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 and a normal physical examination showing no signs of heart failure or respiratory disease, as this represents physiological dyspnea of pregnancy. 1, 2

Physiological Basis for Reassurance

• Shortness of breath on exertion occurs in approximately 50% of pregnant women and is a normal physiological adaptation to pregnancy 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, palpitations, or unexplained hypotension 1, 4

Physical examination findings requiring further workup:

• Oxygen desaturation with exertion (SpO2 <95%) 1, 4
• Tachypnea at rest (>20 breaths/min) or persistent tachycardia 1
• Abnormal lung auscultation or unilateral leg swelling 1
• Maternal early warning criteria including systolic BP >160 mmHg, diastolic BP >100 mmHg, or heart rate >130 bpm 5

Why Not Iron Supplementation or Chest X-ray?

Iron supplementation (Option B) is not indicated unless there is documented anemia, which would present with additional findings beyond isolated exertional dyspnea 1, 2

Chest X-ray (Option C) is not appropriate as first-line management when the physical examination is normal and there are no concerning features. While chest X-rays should not be withheld when clinically indicated during pregnancy, they are reserved for specific clinical scenarios 5, 6:

• Suspected pulmonary embolism (though this would require additional clinical features) 4
• Suspected pneumonia or other acute pulmonary pathology 4
• Evaluation of unexplained oxygen desaturation or abnormal lung sounds 1

Patient Counseling and Activity

Encourage continued physical activity:

• Women with well-controlled mild-moderate respiratory symptoms who are asymptomatic should not restrict activity and should maintain moderate-vigorous physical activity 1, 2

Provide clear return precautions:

• Instruct the patient to seek immediate care if she develops 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

Important Clinical Context

While reassurance is appropriate here, remain vigilant that pulmonary embolism remains the leading cause of pregnancy-related maternal death in developed countries (1 per 1000 to 1 per 3000 deliveries) 1, 4. However, PE typically presents with additional features beyond mild exertional dyspnea, and the question specifically states there are no signs of heart failure or respiratory disease.

The key distinction is that physiological dyspnea of pregnancy is mild, exertional, and occurs with a completely normal physical examination 1, 2, 3. Any deviation from this pattern warrants further investigation.