What cough medications are safe to use during pregnancy?

Safe Cough Medications in Pregnancy

For pregnant women with cough, use albuterol for asthma-related symptoms and ipratropium bromide for non-asthmatic cough suppression—these are the only recommended inhaled medications with adequate safety data, and withholding necessary treatment poses greater risk to the fetus than the medications themselves. 1

Determine the Cause First

The approach depends on identifying whether the cough is asthma-related or non-asthmatic:

• Asthma-related cough presents with wheezing, shortness of breath, chest tightness, or a history of asthma 1
• Non-asthmatic cough includes post-infectious cough following upper respiratory infection or other causes without bronchospasm 1

For Asthma-Related Cough

Albuterol is the preferred and safest option:

• Albuterol has extensive safety data in pregnancy with no evidence of fetal injury 2, 1
• Dosing: 2-4 puffs via MDI every 4-6 hours as needed 1
• If daily controller medication is needed, budesonide is the preferred inhaled corticosteroid due to reassuring pregnancy safety data 2, 1
• Budesonide is FDA Pregnancy Category B, and large birth registry data support its safety 2

For Non-Asthmatic Cough

Ipratropium bromide is the only recommended inhaled anticholinergic:

• This is specifically recommended for cough suppression in pregnancy 1
• It has demonstrated efficacy in controlled trials for post-infectious cough 1
• Dosing options: MDI 4-8 puffs as needed, OR nebulizer 0.25 mg every 20 minutes for 3 doses, then every 2-4 hours as needed 1

Over-the-Counter Cough Medications

Dextromethorphan can be used cautiously:

• Multiple controlled studies show no increased risk of major malformations above the baseline 1-3% rate 3, 4
• A study of 128 first-trimester exposures found a 2.3% major malformation rate, comparable to controls at 2.8% 3
• Despite earlier concerns from animal studies, epidemiologic data in humans do not support teratogenic risk 4
• The FDA label advises consulting a healthcare professional before use in pregnancy 5

Guaifenesin (expectorant):

• The FDA label recommends asking a healthcare professional before use if pregnant or breastfeeding 5
• Limited but reassuring data suggest no increased risk with short-term use 6

Critical Safety Principles

The most important principle: Inadequate control of respiratory symptoms poses greater risk to the fetus than the medications used to treat them 1

Avoid these medications:

• Oral decongestants should be avoided, especially in the first trimester, due to potential associations with cardiac, ear, gut, and limb abnormalities 1
• Antibiotics have no role in treating post-infectious cough unless bacterial sinusitis or confirmed pertussis is present 1
• For pertussis specifically, azithromycin is FDA Pregnancy Category B and preferred over erythromycin 2
• TMP-SMZ is contraindicated in pregnancy due to kernicterus risk 2

Common Pitfalls to Avoid

• Never withhold necessary respiratory medications due to pregnancy concerns—this is the most dangerous error and harms both mother and fetus more than the treatments 1
• Do not assume all cough is benign; consider alternative diagnoses if symptoms persist beyond 8 weeks 1
• Do not use antibiotics empirically for viral post-infectious cough 1

When to Seek Immediate Evaluation

Refer for urgent assessment if the patient has:

• Coughing up blood
• Significant breathlessness
• Prolonged fever with systemic illness
• Symptoms persisting beyond 3 weeks without improvement 1

Non-Pharmacological Support

• Maintain adequate hydration and nutrition throughout pregnancy to support immune function 1