What are the steps to manage an emergency pregnancy in a patient with potential complications and pre-existing medical conditions, such as diabetes (Diabetes Mellitus) and hypertension (High Blood Pressure)?

Managing Emergency Pregnancy with Diabetes and Hypertension

Immediately discontinue ACE inhibitors, ARBs, and statins upon pregnancy confirmation, as these medications are teratogenic and contraindicated in pregnancy, causing fetal renal dysplasia, oligohydramnios, and fetal death. 1, 2, 3

Immediate Medication Review (First Priority)

Medications to Stop Immediately

• ACE inhibitors and ARBs must be discontinued immediately due to associations with fetal renal anomalies, oligohydramnios, pulmonary hypoplasia, intrauterine growth restriction, and fetal death 1, 2, 3
• Statins are pregnancy category X and must be stopped in all sexually active women of childbearing age not using reliable contraception 1, 2
• Atenolol should be discontinued due to its association with fetal growth restriction and lower birth weight 1

Safe Antihypertensive Alternatives

• Switch to methyldopa (750 mg to 4 g daily in divided doses) as first-line therapy, which has the best safety record with no evidence of adverse effects in mothers or babies including long-term pediatric follow-up 4, 1, 2
• Labetalol (100 mg twice daily up to 2400 mg/day) is an effective alternative alpha-beta blocker with vasodilation properties 4, 1, 2
• Long-acting nifedipine may be used, but avoid sublingual or intravenous administration due to risk of rapid blood pressure reduction causing myocardial infarction or fetal distress 4, 1, 2
• Target blood pressure: 110-135/85 mmHg to reduce risk of accelerated maternal hypertension while minimizing impaired fetal growth 1, 2, 3

Diabetes Management

Glycemic Targets During Pregnancy

• Fasting glucose: 70-95 mg/dL (3.9-5.3 mmol/L) 4, 3
• 1-hour postprandial: 110-140 mg/dL (6.1-7.8 mmol/L) 4, 3
• 2-hour postprandial: 100-120 mg/dL (5.6-6.7 mmol/L) 4, 3
• A1C target: <6% if achievable without significant hypoglycemia, but may be relaxed to <7% if necessary to prevent hypoglycemia 4, 3

Insulin Management

• Insulin is the preferred first-line medication for managing both type 1 and type 2 diabetes during pregnancy, as it does not cross the placenta to a measurable extent 1, 3
• Implement physiologic basal-bolus regimens with rapid-acting insulin for meals and long-acting insulin for basal coverage 3
• Frequent self-monitoring of blood glucose with preprandial and postprandial testing is required 4, 3

Oral Medications

• Metformin may be continued throughout pregnancy if already in use, as it does not increase fetal anomalies and may reduce neonatal hypoglycemia and maternal weight gain 1, 2, 3
• Glyburide may be continued alongside insulin if already in use, but should be discontinued at least two weeks before expected delivery date due to risk of prolonged neonatal hypoglycemia 1, 2

Preeclampsia Prevention

• Start low-dose aspirin 100-150 mg daily at 12-16 weeks gestation to reduce preeclampsia risk in women with both diabetes and hypertension 1, 2, 3
• Women with both conditions have significantly increased risk for preeclampsia and require close monitoring 3

Comprehensive Initial Assessment

Medical Evaluation Required

• General evaluation of overall health including assessment of diabetes complications and comorbidities 4
• Screen for diabetic ketoacidosis/severe hyperglycemia, severe hypoglycemia/hypoglycemia unawareness 4
• Evaluate for hypertension, nephropathy, retinopathy, neuropathy, and macrovascular disease 4
• Comprehensive ophthalmologic examination at baseline and as needed throughout pregnancy for women with preexisting diabetic retinopathy 3
• Baseline renal function assessment with serum creatinine and urine albumin-to-creatinine ratio 4, 3
• ECG in women starting at age 35 years who have cardiac signs/symptoms or risk factors 4

Laboratory Screening

• Comprehensive metabolic panel, lipid panel, TSH, coagulation panel including fibrinogen 4
• Screen for anemia 4
• Infectious disease screening: Neisseria gonorrhea/Chlamydia, Hepatitis C, HIV, syphilis 4
• Genetic carrier screening based on history (cystic fibrosis, sickle cell, Tay-Sachs, thalassemia) 4

Immunization Update

• Ensure current immunizations: Rubella, varicella, hepatitis B, influenza 4
• Tetanus vaccination is safe in pregnancy and should be given when indicated 5

Obstetric History Review

• Evaluate previous adverse pregnancy outcomes: infant death, fetal loss, birth defects, low birth weight, preterm birth 4
• Review history of: cesarean section, congenital malformations, hypertensive disorders of pregnancy, postpartum hemorrhage, preterm delivery, macrosomia, Rh incompatibility, thrombotic events 4

Medical Nutrition Therapy

• Referral to registered dietitian nutritionist to establish food plan and insulin-to-carbohydrate ratio 4, 3
• Consistent carbohydrate intake to match insulin dosing and avoid glucose fluctuations 3
• Promote healthy prepregnancy weight (ideal BMI 19.8-26.0 kg/m²) through exercise and nutrition 4
• Daily multivitamin containing at least 400 mcg folic acid 4, 2

Monitoring for Complications

Hypertensive Disorders

• Superimposed preeclampsia develops in 20-25% of women with chronic hypertension and carries risk to both mother and baby 4
• Monitor for signs of preeclampsia: proteinuria, headache, visual disturbance, pulmonary edema 4
• HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) requires immediate recognition 4

Nephropathy Considerations

• Women with serum creatinine ≥3 mg/dL or creatinine clearance <50 ml/min should be counseled that pregnancy may induce permanent worsening of renal function in 40% of patients 4
• Proteinuria >190 mg/24h before or during early pregnancy is associated with increased risks of pregnancy-induced hypertension 4

Retinopathy Monitoring

• Rapid implementation of tight glycemic control in the setting of retinopathy is associated with worsening of retinopathy 3
• Regular ophthalmologic follow-up throughout pregnancy is essential 3

Common Pitfalls to Avoid

• Do not delay medication review - every day of exposure to teratogenic medications increases fetal risk 3
• Do not use vasopressors except for intractable hypotension unresponsive to fluid resuscitation, as they adversely affect uteroplacental perfusion 5
• Do not use diuretics as first-line therapy - they reduce plasma volume expansion and may promote preeclampsia occurrence 4
• Do not rely on A1C alone during pregnancy - commonly used estimated A1C calculations should not be used in pregnancy as A1C is slightly lower due to increased red blood cell turnover 4
• Avoid rapid blood pressure reduction with sublingual or intravenous nifedipine, which can cause myocardial infarction or fetal distress 4

Multidisciplinary Care Team

• Management should involve: endocrinologist, maternal-fetal medicine specialist, registered dietitian nutritionist, and diabetes educator when available 2, 3
• Frequent phone contact for adjustment of insulin doses and treatment regimen is advised 4
• Regular prenatal visits at 1-2 month intervals depending on mastery of management program 4

Contraception Until Optimization

• Effective contraception should be used until glycemic targets are achieved and medications are optimized 4, 2
• This prevents pregnancy during the critical period when teratogenic medications are being adjusted and glycemic control is being established 2