Is prochlorperazine safe to use in a 17-week pregnant woman?

Safety of Prochlorperazine in a 17-Week Pregnant Woman

Prochlorperazine can be used in a 17-week pregnant woman for severe, intractable nausea and vomiting that is unresponsive to first-line therapies, but should not be considered a first-line option due to potential risks. 1, 2

Safety Profile and Recommendations

• The FDA label states that safety of prochlorperazine during pregnancy has not been established, and it is not recommended for use in pregnant patients except in cases of severe, intractable nausea and vomiting where potential benefits outweigh possible hazards 2

• Prochlorperazine is listed in European guidelines as a first-line option for hyperemesis gravidarum, though with caution 1

• The American College of Gastroenterology suggests reserving prochlorperazine for severe cases not responsive to first-line therapies 1

• There have been reported instances of prolonged jaundice, extrapyramidal signs, and altered reflexes in newborns whose mothers received phenothiazines during pregnancy 2

• Neonates exposed to antipsychotic drugs during the third trimester are at risk for extrapyramidal and/or withdrawal symptoms following delivery 2

Treatment Algorithm for Nausea and Vomiting in Pregnancy

First-line options (try before prochlorperazine):

• Vitamin B6 (pyridoxine) supplementation 1
• Doxylamine and pyridoxine combination 1
• Cyclizine 3
• Promethazine 3

Second-line options:

• Metoclopramide - considered to have similar efficacy to phenothiazines but with fewer adverse events 1
• Domperidone 3

Third-line options (for severe cases):

• Prochlorperazine - only when first and second-line options have failed 1, 2
• Ondansetron - may be used for severe cases requiring hospitalization 1
• Corticosteroids 3

Potential Adverse Effects of Prochlorperazine in Pregnancy

• May cause extrapyramidal symptoms including akathisia and oculogyric crisis 4
• Can cause somnolence, postural hypotension, motor and sensory instability 2
• May intensify or prolong the action of central nervous system depressants 2
• Potential risk of third-trimester exposure includes neonatal agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, and feeding disorders 2

Monitoring Recommendations

• If prochlorperazine must be used, monitor closely for:
  • Extrapyramidal symptoms in the mother 4
  • Signs of sedation or hypotension 2
  • Fetal growth with additional ultrasounds every 3-4 weeks 3
  • Consider fetal umbilical artery Doppler exams if growth restriction is suspected 3

Alternative Approaches

• Non-drug therapies should be tried first when possible (relaxation, sleep, massage, ice packs, biofeedback) 5
• For migraine specifically, paracetamol (acetaminophen) 1000 mg is considered the first-choice drug treatment during pregnancy 5
• If antiemetic therapy is required, metoclopramide may be a safer alternative, especially during the second and third trimesters 5, 1

Key Considerations

• At 17 weeks of pregnancy, the patient is in the second trimester, when many medications have lower teratogenic risk compared to first trimester 3
• The decision to use prochlorperazine should be based on the severity of symptoms and failure of safer alternatives 1, 2
• The 2023 EASL guidelines specifically list prochlorperazine as compatible with all trimesters of pregnancy 3