Edema is common during late pregnancy. It typically involves the lower extremities but occasionally appears as swelling or puffiness in the face or hands.
Etiology
The most common cause of edema in pregnancy is
Physiologic edema results from hormone-induced sodium 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)
-
Cellulitis (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.
Peripartum cardiomyopathy can cause other nonspecific symptoms of pregnancy, including dyspnea and fatigue.
When extensive, cellulitis, which usually causes focal erythema, may resemble general edema.
Some Causes of Edema During Late Pregnancy
Evaluation
Evaluation of patients with lower-extremity edema during late pregnancy aims to exclude DVT, preeclampsia, peripartum cardiomyopathy, and other pathologic causes of edema. Physiologic edema is a diagnosis of exclusion.
History
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, preeclampsia, and peripartum cardiomyopathy.
Risk factors for DVT include
Risk factors for preeclampsia include
-
Chronic hypertension
-
Personal or family history of preeclampsia
-
Age < 17 or > 35
-
First pregnancy
-
Vascular disorders
-
Abnormal maternal serum screening results
-
Obesity
Risk factors for peripartum cardiomyopathy include
-
Age > 30
-
History of cardiomyopathy
-
African descent
-
History of hypertension and/or hypertensive disorders of pregnancy (eg, preeclampsia)
Review of symptoms should seek symptoms of possible causes, including the following:
-
Nausea and vomiting, abdominal pain, and jaundice: Preeclampsia
-
Pain, redness, or warmth in an extremity: DVT or cellulitis
-
Dyspnea: Pulmonary edema, peripartum cardiomyopathy, or preeclampsia
-
Sudden increase in weight or edema of the hands and face: Preeclampsia
-
Headache, confusion, mental status changes, blurry vision, or seizures: Preeclampsia
Past medical history should include history of DVT, pulmonary embolism, cardiac disease, preeclampsia, and hypertension.
Physical examination
Examination begins with review of vital signs, particularly blood pressure.
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.
Red flags
Interpretation of findings
Although edema is common during pregnancy, considering and ruling out the most dangerous causes (preeclampsia, peripartum cardiomyopathy, and DVT) are important:
-
If blood pressure is > 140/90 mm Hg, preeclampsia should be considered.
-
If edema involves only one leg, particularly when redness, warmth, and tenderness are present, DVT and cellulitis should be considered.
-
Bilateral leg edema suggests a physiologic process, preeclampsia, or peripartum cardiomyopathy as the cause.
-
Symptoms or signs of pulmonary edema, particularly in patients who have preeclampsia (or other risk factors), suggest peripartum cardiomyopathy.
Clinical findings help suggest a cause (see table Some Causes of Edema During Late Pregnancy). Additional findings may suggest preeclampsia (see table Some Findings That Suggest Preeclampsia).
Some Findings That Suggest Preeclampsia
Testing
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-hour collection. Many laboratories can more rapidly assess urine protein by measuring and calculating the urine protein:urine creatinine ratio. Proteinuria is no longer required to diagnose preeclampsia; abnormal laboratory or clinical findings of preeclampsia in patients with hypertension may also confirm preeclampsia.
If DVT is suspected, lower-extremity duplex ultrasonography is done.
If peripartum cardiomyopathy is suspected, ECG, chest X-ray, and echocardiography are done. BNP or NT-proBNP is measured.
Treatment
Key Points
-
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, using compression stockings, and wearing loose clothing that does not restrict blood flow.
-
Hypertension and proteinuria indicate preeclampsia; absence of proteinuria does not exclude preeclampsia.
-
Evaluate patients for DVT if they have unilateral leg edema, redness, warmth, and tenderness.
-
Evaluate patients for peripartum cardiomyopathy if they have dyspnea and if the physical examination detects evidence of fluid overload.
-
Because preeclampsia significantly increases the risk of peripartum cardiomyopathy, rapidly evaluate patients who have preeclampsia and possible cardiac dysfunction and/or pulmonary edema for peripartum cardiomyopathy.
