A 32-Year-Old Primigravida at 24 Weeks Gestation Is Evaluated for Excessive

A 32-year-old primigravida at 24 weeks gestation is evaluated for excessive tiredness.  The patient feels sleepy throughout the day and keeps dozing off at work.  Her overnight sleep is poor and she does not feel refreshed on awakening in the morning.  She also reports occasional morning headaches.  The patient had mild nausea during the first trimester but her pregnancy has otherwise been uneventful.  She has no known medical issues and her only medication is prenatal vitamins.  The patient drinks alcohol occasionally but stopped after conception and does not use tobacco or illicit drugs.
Blood pressure is 142/90 mm Hg, pulse is 98/min, respirations are 18/min, and SaO₂ is 96% on room air.  The patient's pre-pregnancy weight was 76 kg (167.6 lb) with BMI of 28 kg/m²; she has gained 7 kg (15.4 lb) during the pregnancy.  Examination shows normal thyroid gland, prominent jugular venous pulse estimated at 2 cm above the sternal angle, clear lungs, grade 2/6 systolic ejection murmur, and gravid uterus appropriate for gestation.  There is mild ankle edema.  Fetal heart rate is within normal limits.
Laboratory studies are significant for hemoglobin of 11.4 g/dL and trace protein in urine.
Which of the following is the most appropriate next step in management of this patient?

A) Begin antihypertensive therapy
B) Obtain comprehensive iron studies
C) Perform overnight polysomnography
D) Perform resting echocardiography
E) Reassure that these are normal pregnancy symptoms

Correct Answer:

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