What medications are safe for pregnant women?

Safe Medications for Pregnant Women

Pregnant women can safely use several medications including hydroxychloroquine, azathioprine, cyclosporine, tacrolimus, sulfasalazine, colchicine, acetaminophen, and certain inhaled respiratory medications, while methotrexate, mycophenolate, cyclophosphamide, ACE inhibitors, and angiotensin receptor blockers are absolutely contraindicated. 1, 2, 3

Core Principle: Untreated Disease Often Poses Greater Risk

The risk of untreated maternal disease to both mother and fetus typically outweighs the risk of appropriate medication use during pregnancy. 1, 3 This fundamental principle should guide all treatment decisions, as active maternal disease is associated with adverse pregnancy outcomes including preterm birth, growth restriction, and fetal compromise. 1

Safe Medications by Category

Antirheumatic and Immunosuppressive Drugs

Compatible medications that can be continued throughout pregnancy include: 1, 3

• Hydroxychloroquine/chloroquine - Should be continued if already taking; strongly recommended for SLE patients 1
• Azathioprine - Safe up to 2 mg/kg/day in women with normal thiopurine metabolism 1, 2
• Cyclosporine and tacrolimus - Use at lowest effective dose with trough level monitoring 1, 3
• Sulfasalazine - Up to 2 g/day, but requires concomitant folic acid supplementation due to folate absorption interference 1, 2, 3
• Colchicine - 1-2 mg/day is compatible 1, 2
• Prednisone/prednisolone - Not associated with increased major birth defects; taper to ≤5 mg/day when possible 2

Pain and Fever Management

Acetaminophen (paracetamol) is the first-line analgesic and antipyretic during pregnancy, used by 40-65% of pregnant women. 2 However, recent evidence suggests using the lowest effective dose for the shortest possible time, only when medically indicated. 4

NSAIDs require careful timing: 1, 2, 3

• Can be used short-term (7-10 days) in first and second trimester only
• Prefer nonselective NSAIDs with short half-life (e.g., ibuprofen) at lowest effective dose
• Must be discontinued after gestational week 28 due to risks of oligohydramnios and premature ductus arteriosus closure 1, 2, 3

Low-dose aspirin (81-100 mg daily) starting in first trimester is recommended for SLE patients and those at high risk for preeclampsia. 1

Respiratory Medications

For asthma and respiratory symptoms: 2, 3

• Albuterol (salbutamol) - Preferred short-acting beta-agonist with most extensive safety data 2, 3
• Budesonide - Preferred inhaled corticosteroid with reassuring data from over 52,000 first-trimester exposures 2, 3
• Beclomethasone - Also has extensive safety data 2, 3
• Treating respiratory distress is safer than leaving it untreated, as maternal hypoxia compromises fetal oxygen supply 2

Cold and Allergy Symptoms

For first trimester cold symptoms: 2

• Acetaminophen for fever/pain
• Saline nasal sprays for congestion
• Short-acting beta-agonists if respiratory symptoms develop

Chlorpheniramine has a good safety record for antihistamine needs. 5

Gastrointestinal Medications

Most antacids have excellent safety profiles. 5

Metoclopramide can be used but requires caution - it should be used during pregnancy "only if clearly needed" per FDA labeling, as animal studies show no harm but human data is limited. 6

HIV Postexposure Prophylaxis

Pregnancy is not a contraindication for antiretroviral postexposure prophylaxis (nPEP). 1 Pregnant women should have rapid access to nPEP when indicated, though expert consultation is beneficial. 1 Drugs not recommended include cobicistat-boosted atazanavir, darunavir, and elvitegravir due to lack of safety data or inferior efficacy. 1

Absolutely Contraindicated Medications

These medications are proven teratogens and must be avoided: 1, 2, 3

Discontinue Before Conception:

• Methotrexate - Stop 1-3 months before conception; causes miscarriage and major birth defects 1, 3
• Mycophenolate - Stop 1.5 months before conception 1, 3
• Cyclophosphamide - Stop 3 months before conception 1, 3

Stop Immediately Upon Pregnancy Recognition:

• ACE inhibitors and angiotensin receptor blockers - Cause fetal renal dysplasia, oligohydramnios, pulmonary hypoplasia, and growth restriction 1, 2, 3
• Statins - Should be avoided throughout pregnancy 1, 3
• Warfarin and vitamin K antagonists - Risk of coumarin-embryopathy and bleeding, though pregnancy doesn't need termination if exposed; close follow-up required 1, 3

Special Clinical Situations

Systemic Lupus Erythematosus (SLE)

All SLE patients should: 1

• Take hydroxychloroquine during pregnancy if possible (strongly recommended to continue if already taking)
• Receive low-dose aspirin (81-100 mg daily) starting in first trimester
• Have antiphospholipid antibodies tested once before or early in pregnancy (do not repeat during pregnancy)
• Undergo disease activity monitoring at least once per trimester with clinical exam and labs

Scleroderma Renal Crisis

This represents a critical exception to standard pregnancy medication rules. Despite being contraindicated in pregnancy, ACE inhibitors or angiotensin receptor blockers should be used for active scleroderma renal crisis in pregnancy because the risk of maternal or fetal death with untreated disease exceeds medication risks. 1 This rare condition (2% of scleroderma pregnancies) can be confused with preeclampsia. 1

Breastfeeding Considerations

Women should not be discouraged from breastfeeding while taking compatible medications. 1 Breastfeeding provides protection against infectious morbidity, inflammatory bowel disease, obesity, diabetes, and childhood cancers for infants, while reducing maternal risks of diabetes, hypertension, and multiple cancers. 1 Most pregnancy-compatible medications are also compatible with breastfeeding. 3

Critical Counseling Points

Shared decision-making is essential - treatment choices should involve comprehensive discussion between healthcare providers and patients about risks and benefits. 1

Conception timing matters - for women with rheumatic or autoimmune diseases, pregnancy should be postponed until optimal disease control is achieved with pregnancy-compatible medications. 1

The 10% rule - an estimated 10% or more of birth defects result from maternal drug exposure, but congenital abnormalities from teratogenic drugs account for less than 1% of total congenital abnormalities. 5, 7 This context helps balance appropriate concern with unnecessary medication avoidance.

Pharmacokinetic changes in pregnancy may require dose adjustments or more frequent dosing for certain medications, particularly antiretrovirals. 1