The woman who needs same-day evaluation
Among the four women, only the one at 34 weeks has a danger sign: new puffiness of the face and fingers that has developed over the past 2 days. Swelling of the face and hands, as opposed to dependent swelling of the ankles, can be an early sign of preeclampsia. Her blood pressure today is 128/80 mmHg, which is normal, but a single normal reading does not rule out the condition. New swelling of the face and hands in late pregnancy is a danger sign that needs same-day evaluation, even with a normal blood pressure reading.
Why a normal reading does not reassure
Preeclampsia can evolve quickly, and blood pressure varies from reading to reading. Generalized edema reflects fluid shifting out of the blood vessels because of endothelial damage, which is part of the disease process. Same-day evaluation lets the provider repeat blood pressure measurements, test the urine for protein, review symptoms such as headache, visual changes, and epigastric pain, and assess the fetus. Sending her home with advice alone could delay the diagnosis of a condition that can progress to eclampsia.
Interpreting the other three women
| Week | Finding | Interpretation |
|---|
| 30 weeks | Dizziness lying on her back, relieved by turning to her side; BP 104/64 mmHg | Supine hypotensive syndrome; teach her to avoid lying flat |
| 32 weeks | Ankle swelling by evening, gone by morning; BP 138/88 mmHg, similar since early pregnancy | Below the 140/90 mmHg threshold; dependent edema is a common discomfort |
| 34 weeks | New puffy face and fingers for 2 days; BP 128/80 mmHg | Danger sign; same-day evaluation |
| 35 weeks | Short of breath on stairs, comfortable at rest; BP 118/76 mmHg | Expected as the enlarging uterus raises the diaphragm |
The distractor that looks most worrying
Watch out! The woman at 32 weeks has the highest blood pressure of the four, and many test-takers choose her. Her reading of 138/88 mmHg is still below the 140/90 mmHg threshold for hypertension in pregnancy, and it has been similar since early pregnancy, so it is not a new rise. Her ankle swelling is dependent edema that resolves overnight, which is a normal discomfort of late pregnancy. She still needs routine follow-up and teaching on danger signs, but not same-day referral.
Exam takeaway
Distinguish dependent ankle edema, which is common, from new edema of the face and hands, which is a danger sign. Key point! When choosing whom to refer, look for a new change that matches a known danger sign rather than simply the highest number. Mothers' classes are a good opportunity to teach every pregnant woman the danger signs that should bring her back to the facility the same day, including swelling of the face and hands, severe headache, blurred vision, and vaginal bleeding.