediate evaluation for any of the following:

• Sudden severe headache, visual changes, or epigastric pain (preeclampsia signs, though her blood pressure is currently normal at 118/72 mmHg). 2, 1

• Decreased fetal movement, vaginal bleeding or fluid leakage. 1

• Regular contractions before 37 weeks (preterm labor). 1

• Severe, unrelenting abdominal pain. 1

Common Pitfalls to Avoid

Do not restrict salt intake or recommend weight reduction during pregnancy, as these interventions are not beneficial and may be harmful. 2

Do not use the supine position for any activity during the third trimester, including sleep, rest, or physical therapy, due to vena cava compression. 2, 1

Do not dismiss these symptoms as trivial—while physiologic, they significantly impact quality of life and warrant active management. 3, 4