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Lower-Extremity Edema During Late Pregnancy

By

Emily E. Bunce

, MD, Wake Forest Baptist Health;


Robert P. Heine

, MD, Wake Forest School of Medicine

Last full review/revision Dec 2020| Content last modified Dec 2020
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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

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

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.

Table
icon

Some Causes of Edema During Late Pregnancy

Cause

Suggestive Findings

Diagnostic Approach

Physiologic edema

Symmetric, bilateral leg edema that lessens with recumbency

Diagnosis of exclusion

DVT

Tender unilateral swelling of a leg or calf, erythema, and warmth

Sometimes presence of risk factors for DVT

D-dimer testing and/or lower-extremity duplex ultrasonography depending on level of suspicion (if low level, D-dimer as a screening test; if high level, lower-extremity duplex ultrasonography)

Symmetric, bilateral leg edema

Elevated jugular venous pressure (distended neck veins)

3rd heart sound (S3) heard during cardiac auscultation

Crackles, decreased breath sounds, detected during physical examination

Chest x-ray

ECG

Echocardiography

BNP or NT-proBNP

Preeclampsia

Hypertension and proteinuria, with or without significant nondependent edema (eg, in face or hands), which, when present, is not red, warm, or tender

Sometimes presence of risk factors for preeclampsia

When preeclampsia is severe, possibly additional symptoms of headache; pain in the right upper quadrant, epigastric region, or both; and visual disturbances

Possibly papilledema, visual field deficits, and lung crackles (in addition to edema), detected during physical examination

Blood pressure measurement

Urine protein measurement

Complete blood count, electrolytes, blood urea nitrogen, glucose, creatinine, liver tests

Cellulitis

Tender unilateral swelling in a leg or calf, erythema (asymmetric), warmth, and sometimes fever

Manifestations often more circumscribed than in DVT

Ultrasonography to rule out DVT unless swelling is clearly localized

Examination for source of infection

BNP = brain (B-type) natriuretic peptide; DVT = deep venous thrombosis; NT-proBNP = N-terminal pro b-type natriuretic peptide.

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

  • Venous insufficiency

  • Trauma

  • Hypercoagulability disorder

  • Thrombotic disorders

  • Cigarette smoking

  • Immobility

  • Cancer

Risk factors for preeclampsia include

Risk factors for peripartum cardiomyopathy include

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

The following findings are of particular concern:

  • Blood pressure 140/90 mm Hg

  • Unilateral leg or calf warmth, redness, or tenderness, with or without fever

  • Systemic symptoms or signs of preeclampsia, particularly mental status changes

  • Symptoms or signs of pulmonary edema

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).

Table
icon

Some Findings That Suggest Preeclampsia

System or Body Part

Symptom

Clinical Finding

Eyes

Blurry vision

Visual field deficits, papilledema

Cardiovascular

Dyspnea

Increased S3 or audible S4 heart sound

Tachypnea, rales, crackles

Gastrointestinal

Nausea, vomiting, jaundice

Epigastric or right upper quadrant tenderness

Genitourinary

Decreased urine output

Oliguria

Neurologic

Confusion, headache

Abnormal mental status

Extremities

Weight gain that is sudden and dramatic

Edema of legs, face, and hands

Skin

Rash

Petechiae, purpura

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

Specific causes of edema during pregnancy are treated.

Physiologic edema can be reduced by the following:

  • Intermittently lying on the left side (left lateral decubitus position), which moves the uterus off the inferior vena cava

  • Intermittently elevating the lower extremities

  • Wearing elastic compression stockings

  • Wearing loose clothing that does not restrict blood flow, particularly in the legs

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.

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