Table: Treatment Options in Pregnancy

Treatment of acute and chronic conditions in pregnancy.

New table added 13th March 2020

  • Avoid all medication in first trimester if possible
  • Prescribe medication only if the expected benefit to the mother is greater than the risk to the foetus, but also consider the harms of not treating
  • Prescribe established drugs in preference to new or untried agents; use minimum effective dose and minimise polypharmacy
  • Advise the woman to take folic acid (400 microgram daily) throughout the first 12 weeks of pregnancy if she is not already doing so
  • Advise the woman to take vitamin D 400 units (10 microgram) daily, or >1000 units (25 microgram) daily if high risk of deficiency (eg, darker skin, limited exposure to sunlight)1

FIRST-LINE TREATMENTSECOND/SUBSEQUENT LINE TREATMENT
MINOR AILMENTS
CONSTIPATION2
If lifestyle measures insufficient:
- Offer short-term treatment with oral laxatives starting with a bulk-forming laxative eg, ispaghula
If stools remain hard:
- Add or switch to lactulose

If stool soft but difficult to pass, or there is sensation of incomplete emptying:
- Consider short course of senna

If response still inadequate:
- Consider prescribing a glycerol suppository
Note: Advise patient on lifestyle measures such as increasing dietary fibre, fluid intake, and activity levels.
DYSPEPSIA2
If symptoms mild and not controlled by lifestyle changes:
- Antacid or alginate (eg, Gaviscon Advance; alginates particularly useful if GORD symptoms dominant)

Antacids containing aluminium and magnesium (eg, Maalox*,
Mucogel*) can be used as required; calcium-containing products only recommended for short-term or occasional use
If symptoms severe or persistent:
- Consider ranitidine* or omeprazole
Notes: Advise patient on lifestyle measures such as eating smaller meals more frequently, avoiding fatty and spicy foods and caffeine, and raising head of bed.
Do not prescribe: Products containing sodium bicarbonate or magnesium trisilicate
HAEMORRHOIDS2
If lifestyle measures insufficient:
-
Topical prep*
Notes: Advise patient on lifestyle measures such as increasing daily fibre and fluid intake, avoiding straining, and maintaining perianal hygiene.
NAUSEA AND VOMITING2,3
If anti-emetic needed:
- Promethazine* 12.5-25mg every 4 to 8 hrs, or
- Cyclizine* 50mg every 8 hrs

Assess after 24 hrs then weekly
If no dehydration or ketonuria, switch to:
- Metoclopramide* 5–10mg every 8 hrs (max 5 days; do not use in women <20 years), or
- Prochlorperazine* 5–10mg every 6 to 8 hrs daily, or
- Ondansetron* 4–8mg every 6 to 8 hrs (NB contraindicated in 1st trimester)

Assess after 24 hrs then weekly; seek specialist advice if poor response
Notes: Advise patient that symptoms usually resolve by around 16 weeks of pregnancy.
For mild symptoms consider recommending ginger or P6 (wrist) acupressure.
Do not prescribe: Hypnosis
PAIN4
- Paracetamol- NSAIDs (before 30 weeks)
- Codeine
Notes: Consider recommending non-drug measures eg, relacation and deep breathings, gentle exercise, physiotherapy.
PRURITUS WITH RASH5
Polymorphic or atopic eruption of pregnancy:
- Emollients can be used liberally to soothe the skin
- Moderately potent topical steroids can be used to reduce inflammation
- Offer a sedating antihistamine (eg, chlorphenamine* or promethazine*) if itch is causing sleeping difficulties
Notes: Advise patient that symptoms usually last 4–6 weeks, and provide self-care advice to relieve itching.
Refer to dermatologist if rash is particularly severe or unresponsive to treatment.
RHINITIS6
- Nasal saline irrigation Topical:
- Sodium cromoglicate nasal spray
- Corticosteroid nasal spray (beclometasone, fluticasone or budesonide)

Systemic:
- Loratadine, cetirizine or chlorphenamine
Do not prescribe: Decongestants
FIRST-LINE TREATMENTSECOND/SUBSEQUENT LINE TREATMENT
INFECTIONS
COUGH7
- Amoxicillin 500mg tds for 5 days - Erythromycin 250-500mg qds or 500mg-1g bd for 5 days
Do not prescribe: Tetracyclines
PNEUMONIA (COMMUNITY-ACQUIRED)8
Low severity:
- Amoxicillin 500mg tds for 5 days

Moderate severity:
- Amoxicillin 500mg tds for 5 days. If atypical pathogens suspected, add erythromycin 500mg qds for 5 days

High severity:
- Co-amoxiclav 500/125mg orally or 1.2g iv tds for 5 days +
erythromycin 500mg qds orally for 5 days
Low severity:
- Erythromycin 500mg qds for 5 days
Do not prescribe: Tetracyclines
SINUSITIS9
- Phenoxymethylpenicillin (penicillin V) 500mg qds for 5 days - Erythromycin 250-500mg qds or 500mg-1g bd for 5 days
Notes: Antibiotics not recommended unless symptoms have lasted >10 days with no improvement. Consider delayed prescribing.
SORE THROAT10
- Phenoxymethylpenicillin (penicillin V) 500mg qds or 1g bd for 5–10 days - Erythromycin 250–500mg qds or 500mg–1g bd for 5 days
Notes: Antibiotics recommended only if FeverPAIN score >4 or Centor score >3 (consider delayed prescribing) or if patient very unwell, has symptoms and signs of a more serious illness, or at high risk of complications. Delayed prescribing can be considered if FeverPAIN score is 2 or 3.
UTI11
If eGFR >45ml/min:
- Nitrofurantoin 100mg modified-release twice daily (or 50mg four times daily) for 7 days
(NB avoid at term)
If nitrofurantoin not suitable or no improvement in symptoms after taken for 48 hrs:

- Amoxicillin (only if culture results available and susceptible) 500mg three times daily for 7 days

- Cefalexin 500mg twice daily for 7 days

Do not prescribe: Trimethoprim
VAGINAL CANDIDIASIS12
- Intravaginal clotrimazole or miconazole for >7 days

For vulval symptoms:
- Topical imidazole (eg, clotrimazole 1% or 2% cream 2 to 3 times daily, or ketoconazole 2% cream 1 to 2 times daily)
Do not prescribe: Oral antifungals
FIRST-LINE TREATMENTSECOND/SUBSEQUENT LINE TREATMENT
CHRONIC CONDITIONS
ANXIETY DISORDERS13,14 (generalised anxiety disorder, panic disorder, social anxiety disorder, PTSD, OCD)
- Offer psychological intervention

If medication is needed:
- SSRI

If already taking an SSRI, SNRI or TCAD:
- Options are to continue the drug, change to a drug with a lower risk of adverse effects, switch to high-intensity psychological intervention, or combine medication with psychological intervention
Notes: No psychotropic medication has a marketing authorisation specifically for women who are pregnant.
Do not prescribe: Benzodiazepines (except for short-term treatment of severe anxiety and agitation) - withdraw gradually
ASTHMA15
- Continue short-acting and long-acting ß2 agonists, inhaled corticosteroids, xanthines, oral steroids and sodium cromoglicate as normal

- If leukotriene receptor antagonists are required, do not withhold
Notes: Monitor women with moderate/severe asthma closely.
Counsel patient on the importance and safety of continuing their medications during pregnancy to ensure good asthma control.
CORONARY HEART DISEASE16
- Low-dose aspirin - Clopidogrel (only when strictly necessary and for shortest duration)
DEPRESSION13
Mild to moderate depression:
- Consider facilitated self-help

Mild depression with history of severe depression:
- Consider a TCAD, SSRI or SNRI

Moderate to severe depression:
- Consider TCAD, SSRI or SNRI if high-intensity psychological intervention declined or ineffective (consider a combination of the two if either alone is insufficient)

If already taking a TCAD, SSRI or SNRI for mild to moderate depression:
- Consider gradual withdrawal and facilitated self-help

If already taking a TCAD, SSRI or SNRI for moderate depression and patient wants to stop:
- Consider switching to high-intensity psychological intervention or changing medication

If already taking a TCAD, SSRI or SNRI for severe depression:
- Options are to continue the drug, change to a drug with a lower risk of adverse effects, switch to high-intensity psychological intervention, or combine medication with psychological intervention
Notes: No psychotropic medication has a marketing authorisation specifically for women who are pregnant.
In general, antidepressants should not be discontinued suddenly on discovering a pregnancy.
HYPERLIPIDAEMIA16
Notes: No expected disadvantages to the mother from temporary interruption of statin therapy during pregnancy.
Do not prescribe: Statins
HYPERTENSION16,17
- Labetalol If labetalol unsuitable:
- Nifedipine

If labetalol and nifedipine unsuitable:
- Methyldopa

- Offer aspirin 75–150mg once daily from 12 weeks
IRON DEFICIENCY ANAEMIA18
Hb <110g/L up until 12 weeks or <105g/L beyond 12 weeks:
- Offer 100–200mg elemental iron daily (as ferrous salt) and check Hb after 2 weeks

Advise patient to take oral iron on an empty stomach, 1 hr before meals, with a source of vitamin C (eg, orange juice)

Once Hb is in the normal range, continue supplementation for 3 months and until >6 weeks postpartum
Notes: Consider referral to secondary care if significant symptoms and/or severe anaemia (Hb <70g/L), late gestation (>34 weeks) or lack of response to oral iron.
MIGRAINE (ACUTE)19,20
If non-pharmacological measures insufficient:
- Paracetamol
- NSAIDs (before 30 weeks)

If NSAID unsuitable:
- Sumatriptan

If nausea and vomiting:
- Metoclopramide can be considered
Notes: Where possible, preventive drugs should be stopped. If necessary, propranolol, amitriptyline or verapamil can be considered.
Do not prescribe: Ergotamine, aspirin, opioids
SMOKING CESSATION21
- Refer woman to smoking cessation clinic for behavioural support

- Consider nicotine replacement therapy (intermittent dose forms such as gum and lozenges preferred to patches; consider patches if woman has significant pregnancy-related nausea and/or vomiting)
Notes: Ideally women who are pregnant should stop smoking abruptly without using medication; however, use of nicotine replacement therapy is safer than continuing to smoke.
Do not prescribe: Varenicline, bupropion

*Use unlicensed in pregnancy

References

  1. RCOG. Vitamin D in pregnancy (June 2014).
  2. CKS. Antenatal care - uncomplicated pregnancy. Managing common minor ailments (updated February 2019).
  3. RCOG. The management of nausea and vomiting of pregnancy and hyperemesis gravidarum (June 2016).
  4. BUMPS. Pain relief (July 2019).
  5. CKS. Management of itch with rash in pregnancy (updated July 2015).
  6. Scadding GK et al. BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (updated 2017). Clin Exp Allergy 2017; 47: 856–89.
  7. NICE. Cough (acute): antimicrobial prescribing (February 2019).
  8. NICE. Pneumonia (community-acquired): antimicrobial prescribing (September 2019).
  9. NICE. Sinusitis (acute): antimicrobial prescribing (October 2017).
  10. NICE. Sore throat (acute): antimicrobial prescribing (January 2018).
  11. NICE. Urinary tract infection (lower): antimicrobial prescribing (October 2018).
  12. CKS. Candida - female genital (updated May 2017).
  13. NICE. Antenatal and postnatal mental health: clinical management and service guidance (December 2014).
  14. McAllister-Williams RH et al. British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum. J Psychopharmacol 2017; 31: 519–52.
  15. BTS. British guideline on the management of asthma (updated July 2019).
  16. Regitz-Zagrosek V et al. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018; 39: 3165–241.
  17. NICE. Hypertension in pregnancy: diagnosis and management (June 2019).
  18. Pavord S et al. UK guidelines on the management of iron deficiency in pregnancy. Br J Haematol 2012; 156: 588–600.
  19. BUMPS. Treatment of migraine in pregnancy (August 2016).
  20. CKS. Migraine (updated April 2019).
  21. CKS. Smoking cessation (updated March 2018).

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