Safe Medications During Pregnancy
For most common conditions in pregnancy, well-established safe medications exist, and maintaining disease control is typically safer than withholding treatment. The key principle is that uncontrolled maternal disease often poses greater risks to both mother and fetus than appropriate medication use 1, 2.
Definitively Safe Medications
Respiratory Conditions
- Albuterol (salbutamol) is the preferred short-acting beta-agonist throughout all trimesters of pregnancy, with the most extensive safety data available 1, 2.
- Budesonide is the preferred inhaled corticosteroid due to reassuring data from over 52,000 first-trimester exposures showing no increased risk of congenital malformations 1, 2.
- Beclomethasone and fluticasone are also compatible alternatives, though budesonide has more pregnancy-specific data 2.
- Salmeterol is preferred over formoterol for long-acting beta-agonists due to greater clinical experience 2.
Rheumatologic and Autoimmune Conditions
- Hydroxychloroquine, azathioprine (up to 2 mg/kg/day), cyclosporine, tacrolimus, sulfasalazine (up to 2 g/day), and colchicine (1-2 mg/day) are all safe throughout pregnancy 1, 2.
- Prednisone and budesonide are considered low-risk corticosteroids for autoimmune hepatitis and other conditions 1.
- Sulfasalazine requires concomitant folic acid supplementation due to interference with folate absorption 1.
Gastrointestinal Conditions
- Mesalamine is safe for inflammatory bowel disease throughout pregnancy 2.
- Amoxicillin-clavulanic acid and metronidazole are recommended for GI infections 2.
- For cholestasis-related pruritus, ursodeoxycholic acid, cholestyramine, rifampin, or S-adenosyl-L-methionine may be used 1.
Pain and Fever Management
- Acetaminophen has an excellent safety profile and is the preferred analgesic/antipyretic 3, 4.
- NSAIDs (particularly ibuprofen) can be used short-term (7-10 days) in the first and second trimester only, but must be discontinued after gestational week 28 due to risks of oligohydramnios and premature ductus arteriosus closure 1.
Other Safe Medications
- Low-dose aspirin (100-162 mg/day) starting at 12-16 weeks gestation reduces preeclampsia risk 1.
- Chlorpheniramine is safe for allergies 3.
- Most antacids have good safety records 3.
- Folic acid supplementation is indicated and safe, particularly for megaloblastic anemia of pregnancy 5.
Absolutely Contraindicated Medications
Teratogenic Drugs Requiring Preconception Discontinuation
- Methotrexate (discontinue 1-3 months before conception), mycophenolate (discontinue 1.5 months before), and cyclophosphamide (discontinue 3 months before) are proven teratogens causing miscarriage and major birth defects 1, 2.
- Mycophenolate products carry FDA Risk Evaluation and Mitigation Strategies requirements due to high risk of congenital malformations and spontaneous abortions 1.
Cardiovascular Medications
- ACE inhibitors and angiotensin receptor blockers cause fetal renal dysplasia, oligohydramnios, pulmonary hypoplasia, and intrauterine growth restriction and must be stopped at conception 1, 2.
- Warfarin and vitamin K antagonists cause coumarin embryopathy and bleeding complications 2.
- Atenolol is not recommended, though other beta-blockers may be used if necessary 1.
Safe Antihypertensive Alternatives
- Methyldopa, nifedipine, labetalol, diltiazem, clonidine, and prazosin are effective and safe for blood pressure control in pregnancy 1.
- Target blood pressure should be 110-135/85 mmHg 1.
Other Contraindicated Medications
- Statins should be avoided throughout pregnancy 1.
- Chronic diuretic use is not recommended due to restricted maternal plasma volume 1.
Critical Caveats
Disease Control Priority
The most important principle is that failing to control maternal disease activity poses greater risks than appropriate medication exposure 1, 2. Discontinuing necessary medications can lead to disease flares that threaten both maternal and fetal health 1.
Antibiotic Considerations
- Penicillins, cephalosporins, and erythromycins have decades of safety data and are first-line choices 6.
- Aminoglycosides require careful serum level monitoring but can be used when necessary 6.
- Quinolones, sulfonamides (especially near term), and tetracyclines should be avoided unless maternal necessity justifies fetal exposure 6.
Monitoring Requirements
- Liver test monitoring during each trimester is suggested for autoimmune hepatitis, with more frequent monitoring (every 2-4 weeks) for the first 6 months postpartum 1.
- Vitamin K supplementation may be needed with cholestyramine use due to risk of hypoprothrombinemia 1.
- Cyclosporine and tacrolimus should be used at the lowest effective dose with trough level monitoring 1.