Guidelines for Pregnant Patients
Savannah Steinhauser
General Physiologic Changes
- Pregnancy Induces hyperdynamic circulation with increased cardiac output, decreased SVR, and physiologic anemia
Bacteriuria/UTI in Pregnancy
- Acute cystitis: Empiric treatment: Cephalexin, cefpodoxime, amox-clav, fosfomycin (avoid nitrofurantoin/Bactrim in 1st trimester & near term if alternatives). Treat 5–7 days, tailor to culture. If UA negative with dysuria → test for STIs.
- Pyelonephritis: More common in 2nd/3rd trimester. Risk Factors: <20y, nulliparity, smoking, late care, sickle cell trait, pregestational DM. Admit, blood cultures, IV beta-lactam (ceftriaxone or piperacillin-tazobactam) 24–48h; avoid fluoroquinolones. Once afebrile 48h → PO beta-lactam to complete 7–10 days.
- Asymptomatic bacteriuria: Dx: pyuria + >100,000 CFU/mL. 2–7% (often 1st trimester). ~25% progress if untreated. Associated with preterm birth/low birth weight. Treat with beta lactam (or culture specific) for 5-7 days.
Refractory Nausea/Vomiting
- Starts <9w GA. Broad differential (GI, GU, metabolic, OB causes)
- Workup: BMP, Mg, Phos, LFTs, lipase, UA
- Treatment: 1st line: ginger, doxylamine + pyridoxine. 2nd: diphenhydramine, metoclopramide, promethazine, prochlorperazine. 3rd: ondansetron (after 1st trimester)
Hypertension
- Both gestational HTN and preeclampsia/HELLP are typically diagnosed >20w GA
- Work up: CBC, BMP,HFP, urine protein
- Tx options: nifedipine, labetalol, methyldopa (1st line); Hydralazine (2nd line), clonidine (3rd line)
- Avoid: ACEi, ARB, MRA, nitroprusside
Diabetes
- Higher risk for poor control and DKA. Uncontrolled diabetes is 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
VTE
- Risk increases 4-5 fold during pregnancy and post-partum
- LMWH is preferred treatment, Warfarin and DOAC are contraindicated
GERD
- Treatment: Antacids or sucralfate 1g PO TID (1st line), H2 blockers (2nd line), PPI (3rd line).
- Avoid sodium bicarbonate and magnesium
Asthma
- Manage similar to non-pregnant; prefer LABA over leukotriene antagonists if needed.
Obtaining Imaging
- Do not delay necessary studies. Aim fetal exposure <50 mGy (CXR is ~0.01mGy, a KUB is ~2 mGy, and a pelvic CT is anywhere from 10-50 mGy.). Iodinated contrast crosses placenta but not contraindicated. MRI safe; avoid gadolinium unless essential.
