Lower-Extremity Edema During Late Pregnancy
Edema is common during late pregnancy. It typically involves the lower extremities but occasionally appears as swelling or puffiness in the face or hands.
The most common cause of edema in pregnancy is
Physiologic edema results from hormone-induced Na retention. Edema may also occur when the enlarged uterus intermittently compresses the inferior vena cava during recumbency, obstructing outflow from both femoral veins.
Pathologic causes of edema are less common but often dangerous. They include deep venous thrombosis (DVT) and preeclampsia (see Table: Some Causes of Edema During Late Pregnancy). DVT is more common during pregnancy because pregnancy is a hypercoagulable state, and women may be less mobile. Preeclampsia results from pregnancy-induced hypertension; however, not all women with preeclampsia develop edema. When extensive, cellulitis, which usually causes focal erythema, may resemble general edema.
Some Causes of Edema During Late Pregnancy
Evaluation aims to exclude DVT and preeclampsia. Physiologic edema is a diagnosis of exclusion.
History of present illness should include symptom onset and duration, exacerbating and relieving factors (physiologic edema is reduced by lying in the left lateral decubitus position), and risk factors for DVT and preeclampsia. Risk factors for DVT include
Risk factors for preeclampsia include
Review of symptoms should seek symptoms of possible causes, including nausea and vomiting, abdominal pain, and jaundice (preeclampsia); pain, redness, or warmth in an extremity (DVT or cellulitis); dyspnea (pulmonary edema or preeclampsia); sudden increase in weight or edema of the hands and face (preeclampsia); and headache, confusion, mental status changes, blurry vision, or seizures (preeclampsia).
Past medical history should include history of DVT, pulmonary embolism, preeclampsia, and hypertension.
Examination begins with review of vital signs, particularly BP.
Areas of edema are evaluated for distribution (ie, whether bilateral and symmetric or unilateral) and presence of redness, warmth, and tenderness.
General examination focuses on systems that may show findings of preeclampsia. Eye examination includes testing visual fields for deficits, and funduscopic examination should check for papilledema.
Cardiovascular examination includes auscultation of the heart and lungs for evidence of fluid overload (eg, audible S3 or S4 heart sounds, tachypnea, rales, crackles) and inspection of neck veins for jugular venous distention. The abdomen should be palpated for tenderness, especially in the epigastric or right upper quadrant region. Neurologic examination should assess mental status for confusion and seek focal neurologic deficits.
Although edema is common during pregnancy, considering and ruling out the most dangerous causes (preeclampsia and DVT) are important:
Some Findings That Suggest Preeclampsia
If preeclampsia is suspected, urine protein is measured; hypertension plus proteinuria indicates preeclampsia. Urine dipstick testing is used routinely, but if diagnosis is unclear, urine protein may be measured in a 24-h collection. Many laboratories can more rapidly assess urine protein by measuring and calculating the urine protein:urine creatinine ratio.
If DVT is suspected, lower-extremity duplex ultrasonography is done.
Edema is common and usually benign (physiologic) during late pregnancy.
Physiologic edema is reduced by lying in the left lateral decubitus position, elevating the lower extremities, and using compression stockings.
Hypertension and proteinuria indicate preeclampsia.
Unilateral leg edema, redness, warmth, and tenderness require evaluation for DVT.