What medications and supplements should be routinely given to a pregnant patient?

Routine Medications and Supplements in Pregnancy

All pregnant women should take a daily prenatal multivitamin containing folic acid (0.4-5 mg depending on risk), iron (30-60 mg elemental), calcium (1200-1500 mg), vitamin D (≥1000 IU), and vitamin B12 (1 mg every 3 months IM or 1 mg daily orally), starting at least 2-3 months before conception and continuing throughout pregnancy. 1

Folic Acid Supplementation (Risk-Stratified Approach)

Low-Risk Women

• 0.4 mg (400 mcg) daily starting at least 2-3 months before conception through the first trimester 2
• All women of reproductive age (12-45 years) with preserved fertility should receive counseling about folic acid benefits during routine wellness visits, regardless of pregnancy plans, since many pregnancies are unplanned 2
• Continue 0.4-1.0 mg daily from 12 weeks through postpartum and during breastfeeding 1, 2

Moderate-Risk Women

• 1.0 mg daily starting at least 3 months before conception until 12 weeks gestation 2
• Moderate risk includes: diabetes, obesity (BMI >30), family history of neural tube defects in extended family, or use of certain anticonvulsants 1, 2
• After 12 weeks, reduce to 0.4-1.0 mg daily through postpartum 2

High-Risk Women

• 4-5 mg daily starting at least 3 months before conception until 12 weeks gestation 1, 2
• High risk includes: personal history of neural tube defect, previous pregnancy with neural tube defect, or male partner with neural tube defect history 2
• Women with BMI >30 or diabetes should continue 4-5 mg throughout pregnancy 1
• After 12 weeks (for those without ongoing high-risk factors), reduce to 0.4-1.0 mg daily 2

Critical caveat: Women requiring >1 mg folic acid should take only ONE multivitamin tablet per day as directed on the label, then add separate folic acid-only tablets to reach the target dose to avoid vitamin toxicity 2

Iron Supplementation

• 30-60 mg elemental iron daily for all pregnant women 3, 1
• Low-dose supplementation (30 mg/day) is often used during second and third trimesters 1
• Women with adjustable gastric banding may use lower doses (>18 mg) but require monitoring 1
• Avoid routine supplementation in women without anemia (hemoglobin >13.5 g/L) due to potential oxidative stress 4
• Intermittent dosing causes less gastrointestinal upset and oxidative stress compared to daily dosing 4

Monitoring: Check hemoglobin, hematocrit, serum ferritin, and iron studies (including transferrin saturation) at least once per trimester 1

Calcium Supplementation

• 1200-1500 mg daily in divided doses (including dietary intake) 1
• Particularly important in populations with low dietary calcium intake to prevent preeclampsia 1, 5
• Not recommended for women with adequate intake (3 dairy servings/day); reserve for inadequate intake or high preeclampsia risk 4
• Take separately from iron as calcium inhibits iron absorption 1

Vitamin D Supplementation

• ≥1000 IU (40 mcg) daily to maintain serum 25-hydroxyvitamin D levels above 50 nmol/L 1
• Supplementation in the third trimester appears beneficial in deficient women 5
• Monitor serum vitamin D with calcium, phosphate, magnesium, and PTH at least once per trimester 1

Vitamin B12 Supplementation

• 1 mg intramuscularly every 3 months OR 1 mg daily orally (though oral absorption may be reduced) 1, 6
• Check B12 levels before initiating high-dose folic acid to avoid masking B12 deficiency and preventing subacute combined degeneration of the spinal cord 6
• Monitor serum B12 at least once per trimester 1, 6
• Folic acid should be taken in a multivitamin containing 2.6 mcg/day vitamin B12 to mitigate theoretical concerns about masking deficiency 2

Treatment of B12 Deficiency

• With neurological involvement: Hydroxocobalamin 1 mg IM on alternate days until no further improvement, then 1 mg every 2 months 6
• Without neurological involvement: Hydroxocobalamin 1 mg IM three times weekly for 2 weeks, then 1 mg every 2-3 months lifelong 6

Additional Micronutrients

• Thiamine: >12 mg daily 1
• Copper: 2 mg daily (>1 mg for women with adjustable gastric banding) 1
• Zinc: 8-15 mg per 1 mg copper 1
• Selenium: 50 μg daily 1
• Vitamin E: 15 mg daily 1
• Vitamin A: 5000 IU daily in beta-carotene form only (never retinol due to teratogenicity risk) 1
• Vitamin K: 90-120 μg daily 1

Iodine Supplementation

• Recommended for women not reaching adequate intake through diet (3 servings dairy + 2g iodized salt) 4
• Potassium iodide supplementation has conflicting recommendations among working groups 4

Immunizations During Pregnancy

• Tdap vaccine: Should be administered during each pregnancy, ideally between 27-36 weeks gestation, regardless of prior vaccination history
• Tdap is safe during pregnancy and provides passive immunity to the newborn 7
• Epinephrine (1:1000) must be immediately available when administering vaccines 7

Special Populations Requiring Intensive Monitoring

Women with History of Bariatric Surgery

• Require more intensive monitoring with checks every 3 months during pregnancy 1, 6
• Higher supplementation doses needed due to malabsorption 1
• Monthly ultrasound monitoring of fetal growth recommended 1
• Should avoid pregnancy for 12-18 months post-surgery to allow weight stabilization 1

Women with Obesity (BMI >30)

• Continue higher folic acid doses (4-5 mg daily) throughout pregnancy 1
• Avoid hypocaloric diets (<1200 calories/day) which can cause ketonemia and affect fetal development 1

Critical Pitfalls to Avoid

• Never use retinol form of vitamin A during pregnancy; only beta-carotene form is safe 1
• Do not exceed one multivitamin tablet per day when taking high-dose folic acid; add folic acid-only supplements to reach target dose 2
• Separate calcium and iron supplementation by several hours to optimize absorption 1
• Check B12 before high-dose folic acid to prevent masking deficiency 6
• Avoid vitamin E supplementation for preeclampsia prevention as it may disrupt physiologic oxidative state and harm pregnancy outcomes 5
• Do not routinely supplement iron in women without anemia (hemoglobin >13.5 g/L) 4
• Avoid vitamin A and D supplementation except in documented deficiency due to toxicity risk 4

Monitoring Schedule Throughout Pregnancy

Every Trimester (at minimum):

• Full blood count, serum ferritin, iron studies 1
• Serum folate or red blood cell folate 1
• Serum vitamin B12 1, 6
• Serum vitamin D with calcium, phosphate, magnesium, PTH 1
• Serum vitamin A 1

Every 3 Months for High-Risk Women:

• All of the above plus more frequent monitoring for women with bariatric surgery history 1, 6