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Guidelines for Pregnant Patients

Ahmad Dbouk and Samuel Lazaroff

Acute Cystitis:

  • Significantly increased prevalence in pregnancy

  • Symptoms: dysuria (urgency/frequency common in pregnancy)

  • Diagnosis: evidence of pyuria and >103 cfu/ml (note, if neg would test for g/c)

  • Treatment: Empiric with cephalexin, cefpodoxime, amoxicillin-clavulanate, fosfomycin. Nitrofurantoin ok in second or third trimester. Avoid Bactrim in first trimester and near term. Tailor based on culture results.

  • Note that asymptomatic bacteriuria is treated in pregnancy (in contrast with general public). Same antibiotic choices as above

Pyelonephritis:

  • Symptoms: fever, flank pain, and nausea/vomiting, dysuria
  • Diagnosis: clinical suspicion + pyuria and bacteriuria
  • Treatment: IV antibiotics for 1 st 24-48hrs; beta-lactams preferred
  • Mild to moderate: ceftriaxone or cefepime
  • Moderate to severe: piperacillin-tazobactam or meropenem

Hyperemesis Gravidarum:

  • 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:
      • First Line: Ginger, doxylamine (25mg PO q6), pyridoxine (20mg PO q6)
      • Second Line: metoclopramide (10mg q6), Promethazine (12.5mg q6)
      • Third Line: ondansetron (8mg q12hrs, 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 (2 nd line), clonidine (2 nd line)
  • Avoid: ACEs, ARBs, MRAs, Nitroprusside

Diabetes:

  • Due to hormonal changes associated with pregnancy, pregnant patients are at higher risk for poor control and DKA
  • Oral regimens are generally transitioned to insulin-based regimens.

GERD:

  • 1st Line: Can use antacids; avoid sodium bicarbonate and magnesium trisilicate
  • 2nd Line: Sucralfate 1g PO TID
  • 3rd Line: Cimetidine 200mg (30min prior to eating)

Asthma:

  • Similar rescue and controller medications as in non-pregnant patient
  • Would favor using LABA over leukotriene receptor antagonists or theophylline for additional therapy