What medications are safe to take during pregnancy?

Safe Medications During Pregnancy

Most medications commonly needed during pregnancy have well-established safety profiles, and uncontrolled maternal disease typically poses greater risks to both mother and fetus than appropriate medication use. 1

Safe Medications by Category

Pain and Fever Management

• Acetaminophen (paracetamol) is the safest first-line analgesic and antipyretic throughout all trimesters, used by 40-65% of pregnant women with extensive safety data. 1, 2, 3
• NSAIDs (ibuprofen, diclofenac) can be used short-term (7-10 days maximum) in the first and second trimester only at the lowest effective dose, but must be completely discontinued after gestational week 28 due to risks of oligohydramnios and premature ductus arteriosus closure. 1, 2
• Opioid analgesics can be used beyond the first trimester when necessary, though fetal respiratory depression risk exists. 4

Respiratory Medications

• Albuterol (salbutamol) is the preferred short-acting beta-agonist throughout all trimesters 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
• Beclomethasone and other inhaled corticosteroids are also compatible with pregnancy. 1
• Salmeterol is preferred over formoterol for long-acting beta-agonists due to greater pregnancy experience. 1

Gastrointestinal Medications

• Ondansetron, metoclopramide, and meclozine are safe antiemetics, though corticosteroids should be omitted in the first trimester. 4
• Histamine H2 blockers and proton pump inhibitors have not demonstrated significant fetal effects and are considered safe. 3
• Mesalamine is recommended for inflammatory bowel disease during pregnancy. 1

Rheumatologic and Immunosuppressive Medications

• 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
• Sulfasalazine requires concomitant folic acid supplementation due to interference with folate absorption. 1
• Prednisone and prednisolone are not associated with increased major birth defects and can be used when needed to control active disease, though should be tapered to ≤5 mg/day when possible and avoided in the first trimester due to increased cleft palate risk. 4, 2
• Cyclosporine and tacrolimus should be used at the lowest effective dose with trough level monitoring. 1

Cholestatic Liver Disease

• Ursodeoxycholic acid (UDCA) can be administered during the second or third trimesters when pregnant women are symptomatic, with no adverse effects observed in mothers or newborns. 4, 1
• Cholestyramine, rifampin, or S-adenosyl-L-methionine may be used for cholestasis-related pruritus. 1
• Vitamin K supplementation may be needed with cholestyramine use due to risk of hypoprothrombinemia. 4

Cardiovascular Medications

• Low-dose aspirin (100-162 mg/day) starting at 12-16 weeks gestation reduces preeclampsia risk. 1
• Labetalol is used for hypertension during pregnancy and does not appear to affect the usual course of labor and delivery, though hypotension, bradycardia, hypoglycemia, and respiratory depression have been reported in infants. 5

Antibiotics

• Ampicillin is safe for bacterial cholangitis. 4
• Amoxicillin-clavulanic acid and metronidazole are recommended for GI infections during pregnancy. 1

Other Safe Medications

• Topical emollients and creams are considered safe based on small studies. 4, 3
• Ginger is considered safe and effective for treating nausea in pregnancy. 3
• Saline nasal sprays are safe for congestion throughout pregnancy. 2

Absolutely Contraindicated Medications

Teratogenic Immunosuppressants

• 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
• Older-generation alkylators (thiotepa, busulfan, chlorambucil, nitrogen mustard) and antimetabolites (aminopterin, methotrexate) have the most pronounced teratogenic and abortive potential. 4

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
• Warfarin and other vitamin K antagonists cause coumarin-embryopathy and bleeding. 1
• Statins should be avoided throughout pregnancy. 1
• Chronic diuretic use is not recommended due to restricted maternal plasma volume. 1

Oncology Medications

• Targeted agents modulating angiogenesis (bevacizumab, sunitinib, sorafenib) should be avoided due to lack of data and past experience with thalidomide. 4
• Imatinib was occasionally associated with low birth weight, premature delivery, and rare cases of hypospadias and meningocele. 4
• Biphosphonates, tamoxifen, and aromatase inhibitors should be deferred after delivery. 4

Critical Timing Considerations

First Trimester (Organogenesis Period)

• Pregnancy termination is advised if chemotherapy or radiotherapy is required during the first trimester. 4
• Corticosteroids should be omitted as antiemetics in the first trimester due to increased cleft palate risk. 4
• MRI scans should be done sparingly in the first trimester, and gadolinium should not be administered due to potential teratogenicity. 4

Second and Third Trimesters

• Chemotherapy can be administered during the second and third trimesters with reasonable safety, though there is increased risk of stillbirth, growth retardation, and premature delivery. 4
• Anthracyclines, 5-fluorouracil, cytarabine, and vinca alkaloids have the least teratogenic potential among chemotherapy agents. 4
• Taxanes and platinum compounds are relatively safe to administer beyond the first gestational trimester based on emerging evidence. 4

After 28 Weeks Gestation

• NSAIDs must be completely discontinued after gestational week 28 to prevent oligohydramnios and premature ductus arteriosus closure. 1, 2

Important Clinical Principles

Disease Control Priority

• Failing to treat maternal disease often poses greater risks to pregnancy outcomes than appropriate medication use. 1, 2
• Untreated severe symptoms, particularly high fever or respiratory distress, can potentially pose more risk to both mother and fetus than judicious use of appropriate medications. 2
• Discontinuing necessary medications can lead to disease flares with worse outcomes. 1

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
• Delivery should take place after weeks 32-35, at least 3 weeks after the last chemotherapy cycle. 4

Postpartum Considerations

• Breastfeeding is not contraindicated with most pregnancy-compatible medications. 1
• Breastfeeding should be avoided during chemotherapy, and placental histological examination should occur after delivery. 4
• Small amounts of labetalol (approximately 0.004% of maternal dose) are excreted in human milk, requiring caution. 5
• Azathioprine excretion in breast milk is minimal, but breastfeeding should be discussed individually. 4

Common Pitfalls to Avoid

• Do not rely on FDA pregnancy categories alone, as most data come from case-control and cohort studies rather than randomized controlled trials. 3
• Avoid unnecessary diagnostic radiation exposure; use chest X-ray and mammography with abdominal shielding, and ultrasound as cornerstones of staging. 4
• Be aware that labetalol metabolites can cause falsely elevated urinary catecholamines and false-positive amphetamine screens. 5
• Recognize that pregnant women often avoid medications due to exaggerated teratogenic risk perceptions, leading to inadequate treatment. 6