Management of Late-Pregnancy Symptoms at 36 Weeks
For this 36-week pregnant woman with back pain, heartburn, breathing difficulties, frequent urination, and constipation, implement a comprehensive symptom-directed approach prioritizing positional modifications, dietary interventions, and stepwise pharmacological therapy when conservative measures fail. 1
Breathing Difficulties and Positional Management
The uterine fundus at 36 weeks reaches the xiphoid process, causing 4 cm superior diaphragmatic displacement that reduces functional residual capacity and limits diaphragmatic excursion. 1
Sleep in a semi-recumbent position with multiple pillows elevating the upper body at 30-45 degrees to reduce upward pressure on the diaphragm and improve lung expansion. 1 This positioning simultaneously addresses both respiratory symptoms and heartburn by preventing nocturnal reflux. 1
Avoid the supine horizontal position entirely during the third trimester, as the gravid uterus compresses the inferior vena cava, decreasing venous return and cardiac output. 2, 1 When lying down, use the left lateral decubitus position, which minimizes vena cava compression while allowing better diaphragmatic movement. 1
Heartburn Management Algorithm
First-Line: Dietary and Lifestyle Modifications
Consume 5-6 small, frequent meals daily rather than 3 large meals to reduce gastric distension and lower esophageal sphincter pressure. 1 The combination of progesterone-induced lower esophageal sphincter relaxation (reducing resting tone by 30-50%) and upward stomach displacement creates severe reflux, particularly when lying flat removes the gravitational barrier. 1
Eliminate spicy, fatty, acidic, and fried foods that exacerbate reflux. 1, 3 Continue sleeping propped up on multiple pillows as already implemented. 1
Second-Line: Pharmacological Therapy
If dietary modifications fail after 1-2 weeks, initiate antacids with or without alginates as first-line pharmacological therapy. 4 The American Gastroenterological Association reports moderate-quality evidence showing complete heartburn relief (RR 1.85) compared to placebo. 1
If symptoms persist despite antacids, escalate to H2-receptor antagonists (all are FDA category B except nizatidine). 4 Proton pump inhibitors are reserved for intractable symptoms or complicated reflux disease, with all except omeprazole being FDA category B. 4
Critical Timing Consideration
Avoid metoclopramide and ondansetron before 10 weeks gestation due to potential risks, though this patient is beyond that window at 36 weeks. 3
Constipation Management
Increase dietary fiber intake to approximately 30 g/day through fruits, vegetables, whole grains, and legumes. 1 Ensure adequate fluid intake of 8-10 glasses of water daily to soften stools. 1
If dietary measures fail, initiate psyllium husk or methylcellulose as first-line pharmacological options due to lack of systemic absorption, making them safe during pregnancy. 1 These bulk-forming laxatives are preferred over stimulant laxatives. 5
Lower Back Pain and Pelvic Pressure
The pronounced lumbar lordosis (up to 45-degree increase), anterior pelvic tilt, and relaxin-induced ligamentous laxity with sacroiliac joint tenderness explain this patient's symptoms. 1
Avoid prolonged standing or walking and alternate positions frequently to alleviate back pain. 1 Maintain neutral lumbar spine positioning during daily activities to optimize bladder control and prevent worsening back problems. 1
Consider pelvic support garments or maternity belts to reduce sacroiliac joint stress and improve stability, particularly given the positive Patrick's test indicating sacroiliac joint involvement. 1
Frequent Urination
This is a normal consequence of the gravid uterus at 36 weeks causing pelvic pressure and bladder compression. No specific intervention is needed beyond reassurance, though maintaining neutral lumbar spine positioning may optimize bladder control. 1
Red Flags Requiring Immediate Evaluation
Immediately evaluate for preeclampsia if sudden severe headache, visual changes, or epigastric pain develop, as this patient's blood pressure is currently normal at 118/72 mmHg. 1
Other red flags include: decreased fetal movement, vaginal bleeding or fluid leakage, regular contractions before 37 weeks (preterm labor), and severe unrelenting abdominal pain. 1
Follow-Up Monitoring
Schedule follow-up visits every 1-2 weeks until delivery given the 36-week gestational age. 1 Instruct the patient to monitor fetal activity daily as basic surveillance. 1 Serial ultrasound examinations starting at 32 weeks are recommended for suboptimally controlled symptoms, though this patient's ultrasound shows normal findings. 1
Multidisciplinary Coordination
While this patient does not have complex inflammatory bowel disease, advanced cirrhosis, or liver transplant, coordinate care between obstetrics and gastroenterology if heartburn becomes intractable or requires proton pump inhibitor therapy. 2 Procedures and medications to optimize maternal health should not be withheld solely because the patient is pregnant, after individualized risk-benefit assessment. 2