What is the most appropriate management for a pregnant woman presenting with shortness of breath on exertion without signs of heart failure or respiratory disease?

Management of Exertional Dyspnea in Pregnancy Without Cardiopulmonary Disease

Reassurance is the most appropriate management for a pregnant woman with mild exertional dyspnea when physical examination is normal and there are no signs of heart failure or respiratory disease, as this represents physiological adaptation to pregnancy. 1, 2

Physiological Basis for Reassurance

• Dyspnea on exertion affects approximately 50% of pregnant women and is a normal physiological response to pregnancy's hemodynamic changes. 3
• The American College of Cardiology and other guideline societies recommend reassurance as the initial approach for patients with mild shortness of breath on exertion and a normal physical examination. 1
• A normal physical examination effectively rules out the need for invasive testing in the absence of concerning features such as oxygen desaturation, tachypnea, abnormal lung sounds, or signs of cardiopulmonary compromise. 1

Critical Red Flags That Would Change Management

Before providing reassurance, you must actively exclude these warning signs:

Symptoms requiring immediate evaluation:

• Severe dyspnea at rest, chest pain (particularly pleuritic), syncope or presyncope, hemoptysis, and palpitations or unexplained hypotension. 1

Physical examination findings requiring further workup:

• Oxygen desaturation with exertion (SpO2 <95%), tachypnea at rest (>20 breaths/min), persistent tachycardia, abnormal lung auscultation, and unilateral leg swelling. 1
• The European Heart Journal identifies shortness of breath as a maternal early warning criterion that warrants evaluation when accompanied by other concerning features. 4

Why Not Iron Supplementation or Chest X-ray?

Iron supplementation (Option B):

• While anemia can cause dyspnea, iron supplementation should only be initiated if anemia is documented, not empirically for all pregnant women with dyspnea. 1
• The question specifies no signs of heart failure or respiratory disease, and a normal examination would not suggest severe anemia requiring empiric treatment.

Chest X-ray (Option C):

• Chest X-rays should be restricted during pregnancy and reserved for specific clinical indications, not performed routinely for mild exertional dyspnea with normal examination. 4
• The American College of Obstetricians and Gynecologists states that radiography should not be withheld when clinically indicated, but this does not mean it should be performed without specific concern. 5
• Chest X-ray is appropriate when pulmonary embolism is suspected clinically or when there are abnormal physical findings, but not for reassurance in an otherwise normal examination. 1, 6

Important Context About Pulmonary Embolism Risk

While reassurance is appropriate with a normal examination, you must maintain vigilance:

• Pulmonary embolism remains the leading cause of pregnancy-related maternal death in developed countries, with an incidence of 1 per 1000 to 1 per 3000 deliveries. 1, 6
• Pregnancy creates a hypercoagulable state due to increased coagulation factors and decreased venous flow from uterine compression. 1
• However, the absence of clinical signs (normal oxygen saturation, no tachycardia, no chest pain, no unilateral leg swelling) makes PE unlikely and does not warrant empiric imaging. 1

Patient Counseling and Activity Recommendations

Encourage continued physical activity:

• Patients with well-controlled mild-moderate respiratory symptoms who are asymptomatic should not restrict activity and should be encouraged to maintain moderate-vigorous physical activity. 1, 2
• Women with physiological dyspnea of pregnancy benefit from continued exercise without restriction. 2

Provide clear return precautions:

• Patients should be instructed to seek immediate care if they develop chest pain, severe dyspnea at rest, palpitations, syncope, or signs of fluid overload. 1, 2
• Schedule routine follow-up to reassess symptoms and ensure no progression. 2

Common Pitfalls to Avoid

• Do not order imaging studies without clinical indication simply because the patient is pregnant—this leads to unnecessary radiation exposure and anxiety. 4, 5
• Do not dismiss all dyspnea as "normal pregnancy" without performing a thorough physical examination to exclude pathologic causes. 4, 7
• Research suggests that some pregnant women with significant dyspnea may have subtle cardiac involvement detectable on echocardiography, but this does not change initial management when examination is normal. 7
• Maintain vigilance for the 24-48 hour postpartum period, which represents a second critical high-risk window for cardiorespiratory decompensation. 6