What over-the-counter (OTC) medications are safe for pregnant women to use for cough, congestion, and upper respiratory infections?

Safe OTC Medications for Cough, Congestion, and Upper Respiratory Infections During Pregnancy

For pregnant women with cold symptoms, saline nasal rinses and acetaminophen are the safest first-line treatments, while oral decongestants should be avoided entirely and first-generation antihistamines should not be used. 1

First-Line Safe Treatments

Non-Pharmacological (Safest Option)

• Saline nasal rinses are the safest and most effective treatment for nasal congestion and should be recommended first 2, 1
• No systemic absorption means zero fetal risk
• Can be used as frequently as needed throughout all trimesters

Acetaminophen for Pain and Fever

• Acetaminophen is the preferred medication for pain and fever control during pregnancy 1
• Use at the lowest effective dose for the shortest possible time 3, 4
• Should only be used when medically indicated, not routinely 3
• Recent evidence suggests potential neurodevelopmental risks with prolonged use, but it remains the safest analgesic/antipyretic option when needed 3, 4, 5
• Critical caveat: High fever itself poses greater risk to the fetus than acetaminophen treatment 4

For Persistent Nasal Symptoms

• Intranasal corticosteroid sprays (budesonide preferred) are safe for persistent congestion 2, 1
• Budesonide has the most reassuring pregnancy safety data among intranasal steroids 2
• Minimal systemic absorption makes this safer than oral medications

Second-Line Treatments (Use with Caution)

For Cough

• Albuterol is the preferred treatment if cough is asthma-related (wheezing, chest tightness, shortness of breath) 2, 6

• Extensive safety data with no evidence of fetal injury 2, 6

• Dose: 2-4 puffs via MDI every 4-6 hours as needed 6

• Ipratropium bromide for non-asthmatic cough (post-viral, dry cough) 6

• The only recommended inhaled anticholinergic in pregnancy 6

• Dose: 4-8 puffs MDI as needed 6

• Dextromethorphan has limited pregnancy data and should be used cautiously 7

• No strong recommendation for or against use in available guidelines

For Allergic Symptoms

• Second-generation antihistamines (cetirizine or loratadine) can be considered if allergic component is present 1
• Use only when symptoms significantly impact quality of life
• Avoid first-generation antihistamines (diphenhydramine, chlorpheniramine) due to sedative and anticholinergic effects 2, 1

Short-Term Nasal Decongestants

• Topical nasal decongestants (oxymetazoline, phenylephrine spray) may be used for maximum 3 days if severe congestion 1
• Risk of rebound congestion limits utility 1
• Still safer than oral decongestants

Medications to AVOID During Pregnancy

Absolutely Contraindicated

• Oral decongestants (pseudoephedrine, phenylephrine) should NOT be used, especially in first trimester 2, 1

• Associated with fetal gastroschisis and maternal hypertension 2

• No role in treating upper respiratory infections 2

• First-generation antihistamines should be avoided 2, 1

• Sedative and anticholinergic properties pose unnecessary risks 2

• Aspirin and NSAIDs (ibuprofen, naproxen) are contraindicated 2, 1

• Aspirin is FDA Category D 2, 1

• NSAIDs increase risk of fetal complications, especially after 32 weeks

• Trimethoprim-sulfamethoxazole should not be used in pregnant women 2

• Risk of kernicterus 2

When Antibiotics Are Needed

Antibiotics are NOT indicated for viral upper respiratory infections 6

If Bacterial Infection Confirmed (purulent sinusitis, bacterial pharyngitis)

• Penicillins and cephalosporins are the safest antibiotic classes 2, 1
• Use only when endoscopic evidence of purulence or confirmed bacterial infection 2
• Avoid: tetracyclines, aminoglycosides, fluoroquinolones 2

Critical Clinical Principles

The Most Important Rule

Inadequately controlled respiratory symptoms pose GREATER risk to the fetus than the medications used to treat them 6

• Maternal hypoxia from severe symptoms is more dangerous than appropriate medication use 2
• Never withhold necessary respiratory medications due to pregnancy concerns 6

Common Pitfalls to Avoid

1. Withholding all medications out of excessive caution - this is the most dangerous error 6
2. Using oral decongestants "just this once" - even single use in first trimester carries risk 2
3. Assuming all cough is benign - evaluate for asthma, bacterial infection, or other serious causes if persistent 6
4. Prescribing antibiotics for viral symptoms - no benefit and potential harm 6

When to Escalate Care

Immediate evaluation needed if: 6

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

Practical Treatment Algorithm

Step 1: Start with saline nasal rinses for all patients 2, 1

Step 2: Add acetaminophen ONLY if fever >100.4°F or significant pain, using lowest dose for shortest time 1, 3, 4

Step 3: For persistent nasal congestion after 3-5 days, add intranasal budesonide 2, 1

Step 4: For cough, determine if asthma-related:

• If yes (wheezing, chest tightness): albuterol 2, 6
• If no (post-viral dry cough): ipratropium bromide 6

Step 5: Consider second-generation antihistamine ONLY if clear allergic component 1

Never use: Oral decongestants, first-generation antihistamines, NSAIDs, or antibiotics for viral illness 2, 1, 6