Is Compazine (prochlorperazine) safe to use during pregnancy?

Safety of Compazine (Prochlorperazine) During Pregnancy

Prochlorperazine (Compazine) should only be used during pregnancy for severe nausea and vomiting that is intractable and when potential benefits outweigh possible hazards, as safety during pregnancy has not been definitively established. 1

Risk Classification and Safety Profile

• Prochlorperazine belongs to the phenothiazine class of medications, which requires careful consideration during pregnancy 1
• The FDA drug label specifically states that prochlorperazine is "not recommended for use in pregnant patients except in cases of severe nausea and vomiting that are so serious and intractable that, in the judgment of the physician, drug intervention is required and potential benefits outweigh possible hazards" 1
• Phenothiazines like prochlorperazine have been associated with potential risks to newborns, including:
  • Prolonged jaundice 1
  • Extrapyramidal signs 1
  • Altered reflexes (hyperreflexia or hyporeflexia) 1

Third Trimester Considerations

• Neonates exposed to antipsychotic drugs during the third trimester are at risk for extrapyramidal and/or withdrawal symptoms following delivery 1
• Reported complications in neonates include:
  • Agitation, hypertonia, hypotonia, tremor 1
  • Somnolence, respiratory distress 1
  • Feeding disorders 1
• These complications have varied in severity from self-limited symptoms to cases requiring intensive care and prolonged hospitalization 1

Therapeutic Alternatives for Nausea and Vomiting in Pregnancy

For hyperemesis gravidarum (HG) or severe nausea and vomiting in pregnancy, a step-up approach is recommended:

1. First-line options:

   • Vitamin B6 (pyridoxine) supplementation 2
   • Doxylamine and pyridoxine combination 2
   • Phenothiazines (as a class) are considered first-line for HG according to European guidelines, though with caution 2

2. Second-line options:

   • Metoclopramide - has similar efficacy with fewer adverse events compared to phenothiazines 2
   • No increased risk of congenital defects has been reported with metoclopramide 2

3. Third-line options:

   • Ondansetron - for severe cases requiring hospitalization 2
   • Should be used on a case-by-case basis for persistent symptoms, especially before 10 weeks of pregnancy 2

Potential Adverse Effects of Prochlorperazine

• Prochlorperazine can cause extrapyramidal side effects that may complicate management of nausea and vomiting 3
• Akathisia and dystonic reactions (including oculogyric crisis) have been reported with parenteral prochlorperazine use 3
• These side effects may be particularly problematic in pregnant women already experiencing distress from hyperemesis gravidarum 3

Breastfeeding Considerations

• Phenothiazines are known to be excreted in breast milk 1
• Caution should be exercised when prochlorperazine is administered to nursing women 1
• The FDA label does not provide specific data on concentrations in breast milk or potential effects on the infant 1

Clinical Decision-Making

When considering prochlorperazine in pregnancy:

1. Assess severity: Reserve for severe, intractable nausea and vomiting not responsive to first-line therapies 1, 2
2. Risk-benefit analysis: Weigh maternal benefits against potential fetal risks 1
3. Timing considerations: Be particularly cautious during the third trimester due to risk of neonatal complications 1
4. Monitor closely: Watch for extrapyramidal side effects in the mother 3
5. Consider alternatives: Try safer first-line options before resorting to prochlorperazine 2

Conclusion

While prochlorperazine may be used in pregnancy for severe, intractable nausea and vomiting, it should not be considered a first-line agent due to potential risks to both mother and fetus. The decision to use this medication should be made after careful consideration of the severity of symptoms and failure of safer alternatives.