What medications are safe for pregnant women?

Safe Medications During Pregnancy

Most medications used for common conditions during pregnancy are safe when appropriately selected, with acetaminophen, inhaled respiratory medications (albuterol and budesonide), certain immunosuppressants, and specific antibiotics having the most robust safety data across all trimesters. 1

General Principle

• Uncontrolled maternal disease poses greater risks to both mother and fetus than appropriate medication use, making treatment of active conditions essential rather than optional 1
• Discontinuing necessary medications can lead to disease flares that compromise pregnancy outcomes more than the medications themselves 1

Safe Medications by Category

Pain and Fever Management

• Acetaminophen (paracetamol) is the safest analgesic and antipyretic throughout all trimesters, used by 40-65% of pregnant women 2, 3
• NSAIDs (particularly ibuprofen) can be used short-term (7-10 days maximum) in the first and second trimester only at the lowest effective dose 1, 2
• NSAIDs must be completely discontinued after gestational week 28 due to risks of oligohydramnios and premature ductus arteriosus closure 1, 2
• Low-dose aspirin (100-162 mg/day) starting at 12-16 weeks gestation is safe and reduces preeclampsia risk 1

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 fluticasone are also compatible with pregnancy, though budesonide has more safety data 1
• Salmeterol is preferred over formoterol for long-acting beta-agonists due to greater pregnancy experience 1
• Terbutaline is also considered safe throughout pregnancy 1

Gastrointestinal Medications

• Calcium-based antacids are particularly safe during the first trimester due to minimal systemic absorption 4
• Histamine H2 blockers and proton pump inhibitors have not demonstrated significant fetal effects 3
• Mesalamine is safe for inflammatory bowel disease during pregnancy 1
• Ursodeoxycholic acid, cholestyramine, rifampin, or S-adenosyl-L-methionine may be used for cholestasis-related pruritus 1
• Ondansetron, metoclopramide, and meclozine are safe antiemetics in the first trimester 4

Antibiotics

• Beta-lactams, vancomycin, nitrofurantoin, metronidazole, clindamycin, and fosfomycin are generally considered safe and effective 5
• Amoxicillin-clavulanic acid and metronidazole are safe for GI infections 1
• Fluoroquinolones and tetracyclines should be avoided, though ciprofloxacin has the best safety profile among second-line tuberculosis drugs 6, 5
• Streptomycin must not be used as approximately 1 in 6 babies will have hearing and/or balance problems 6

Immunosuppressants and DMARDs

• 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
• Cyclosporine and tacrolimus should be used at the lowest effective dose with trough level monitoring 1
• Prednisone and prednisolone are not associated with increased major birth defects and should be tapered to ≤5 mg/day when possible 2

Tuberculosis Treatment

• All four first-line tuberculosis drugs (isoniazid, rifampin, ethambutol, and pyrazinamide) have excellent safety records and are not associated with human fetal malformations 6
• Pyridoxine (vitamin B6) should be added to tuberculosis treatment in all pregnant women taking isoniazid 6

Absolutely Contraindicated Medications

• 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
• ACE inhibitors and angiotensin receptor blockers must be stopped at conception due to fetal renal dysplasia, oligohydramnios, pulmonary hypoplasia, and intrauterine growth restriction 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

Critical Monitoring Considerations

• 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
• Insulin requirements drop dramatically after delivery and need immediate reassessment 1
• Ensure adequate fluid intake when using any antacid 4

Breastfeeding Compatibility

• Breastfeeding is not contraindicated with most pregnancy-compatible medications 1