How can a 36-week pregnant woman manage symptoms of back pain, heartburn, and breathing difficulties?

Management of Late-Pregnancy Symptoms at 36 Weeks

For this 36-week pregnant woman with back pain, heartburn, and breathing difficulties, implement a structured non-pharmacologic approach prioritizing positional modifications, dietary changes, and physical support measures, as these interventions directly address the anatomical displacement caused by the gravid uterus at this gestational age. 1

Breathing Difficulties Management

Immediate Positional Interventions

• 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, as the uterine fundus at 36 weeks reaches the xiphoid process causing 4 cm superior diaphragmatic displacement. 1

• Adopt the left lateral decubitus position when lying down rather than supine, as this minimizes inferior vena cava compression while allowing better diaphragmatic movement and maintains cardiac output. 1

• Completely avoid the supine horizontal position, particularly during the third trimester, as the gravid uterus compresses the inferior vena cava, decreasing venous return and cardiac output. 1

Physiological Context

• The thoracic cage undergoes significant adaptations with subcostal angle widening from 68° to approximately 105°, rib cage elevation by 4 cm, and diaphragm elevation by 4-5 cm, all contributing to the sensation of restricted lung expansion. 1

• Breathing exercises may provide additional benefit, as evidence shows improvements in respiratory function and quality of life when implemented 2-3 times weekly for 4-8 weeks, though this evidence comes from non-pregnant populations with chronic conditions. 2, 3

Heartburn Management

Dietary Modifications (First-Line)

• Consume 5-6 small, frequent meals daily rather than 3 large meals to reduce gastric distension and lower esophageal sphincter pressure. 1, 4

• Eliminate spicy, fatty, acidic, and fried foods that exacerbate reflux, and identify patient-specific triggers including foods with strong odors. 1, 4

• Continue sleeping propped up on multiple pillows (as already implemented) to prevent nocturnal reflux through gravitational assistance. 1, 4

Pharmacologic Considerations

• If dietary and positional modifications fail, pharmaceutical treatments show moderate-quality evidence for complete heartburn relief (RR 1.85) compared to placebo, though specific agents should be discussed with her obstetrician. 1, 4

• The American Gastroenterological Association supports escalation to pharmacotherapy when conservative measures are insufficient, with safety profiles established for pregnancy. 1

Lower Back Pain and Pelvic Pressure

Physical Support Measures

• Apply pelvic support garments or maternity belts to reduce sacroiliac joint stress and improve stability, directly addressing the positive Patrick's test and sacroiliac joint tenderness found on examination. 1

• Avoid prolonged standing or walking and alternate positions frequently to prevent worsening of the constant ache that intensifies with these activities. 1

• Maintain neutral lumbar spine positioning during daily activities to optimize biomechanics and prevent further strain on the already pronounced lumbar lordosis (increased by up to 45° from baseline). 1

Clinical Context

• The pronounced lumbar lordosis, anterior pelvic tilt, and relaxin-induced ligamentous laxity create mechanical vulnerability at the sacroiliac joints, explaining the point tenderness and positive provocative testing. 1

• While breathing dysfunction has been associated with back pain in non-pregnant populations (OR 2.0-1.9 for frequent back pain with breathing difficulties), the primary driver here is mechanical pregnancy-related changes. 5

Constipation Management

Dietary Fiber Approach

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

• Ensure 8-10 glasses of water daily to soften stools and facilitate transit. 1

Pharmacologic Options if Needed

• Psyllium husk or methylcellulose are safe first-line pharmacological options due to lack of systemic absorption, making them appropriate for pregnancy. 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 warning signs). 1

• Decreased fetal movement below established baseline. 1

• Vaginal bleeding or fluid leakage suggesting membrane rupture. 1

• Regular contractions before 37 weeks indicating potential preterm labor. 1

• Severe, unrelenting abdominal pain distinct from typical discomfort. 1

Follow-Up Monitoring

• Serial ultrasound examinations starting at 32 weeks may be considered for suboptimally controlled symptoms, though this patient's symptoms appear typical for gestational age. 6

• Patients should be instructed to monitor fetal activity daily as a basic surveillance measure. 6

Common Pitfalls to Avoid

• Do not dismiss breathing difficulties as "normal pregnancy discomfort" without ensuring proper positional modifications are implemented, as supine positioning can significantly compromise maternal hemodynamics. 1

• Avoid recommending complete bed rest for back pain, as this increases venous stasis risk; instead, emphasize position changes and support garments. 1

• Do not delay dietary modifications for heartburn while waiting for pharmacologic intervention, as conservative measures are highly effective and immediately implementable. 1, 4