Can corticosteroids be used during the first trimester of pregnancy?

From the Guidelines

Corticosteroids can be used during the first trimester of pregnancy when medically necessary, but should be prescribed at the lowest effective dose for the shortest duration possible. According to the most recent study from 2021 1, glucocorticoids, such as prednisone and budesonide, are considered compatible with pregnancy, although prednisone may have a possible association with oral clefting. However, a more recent nationwide cohort study of nearly 52,000 pregnancies with first-trimester exposure showed no increased risk of orofacial clefts with corticosteroid exposure 1.

Key Considerations

• Medications like prednisone and budesonide are preferred options as they have minimal systemic absorption and are safer alternatives when appropriate for the condition.
• For acute conditions requiring short courses, prednisone at 20-40mg daily for 5-7 days is typically safe.
• For chronic conditions, maintenance doses below 20mg daily of prednisone are generally considered acceptable.
• The benefits of treating serious maternal conditions like asthma exacerbations, inflammatory bowel disease, or autoimmune disorders usually outweigh potential risks to the fetus.
• Patients should always inform all healthcare providers about their pregnancy when corticosteroids are being considered.

Comparison with Other Options

• MPA products, such as mycophenolate mofetil and mycophenolate sodium, are contraindicated in pregnancy due to their high risk of congenital malformations and spontaneous abortions 1.
• Other immunosuppressive medications, such as azathioprine and CNIs (cyclosporine and tacrolimus), have varying levels of compatibility with pregnancy, but glucocorticoids are generally considered a safer option 1.

Clinical Judgment

• Clinicians should exercise caution when prescribing corticosteroids during the first trimester and consider the potential risks and benefits for each individual patient.
• Consultation with the patient's obstetrician is recommended to ensure the safest possible outcome for both mother and fetus.

From the FDA Drug Label

Corticosteroids have been shown to be teratogenic in many species when given in doses equivalent to the human dose Animal studies in which corticosteroids have been given to pregnant mice, rats, and rabbits have yielded an increased incidence of cleft palate in the offspring. There are no adequate and well-controlled studies in pregnant women. Corticosteroids should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus

Corticosteroids can be used during the first trimester of pregnancy, but only if the potential benefit justifies the potential risk to the fetus 2. The use of corticosteroids during pregnancy should be carefully considered, as they have been shown to be teratogenic in animal studies. The risk of teratogenic effects should be weighed against the potential benefits of treatment. It is essential to monitor infants born to mothers who have received substantial doses of corticosteroids during pregnancy for signs of hypoadrenalism.

From the Research

Use of Corticosteroids During the First Trimester of Pregnancy

• The use of corticosteroids during the first trimester of pregnancy has been associated with an increased risk of congenital malformations, specifically oral clefts 3.
• However, the use of inhaled steroids by pregnant asthmatic women does not appear to reduce intrauterine growth or increase the risk of congenital malformations 4.
• High doses of inhaled corticosteroids during the first trimester of pregnancy may be associated with an increased risk of congenital malformations, but low-to-moderate doses are considered safe 5.

Specific Types of Corticosteroids

• Topical corticosteroids are generally considered safe during pregnancy, but potent/very potent topical corticosteroids may be associated with fetal growth restriction 6.
• Musculoskeletal steroid injections, such as non-systemic injections, have been shown to be safe and effective in pregnant women, with no adverse effects on the mother or baby 7.

Recommendations

• Corticosteroids should be used during the first trimester of pregnancy only when necessary, such as in life-threatening situations or when there are no other safe therapeutic alternatives 3.
• The use of inhaled steroids for persistent asthma during pregnancy is recommended, as it does not appear to increase the risk of congenital malformations or reduce intrauterine growth 4.
• The use of topical corticosteroids during pregnancy should be limited to mild/moderate potency, as potent/very potent topical corticosteroids may be associated with fetal growth restriction 6.