What medications are safe to use during pregnancy?

Safe Medications During Pregnancy

The most important consideration when prescribing medications during pregnancy is to use the lowest effective dose for the shortest duration possible, prioritizing medications with established safety profiles while balancing maternal benefit against potential fetal risks.

First-Line Safe Medications by Category

Respiratory Medications

• Inhaled Bronchodilators
  • Short-acting beta-agonists (SABAs): Salbutamol (albuterol) is compatible throughout pregnancy 1
  • Long-acting beta-agonists (LABAs): Salmeterol is preferred due to greater experience during pregnancy 1
  • Inhaled corticosteroids: Budesonide and beclomethasone have the most safety data 1, 2

Antirheumatic/Anti-inflammatory Medications

• Disease-Modifying Antirheumatic Drugs (DMARDs)

  • Hydroxychloroquine, chloroquine 1
  • Azathioprine (up to 2 mg/kg/day) 1
  • Sulfasalazine (up to 2 g/day with folic acid supplementation) 1
  • Cyclosporine, tacrolimus 1
  • Colchicine (1-2 mg/day) 1

• NSAIDs

  • Safe in first and early second trimester for short-term use (7-10 days) 3
  • Ibuprofen preferred if needed in early pregnancy 3
  • Must be avoided after 28 weeks gestation due to risk of premature closure of ductus arteriosus 3

Gastrointestinal Medications

• Acid Reducers
  • Histamine H2 blockers and proton pump inhibitors have not demonstrated significant fetal effects 4

Topical Medications

• Antifungals

  • First-line: Clotrimazole, miconazole, and nystatin 5
  • Second-line: Butenafine, ciclopirox, naftifine, oxiconazole, and terbinafine 5

• Antivirals

  • First-line: Acyclovir and trichloroacetic acid 5
  • Second-line: Docosanol, imiquimod, and penciclovir 5

Analgesics

• Acetaminophen (Paracetamol)
  • Generally considered safe during any trimester 4
  • Used by approximately 65% of pregnant women 4

Medications to Avoid During Pregnancy

Absolutely Contraindicated

• Teratogens

  • Methotrexate (discontinue at least 6 months before conception) 1
  • Mycophenolate 1
  • Cyclophosphamide 1
  • Mavacamten (for hypertrophic cardiomyopathy) 1

• Antivirals to Avoid

  • Podofilox and podophyllin resin 5

• Antibiotics to Avoid

  • Streptomycin (can cause hearing/balance problems in 1 in 6 babies) 6

Cardiovascular Medications to Avoid

• ACE inhibitors and Angiotensin II Receptor Blockers
  • Associated with renal or tubular dysplasia, oligohydramnion, growth retardation 1

Special Considerations

Biologic Agents in Inflammatory Conditions

• Anti-TNF agents (infliximab, adalimumab) can be continued during pregnancy 1
• These cross the placenta after 20 weeks gestation 1
• If received after 20 weeks, newborns should not receive live vaccines for first 6 months 1
• Certolizumab does not cross the placenta and may be preferred 1

Anticoagulation

• Low-molecular-weight heparin and low-dose warfarin carry acceptable risk during pregnancy for conditions requiring anticoagulation 1
• Direct oral anticoagulants (DOACs) should be avoided due to higher rate of fetal complications 1

Tuberculosis Treatment

• First-line drugs (isoniazid, rifampicin, ethambutol, pyrazinamide) have excellent safety records in pregnancy 6
• Pyridoxine (vitamin B6) should be added when using isoniazid 6

Practical Approach to Medication Use in Pregnancy

1. Evaluate necessity: Determine if medication is essential for maternal health
2. Choose established medications: Select medications with longer safety track records
3. Timing considerations: Some medications safe in certain trimesters but not others
4. Dosing: Use lowest effective dose for shortest duration
5. Monitor: Follow appropriate monitoring parameters (e.g., liver function with certain medications)

Common Pitfalls to Avoid

• Relying solely on FDA pregnancy categories: These are often overly cautious and may not reflect current evidence
• Stopping necessary medications: Untreated maternal disease often poses greater risk than medication
• Assuming all medications in a class have equal safety profiles: Choose specific agents with most safety data
• Overlooking drug interactions: Pregnancy alters drug metabolism and may require dose adjustments

Remember that the risk-benefit assessment must consider both maternal and fetal wellbeing, with untreated maternal disease often posing greater risks than medication use with established safety profiles.