Guidelines for Pregnant Patients
Christine Hamilton
Bacteriuria
- Acute cystitis:
- Treatment: empiric with cephalexin, cefpodoxime, amoxicillin-clavulanate, Fosfomycin. Nitrofurantoin and Bactrim typically avoided in first trimester and near term but safe to try if no appropriate alternatives. Tailor based on culture results. Treat for 5-7 days.
- If UA negative but patient with symptoms of dysuria, obtain STI testing
- Pyelonephritis:
- Higher incidence in pregnancy compared to non-pregnant women, most often in second/third trimesters
- Risk factors: Age <20y, nulliparity, smoking, late presentation to care, sickle cell trait, and pre-existing (not gestational) diabetes
- Associated with preterm birth
- Diagnosis: fever, flank pain, nausea/vomiting, and/or dysuria with bacteriuria. Rule out intraamniotic infection, placental abruption
- Management: Patients typically require admission. Obtain blood cultures and initiate IV antibiotics for 1st 24-48hrs; beta-lactams (CTX or Zosyn) preferred. Avoid fluoroquinolones.
- De-escalation: Once afebrile for 48 hours, switch to PO beta-lactam (preferred) for total 7-10 days.
- Asymptomatic bacteriuria:
- Occurs in 2-7% of pregnant women, most often in first trimester
- Without treatment, ~25% of pregnant women will develop symptomatic UTI
- Complications of untreated bacteriuria associated with preterm birth, low birth weight, and perinatal mortality in some studies
- Diagnosis: pyuria and >100,000 cfu/mL bacteria
Refractory Nausea/Vomiting
- Presentation: hormone mediated nausea/vomiting typically starting before 9wks GA
- Differential: gastroenteritis, hepatitis, biliary tract disease, obstruction, pancreatitis, pyelonephritis, nephrolithiasis, ovarian torsion, DKA, hyperparathyroidism, migraines, preeclampsia
- Workup: BMP, mg, phos, LFTs, lipase (may be mildly elevated in HG), UA
- Treatment
- 1st line: ginger, doxylamine (25mg PO q6h), pyridoxine (20mg PO q6h)
- 2nd line: diphenhydramine (25-50mg q6h), metoclopramide (10mg q6h), promethazine (12.5mg q6h), or compazine (5-10mg q6h)
- 3rd Line: ondansetron (8mg q12h, after 1st trimester)
- Hydration: 1L LR on admission + banana bag q24hrs
Hypertension
- Both gestational HTN and preeclampsia/HELLP are typically diagnosed >20w GA
- Tx options: nifedipine, labetalol, methyldopa, hydral (2nd line), clonidine (2nd line)
- Avoid: ACEi, ARB, MRA, nitroprusside
Diabetes
- Due to hormonal changes associated with pregnancy, pregnant patients are at higher risk for poor control and DKA. Poorly controlled diabetes is also associated with congenital anomalies of the fetus and early pregnancy loss.
- Medication: Metformin and Insulin preferred. GLP-1 agonists, SGLT-2 inhibitors, and DPP-4 inhibitors should be discontinued.
- Consider starting ASA 81mg to reduce risk for preeclampsia
GERD
- 1st line: lifestyle and dietary medication
- 2nd line: antacids or sucralfate 1g PO TID. Avoid sodium bicarbonate and magnesium
- 3rd line: Histamine 2 receptor antagonists such as cimetidine 200mg (30min prior to eating)
- 4th line: PPI such as omeprazole or pantoprazole
Asthma
- Similar rescue and controller medications as in non-pregnant patient
- Would favor using LABA > leukotriene receptor antagonists for additional therapy
Obtaining Imaging
- A missed or delayed diagnosis can pose a greater risk to patients and their pregnancy than the hazard associated with ionizing radiation
- Discuss with radiologist when ordering; often adjustments can be made in pregnancy that maintain imaging integrity and utility
- In general, should limit fetal ionizing radiation exposure to <50 mGy (for reference, a two-view CXR is ~0.01mGy, a KUB is ~2 mGy, and a pelvic CT is anywhere from 10-50 mGy. Iodinated contrast is not contraindicated but can cross the placenta and depress fetal thyroid.
- MRI is safe in pregnancy and in some cases preferred, particularly in the first trimester however gadolinium contrast should generally be avoided unless absolutely necessary.
