Your pregnant patient complains of hemorrhoids. On physical examination, vital signs are 98.6 T, 80 pulse, 14 resps/min, 110/ 60. Heart has regular rate and rhythm, no S3, no murmurs. Lungs are clear to auscultation

Question

Abdominal examination is negative. Uterus fundus is at the umbilicus. Ankles show +1/4 bilateral ankle non-pitting edema. Dorsalis pedis pulses +2/4 bilaterally. Rectal exam: + external haemorrhoid. Urine dipstick is negative for protein. The clinician should:
A. Explain to patient to lie in left lateral recumbent position at night
B. Refer patient to obstetric physician for diuretic prescription
C. Obtain 24-hour urine for protein
D. Obtain HbA1c and fasting serum glucose

Answer 1

ANS: A
A 30% to 50% increase in cardiac output occurs during pregnancy (Sakornbut, 2008b). This increase begins as early as 10 weeks of gestation and peaks at 20 to 24 weeks. A 40% to 50% increase in blood volume results in an increased venous pressure below the level of the uterus. This increased pressure can result in varicosities in the legs and perineum (hemorrhoids), especially when the pregnant woman is in an upright position, such as with prolonged sitting or standing. An enlarging uterus compresses the vena cava or pelvic and lower extremity veins, leading to venous pooling, which can result in edema, hypotension, dizziness, or even syncope. In order to lessen these complications, the pregnant woman should be instructed not to lie in a supine or recumbent position, but rather in a left lateral tilt.