Clinical Approach: Primigravida at 36 Weeks with B/L Swelling of Feet and Hands

Step 1 - Differential Diagnosis

Step 2 - Key History to Elicit

• Headache (frontal/occipital) - suggests raised BP
• Visual disturbances (blurring, flashes, scotomas)
• Epigastric / RUQ pain (hepatic involvement)
• Oliguria or reduced urine output
• Sudden onset vs gradual swelling - sudden = more sinister
• Swelling in the morning (pathological) vs. evening (physiological)
• Preceding BP before pregnancy
• History of renal/cardiac/thyroid disease
• Fetal movements (reduced = fetal compromise)

Step 3 - Examination

1. Blood pressure - measured on two occasions ≥4 hours apart
   • ≥140/90 mmHg = diagnostic threshold for hypertension in pregnancy
   • ≥160/110 mmHg = severe feature
2. Fundal height and fetal presentation
3. Pitting vs. non-pitting edema - location (pedal, hand, facial, sacral), grade
4. Facial puffiness (periorbital edema - classically suggests pre-eclampsia)
5. Reflexes - hyperreflexia suggests impending eclampsia
6. Clonus - ≥3 beats is significant
7. Urine dipstick for proteinuria (≥1+ is significant; ≥300 mg/24 hr is diagnostic)
8. Fundoscopy - papilledema, retinal changes
9. JVP, heart sounds for cardiac cause

Step 4 - Investigations

Step 5 - Diagnosis

• BP ≥140/90 mmHg on two readings ≥4 hours apart AND
• Proteinuria ≥300 mg/24 hr OR any of: thrombocytopenia, renal insufficiency, liver dysfunction, pulmonary edema, cerebral/visual disturbances

• BP ≥160/110 mmHg
• Platelets <100,000/μL
• Creatinine >1.1 mg/dL
• AST/ALT >2x normal
• Pulmonary edema
• Cerebral or visual disturbances
• Persistent epigastric/RUQ pain

Step 6 - Management

A. If physiological edema (no HTN, no proteinuria, clinically well):

• Reassure and educate
• Advise elevation of limbs, avoid prolonged standing
• Reduce salt intake
• Light compression stockings
• Increase monitoring frequency (BP check weekly)
• No diuretics (harmful in pregnancy)

B. If Pre-eclampsia without severe features:

• Hospital admission for monitoring
• BP monitoring every 4-6 hours
• Daily urine protein
• Twice-weekly labs (CBC, LFT, creatinine)
• Fetal monitoring: NST, USG, Doppler
• Delivery at 37 weeks (expectant management until 37 wks per ACOG)
• Antihypertensive if BP persistently ≥140/90: Labetalol, Nifedipine (oral), Methyldopa
• No diuretics (reduce placental perfusion)

C. If Pre-eclampsia with severe features:

• IV Magnesium Sulfate - seizure prophylaxis (4g IV bolus over 20 min, then 1-2 g/hr maintenance)
  • Monitor for toxicity: loss of patellar reflexes, respiratory depression, treat with IV Calcium Gluconate 1g
• IV Antihypertensives for acute severe HTN: Hydralazine, IV Labetalol, Nicardipine
• Target BP: 140-150/90-100 (avoid sudden drops - fetal compromise)
• Deliver at 34 weeks or as soon as stable - delivery is the ONLY definitive treatment
• Fetal corticosteroids (betamethasone 12 mg IM x2, 24 hrs apart) if <34 weeks for lung maturity

D. If HELLP syndrome:

• Immediate hospitalization, IV MgSO4, BP control
• Correct coagulopathy if present
• Delivery regardless of gestational age if severe

Mnemonic - Signs of Impending Eclampsia (HELLP):

• Headache (severe, frontal)
• Epigastric pain / visual disturbances
• Liver enzymes raised
• Low platelets
• Proteinuria ++ / Blood pressure severe

Summary for This Case:

Sources: Morgan and Mikhail's Clinical Anesthesiology 7e, p. 1644-1647; Tintinalli's Emergency Medicine, Table 100-1; Creasy & Resnik's Maternal-Fetal Medicine

Diagnosis: Physiological (Dependent) Edema of Pregnancy

• ✅ Normal BP
• ✅ No albumin on dipstick (rules out pre-eclampsia, nephrotic syndrome)
• ✅ No sugar (rules out gestational diabetes as a contributing cause)
• ✅ Normal investigations
• ✅ 36 weeks gestation (third trimester - peak incidence)

Why Does It Happen? (Pathophysiology)

1. Plasma volume expands by 40-50% (up to 1.5 L extra) - driven by RAAS activation and aldosterone
2. Total body water increases by 6-8 litres with net retention of ~900 mEq of sodium
3. Decreased plasma osmolality (serum Na drops by 4-5 mEq/L)
4. Growing uterus compresses the inferior vena cava (IVC) and pelvic veins - reduces venous return from lower limbs, causing hydrostatic pressure to rise in leg veins
5. Decreased serum albumin (dilutional) - reduces oncotic pressure slightly
6. All of the above push fluid into the interstitium, especially in dependent areas (feet, ankles, hands in third trimester)

Characteristics of Physiological Edema

Why Hands Swell Too?

• Generalized sodium and water retention
• Carpal tunnel-like venous/lymphatic congestion
• Reduced activity and gravity effects on upper limbs during rest/sleep

Management

1. Rest with feet elevated above heart level - helps venous drainage
2. Avoid prolonged standing or sitting
3. Lie in left lateral position - relieves IVC compression by uterus, improves venous return
4. Moderate salt restriction in diet
5. Adequate hydration paradoxically helps (dehydration worsens RAAS activation)
6. Light walking - calf muscle pump aids venous return
7. Comfortable, loose footwear
8. No diuretics - diuretics are harmful in pregnancy (reduce uteroplacental blood flow, cause fetal electrolyte disturbances)

When to Return Immediately (Red Flags to Counsel About)

• Headache or visual disturbances
• Sudden worsening of swelling
• Facial/periorbital puffiness
• Epigastric pain
• Reduced fetal movements
• Any rise in blood pressure at home

Follow-Up

• Weekly BP monitoring at antenatal visits
• Urine dipstick at each visit
• Fetal growth scan if clinically indicated
• Expected: swelling will resolve spontaneously within days to weeks after delivery

Physiological edema affects up to 80% of pregnancies and requires no treatment other than reassurance and positional measures.