What are the key investigations and management for pregnancy, including medications and non-medical management?

Key Investigations and Management for Pregnancy

Preconception Investigations and Optimization

All women planning pregnancy should undergo comprehensive preconception screening and optimization, with particular attention to achieving optimal health status before conception. 1

Laboratory Testing

• Complete blood count to screen for anemia 1
• Blood type and Rh screen 1
• Urinalysis 1
• Rubella immunity testing with vaccination if seronegative 1
• Syphilis screening 1
• Hepatitis B and C screening 1
• HIV testing 1
• Gonorrhea and Chlamydia screening 1
• Thyroid-stimulating hormone (TSH) measurement 1
• Diabetes screening (fasting glucose or HbA1c) 1
• Cervical cytology (Pap smear) as indicated 1

Genetic Carrier Screening (Based on Ethnicity and History)

• Cystic fibrosis 1
• Sickle cell anemia 1
• Tay-Sachs disease 1
• Thalassemia 1

Specialized Testing for Women with Diabetes

• Comprehensive ophthalmologic examination 1
• Serum creatinine and urine albumin-to-creatinine ratio 1
• Lipid panel 1
• ECG in women ≥35 years or with cardiac symptoms/risk factors 1
• Comprehensive foot examination 1

Preconception Medications and Supplementation

Essential Supplementation

Folic acid 400 mcg (0.4 mg) daily should be started at least 3 months before conception and continued through early pregnancy to prevent neural tube defects. 1, 2

• Women taking sulfasalazine require higher dose folic acid 5 mg daily 1
• Women with significant small bowel resections or active small bowel disease require 5 mg daily 1

Immunizations Before Pregnancy

• Inactivated influenza vaccine 1
• Tdap (tetanus, diphtheria, pertussis) 1
• Hepatitis B vaccine if not immune 1
• Rubella vaccine if seronegative (wait 1 month before conceiving) 1
• Varicella vaccine if not immune (wait 1 month before conceiving) 1
• COVID-19 vaccination in certain populations 1
• Human papillomavirus vaccine as indicated 1

Medication Review and Adjustments

The following medications must be discontinued at least 3 months before conception due to teratogenicity: 1, 3

• Methotrexate 1
• JAK inhibitors 1
• Sphingosine-1-P modulators 1

ACE inhibitors and ARBs must be immediately discontinued when pregnancy is planned or confirmed due to severe fetotoxicity causing renal dysgenesis. 4, 5, 3

• Avoid FDA pregnancy category X medications entirely 1
• Avoid most category D medications unless maternal benefits clearly outweigh fetal risks 1
• Review all over-the-counter medications, herbs, and supplements for safety 1

Specific Management for Women with Diabetes

Women with diabetes should achieve HbA1c <6.5% before conception to minimize risk of congenital malformations, preeclampsia, and preterm birth. 3

• Use effective contraception until glycemic targets achieved 1, 3
• Target fasting glucose <95 mg/dL before conception 3
• Optimize insulin regimen with basal-bolus therapy 3

Non-Medical Preconception Management

Lifestyle Modifications

• Achieve healthy prepregnancy BMI 19.8-26.0 kg/m² through nutrition and exercise 1
• Consume "five-a-day" (2 servings fruit, 3 servings vegetables) 1
• Engage in regular moderate exercise 1, 5
• Smoking cessation using the five A's approach (Ask, Advise, Assess, Assist, Arrange) 1
• Complete alcohol abstinence 1
• Avoid substance abuse 1
• Dental care including regular flossing 1
• Adequate sleep 1
• Avoid hyperthermia (hot tubs) 1

Nutritional Assessment

• Evaluate anthropometric factors (BMI) 1
• Assess biochemical factors (anemia, vitamin deficiencies) 1
• Screen for vitamin B12 and folate deficiency 1
• Ensure adequate calcium intake 5
• Correct dietary nutritional deficiencies 1
• Review safe food preparation techniques 1
• Limit caffeine intake 1

Psychosocial Screening and Support

• Screen for depression and anxiety 1
• Screen for domestic violence 1
• Assess major psychosocial stressors 1
• Evaluate barriers to care 1

Reproductive Life Planning

• Discuss pregnancy intentions and timing 1
• Provide effective contraception until ready for pregnancy 1, 3
• Discuss emergency contraception options 1

Management During Pregnancy

Glycemic Management for Women with Diabetes

Insulin is the preferred first-line medication for managing diabetes during pregnancy because it does not cross the placenta. 3

Glycemic Targets During Pregnancy

• Fasting plasma glucose <95 mg/dL 1, 3
• 1-hour postprandial glucose <140 mg/dL 1, 3
• 2-hour postprandial glucose <120 mg/dL 1, 3
• Optimal HbA1c <6% if achievable without significant hypoglycemia 3

Insulin Regimen

• Implement physiologic basal-bolus regimens 3
• Use rapid-acting insulin for meals 3
• Use long-acting insulin for basal coverage 3
• Adjust insulin doses frequently as pregnancy progresses due to increasing insulin resistance 1

Medical Nutrition Therapy During Pregnancy

• Maintain consistent carbohydrate intake to match insulin dosing 1, 3
• Referral to registered dietitian nutritionist is essential 1
• Establish insulin-to-carbohydrate ratio 1
• Provide adequate calories for fetal/maternal health and appropriate gestational weight gain 3
• Focus on high-quality carbohydrates, adequate fiber, and appropriate fat intake 1
• Ensure adequate fruit and vegetable consumption 1

Hypertension Management During Pregnancy

For chronic hypertension or gestational hypertension, first-line medications are labetalol, methyldopa, or extended-release nifedipine. 4, 5

Blood Pressure Targets

• Maintain BP 110-135/80-85 mmHg 4, 3
• Treat confirmed office BP ≥140/90 mmHg 5
• Keep diastolic BP not below 80 mmHg 5

First-Line Antihypertensive Medications

• Labetalol (alpha/beta-blocker): 100 mg twice daily up to 2400 mg/day 4, 5
• Methyldopa (oral): safe and effective for acute and chronic use 4, 5
• Nifedipine extended-release (oral): effective dihydropyridine calcium channel blocker 4, 5

Management of Severe Hypertension/Preeclampsia

For severe hypertension (BP ≥160/110 mmHg) or preeclampsia, immediate hospitalization and urgent treatment with intravenous labetalol, oral methyldopa, or oral nifedipine is required. 4, 5

• Hydralazine IV is no longer first-line due to greater perinatal adverse effects 4
• Never use nifedipine sublingual or IV due to risk of excessive rapid BP reduction 4
• Avoid combining calcium channel blockers with IV magnesium 4
• Sodium nitroprusside only when other treatments fail due to fetal cyanide toxicity risk with prolonged use 4, 5
• Diuretics are not recommended for BP control in pregnancy 4

Preeclampsia Prevention

Women at high risk for preeclampsia should receive low-dose aspirin 100-150 mg daily starting at 12-16 weeks gestation until 36-37 weeks or delivery. 5, 3, 6

• Calcium supplementation ≥1 g daily, particularly in high-risk women 5
• Normal diet without salt restriction 4
• Do not recommend weight reduction in obese pregnant women 4

Monitoring During Pregnancy

For Women with Diabetes

• Frequent blood glucose monitoring or continuous glucose monitoring 1
• Comprehensive ophthalmologic examination at baseline and as needed throughout pregnancy 3
• Monitor for diabetic ketoacidosis and severe hyperglycemia 1
• Monitor for severe hypoglycemia 1
• Serial ultrasound for fetal growth monitoring 1

For Women with Hypertension

• Blood pressure measured 4 times daily if hospitalized 7
• Weight and urine protein 3 times weekly 7
• Creatinine clearance weekly 7
• Serial sonography to monitor fetal growth 7
• Monitor for symptoms: severe headache, scotomata, rapid weight gain 7, 8

General Pregnancy Monitoring

• At least one visit in consultant-led obstetric clinic 1
• Joint IBD-antenatal clinics for women with inflammatory bowel disease 1
• Mental health screening before, during, and after pregnancy 1
• VTE prophylaxis for outpatients with active IBD during third trimester 1

Medications to Continue During Pregnancy

• Insulin therapy (adjust doses as needed) 3
• Antihypertensive medications (labetalol, methyldopa, nifedipine) 4, 5
• Thyroid hormone replacement if indicated 1
• Low-dose aspirin for preeclampsia prevention 5, 3
• Folic acid supplementation 1, 2
• Vitamin D supplementation 1

Medications for Specific Conditions

Magnesium Sulfate

• Use during labor and for at least 24 hours postpartum in women with severe preeclampsia to prevent seizures 8
• Use for treatment of eclamptic seizures 6
• Use for neuroprotection of preterm neonates 6

Corticosteroids

• Administer antenatal corticosteroids between 24-34 weeks gestation in women with severe preeclampsia to reduce neonatal mortality and morbidity 6, 8

Delivery and Postpartum Management

Timing and Mode of Delivery

• Delivery is the only curative treatment for preeclampsia 4
• Mode of delivery determined by obstetric considerations and patient preference 1
• Consider cesarean section for women with active perianal disease, ileoanal pouch, or ileorectal anastomosis 1

Postpartum Care

• VTE prophylaxis important after cesarean section 1
• Close monitoring and rapid insulin dose reduction immediately postpartum to prevent hypoglycemia 3
• Continue medications that are low-risk in pregnancy as they are also low-risk in breastfeeding 1
• Breastfeeding is preferred and does not affect IBD course 1

Postpartum Screening

• Women with gestational diabetes: 75-g oral glucose tolerance test at 4-12 weeks postpartum using nonpregnancy criteria 3
• Postnatal blood pressure monitoring 6
• Screen for postnatal depression 9

Long-term Follow-up

Women with pregnancy complications (preeclampsia, gestational diabetes, preterm birth, stillbirth) have increased risk of cardiovascular disease, diabetes, chronic kidney disease, and mental health disorders in later life and require long-term counseling and screening. 1, 9

• Counsel about increased cardiovascular disease risk after preeclampsia 1, 9
• Screen for diabetes after gestational diabetes 9
• Monitor for chronic kidney disease after preeclampsia 9
• Screen for mental health disorders after pregnancy loss or complications 9