What medications are safe to use during pregnancy and which ones should be avoided?

Safe and Unsafe Medications During Pregnancy

The most important medications to avoid during pregnancy include ACE inhibitors, angiotensin receptor blockers, statins, methotrexate, mycophenolate, cyclophosphamide, and NSAIDs after 28 weeks gestation, while safe alternatives include acetaminophen, certain antihypertensives (methyldopa, nifedipine, labetalol), and specific antirheumatic drugs (hydroxychloroquine, sulfasalazine, azathioprine). 1, 2, 3

Safe Medications During Pregnancy

Pain Management and Fever

• Acetaminophen is considered the first-line medication for treating pain and fever in pregnant women 4
• For moderate to severe pain or fever during pregnancy, acetaminophen remains the safest recommendation 4

Respiratory Medications

• Short-acting beta-agonists (SABAs) such as salbutamol (albuterol) and terbutaline are safe throughout pregnancy 2
• Inhaled corticosteroids like budesonide and beclomethasone are preferred due to extensive safety data, though other inhaled corticosteroids are also compatible with pregnancy 2

Antihypertensive Medications

• Methyldopa is considered a first-line option for hypertension during pregnancy 1
• Long-acting nifedipine is considered safe and effective during pregnancy 1
• Labetalol is a safe beta-blocker option during pregnancy 1
• Blood pressure target of 110-135/85 mmHg is recommended during pregnancy to reduce maternal hypertension risk while minimizing impaired fetal growth 3

Gastrointestinal Medications

• Mesalamine is recommended for inflammatory bowel disease during pregnancy 2
• Amoxicillin-clavulanic acid and metronidazole are recommended for GI infections during pregnancy 2

Antirheumatic Medications

• Conventional DMARDs that are safe during pregnancy include: 3
  • Hydroxychloroquine
  • Azathioprine (up to 2 mg/kg daily with normal thiopurine metabolism)
  • Cyclosporine and tacrolimus (at lowest effective dose)
  • Sulfasalazine (up to 2 g/day with daily folic acid supplementation)
  • Colchicine (1-2 mg/day)
• Ursodeoxycholic acid can be safely continued during pregnancy for primary biliary cholangitis 3

Medications to Avoid During Pregnancy

Cardiovascular Medications

• ACE inhibitors and angiotensin receptor blockers must be discontinued before conception or as soon as pregnancy is detected due to risk of fetal renal dysplasia, oligohydramnios, pulmonary hypoplasia, and intrauterine growth restriction 3, 1
• Atenolol is not recommended during pregnancy, though other beta-blockers may be used if necessary 3
• Statins should generally be avoided during pregnancy, though pravastatin may be considered in specific high-risk cases (e.g., familial hypercholesterolemia) after careful risk-benefit discussion 3
• Chronic diuretic use is generally not recommended during pregnancy as it may reduce uteroplacental perfusion 3

Pain Medications

• NSAIDs (including ibuprofen):
  • Should be restricted to the first and second trimester 3
  • Must be discontinued after gestational week 28 (end of second trimester) due to risk of premature closure of the fetal ductus arteriosus and oligohydramnios 3, 5
  • If needed in second trimester, prefer short-term use (7-10 days) of nonselective NSAIDs with short half-life like ibuprofen at lowest effective dose 3

Antirheumatic Medications

• Teratogenic medications that must be discontinued before conception: 3
  • Methotrexate (discontinue 1-3 months before conception)
  • Mycophenolate (discontinue 1.5 months before conception)
  • Cyclophosphamide (discontinue 3 months before conception)
• Obeticholic acid is not recommended during pregnancy or lactation due to lack of safety data 3

Special Considerations

Aspirin Use

• Low-dose aspirin (100-150 mg/day) is recommended starting at 12-16 weeks gestation for women with type 1 or type 2 diabetes to reduce preeclampsia risk 3
• Note that doses <100 mg are not effective in reducing preeclampsia risk 3

Medication Management

• Failing to continue necessary medications can pose greater risks to pregnancy outcomes than medication exposure in many cases 2
• For women with chronic conditions requiring medication, treatment plans should be established before conception when possible 2

Common Pitfalls to Avoid

• Never continuing ACE inhibitors or ARBs once pregnancy is planned or confirmed 1
• Avoiding NSAIDs after 28 weeks gestation due to fetal cardiac and renal risks 3, 5
• Recognizing that approximately 90% of pregnant women use medications during pregnancy, making medication safety knowledge essential 6
• Understanding that only about 10% of medications have sufficient safety data in pregnancy, requiring careful consideration of risks and benefits 7

By following these guidelines for medication use during pregnancy, healthcare providers can help ensure the safety of both mother and fetus while effectively managing medical conditions.