What medications are safe to use during pregnancy?

Medications Safe During Pregnancy

The safest approach to medication use during pregnancy is to use only those medications that are absolutely necessary, with preference given to medications with established safety records and avoiding known teratogens.

First-Line Safe Medications by Category

Asthma Medications

• Inhaled Bronchodilators:

  • Short-acting β2-agonists (SABAs): Salbutamol (albuterol) is preferred and considered compatible throughout pregnancy 1
  • Long-acting β2-agonists (LABAs): Salmeterol is preferred due to greater experience during pregnancy 1

• Inhaled Corticosteroids (ICSs):

  • Budesonide is the preferred ICS due to extensive safety data 1, 2
  • Beclomethasone is also considered safe with substantial pregnancy data 1
  • At usual doses, ICSs have not been associated with increased risk of major malformations, intrauterine growth restriction, preterm delivery, or low birth weight 1

Hypertension Medications

• First-line agents:
  • Methyldopa - extensive safety record with no evidence of adverse effects 3
  • Labetalol - extensive use and no association with teratogenicity 3
  • Nifedipine - considered safe but avoid rapid administration 3

Anti-inflammatory/Immunosuppressive Medications

• Safe throughout pregnancy:
  • Hydroxychloroquine 1
  • Sulfasalazine (with folic acid supplementation) 1
  • Azathioprine/6-mercaptopurine 1
  • Colchicine 1
  • Low-dose prednisone (≤10 mg daily) or equivalent non-fluorinated glucocorticoids 1

Gastrointestinal Medications

• For IBD management:
  • Mesalamine is considered safe throughout pregnancy 1
  • Sulfasalazine (with 1 mg folic acid twice daily) 1

Antibiotics

• Generally considered safe in pregnancy:
  • Penicillins
  • Cephalosporins
  • Azithromycin
  • Nitrofurantoin (avoid near term)
  • Metronidazole 4

Medications to Avoid During Pregnancy

Absolute Contraindications

• Teratogens:
  • Methotrexate - must be discontinued at least 3 months before conception 1
  • Mycophenolate mofetil products - contraindicated due to high risk of congenital malformations 1
  • ACE inhibitors and angiotensin receptor blockers - cause renal dysplasia, oligohydramnios, and growth restriction 3
  • Cyclophosphamide - discontinue 3 months before conception (except for life-threatening conditions in 2nd/3rd trimester) 1

Medications to Avoid in Specific Trimesters

• First trimester:

  • Atenolol - associated with intrauterine growth restriction 3

• Third trimester:

  • NSAIDs - risk of premature closure of ductus arteriosus 1
  • Streptomycin - can cause hearing/balance problems in 1 in 6 babies 5

Special Considerations

Biologics in Pregnancy

• Anti-TNF agents (infliximab, etanercept, adalimumab, golimumab):
  • Can be continued during pregnancy 1
  • For infliximab and adalimumab, which cross the placenta after 20 weeks, avoid live vaccines in infants for 6 months after birth 1
  • Certolizumab does not cross the placenta and may be preferred 1

Disease-Specific Considerations

• Asthma:

  • Untreated asthma poses greater risk to the fetus than medication use 1
  • Maintaining asthma control is critical for oxygen supply to the fetus 1

• Inflammatory Bowel Disease:

  • Conception during remission and maintaining remission through pregnancy is essential 1
  • Active disease poses greater risk than medication use 1

• Autoimmune Hepatitis:

  • Prednisone and budesonide are considered low risk 1

Monitoring Recommendations

• Monitor liver function closely with medications that can cause hepatotoxicity
• For patients on biologics that cross the placenta, plan for appropriate vaccination schedules for the infant
• Monitor disease activity regularly throughout pregnancy (e.g., fecal calprotectin for IBD patients each trimester) 1

Common Pitfalls to Avoid

1. Discontinuing necessary medications: Untreated maternal disease often poses greater risk to the fetus than medication exposure
2. Failing to supplement: When using sulfasalazine, always supplement with folic acid
3. Not planning ahead: Ideally, medication adjustments should be made months before conception
4. Overlooking postpartum flares: Many autoimmune conditions may flare postpartum, requiring medication adjustment
5. Using FDA pregnancy categories alone: These are outdated and don't reflect the nuanced risk-benefit analysis needed

Remember that maintaining maternal health is critical for fetal well-being, and decisions about medication use should balance the risks of untreated disease against potential medication effects.