Hydrocortisone Safety in Pregnancy
Hydrocortisone is safe to use during pregnancy when medically indicated, with no additional risk to mother or fetus beyond the risks present in non-pregnant patients. 1
Safety Profile and Evidence Base
Glucocorticoids during pregnancy, including hydrocortisone, carry no additional risk for mother and child according to EULAR evidence-based recommendations. 1 The spectrum of adverse effects in pregnant patients does not differ from non-pregnant patients, though pregnant women may have baseline increased risk for conditions like osteoporosis, diabetes, and hypertension that overlap with corticosteroid side effects. 1
Fetal Safety Considerations
Hydrocortisone, prednisolone, and methylprednisolone are preferred over dexamethasone during pregnancy because they are extensively metabolized by the placenta, resulting in only 10% of the maternal dose reaching the fetus. 1
There is no evidence that prednisone, prednisolone, or hydrocortisone are teratogenic in humans (FDA risk category B). 1
High doses of corticosteroids have been associated with low birth weight in humans, and animal models have shown cleft palate, but standard therapeutic doses have not demonstrated these effects. 1
Clinical experience with usual doses of prednisone and methylprednisolone throughout pregnancy shows no abnormalities in children, though premature rupture of membranes and low birthweight may occur. 2
Specific Clinical Scenarios
Adrenal Insufficiency Management
Patients with primary adrenal insufficiency may require small dose adjustments during pregnancy, particularly in the last trimester. 1
During delivery, 100 mg hydrocortisone should be administered intravenously at the onset of active labor (contractions every 5 minutes or cervical dilation >4 cm), followed by either continuous infusion of 200 mg/24 hours or 50 mg intramuscularly every 6 hours. 1
After uncomplicated delivery, rapid tapering over 1-3 days to the regular replacement dose is appropriate. 1
Surgical Procedures During Pregnancy
- All patients on glucocorticoid therapy for longer than 1 month who undergo surgery need perioperative management with adequate hydrocortisone replacement (100 mg IV before anesthesia and every 8 hours for 4 doses after major surgery). 1
Topical Hydrocortisone Use
- In a prospective study of 204 patients treated with hydrocortisone foam for hemorrhoids in the third trimester, no adverse events were observed compared with placebo. 1
Critical Warnings and Monitoring
Neonatal Considerations
Infants born to mothers who received substantial doses of corticosteroids during pregnancy should be carefully observed for signs of hypoadrenalism. 3
Life-threatening adrenal suppression requiring hydrocortisone supplementation has been documented in newborns whose mothers received high-dose methylprednisolone in late pregnancy. 4
Dosing During Pregnancy
The FDA label states that adequate human reproduction studies have not been done with corticosteroids, requiring that possible benefits be weighed against potential hazards to mother and fetus. 3
Use the lowest dose compatible with maternal health and well-being. 1
Breastfeeding Compatibility
Hydrocortisone is excreted minimally into breast milk, and breastfeeding by women on low-dose therapy is generally considered safe. 1
Infant exposure can be minimized by avoiding breastfeeding during the first 4 hours after hydrocortisone intake, when equilibrium between milk and serum concentrations is highest. 1
With prolonged treatment at high maternal doses, delaying breastfeeding for 3-4 hours after the dose minimizes transfer to breast milk. 1
Common Pitfalls to Avoid
Do not discontinue necessary hydrocortisone therapy due to pregnancy concerns—the risk of uncontrolled maternal disease typically exceeds any theoretical fetal risk. 1
Do not use dexamethasone or betamethasone for maternal conditions, as these cross the placenta more readily and are intended for fetal treatment. 1
Do not forget stress-dose coverage during labor and delivery in patients on chronic corticosteroid therapy, as this can precipitate adrenal crisis. 1
Do not assume all patients with adrenal insufficiency are adequately educated about sick day rules and stress dosing—verify competency before discharge. 1