What medications are safe to take during pregnancy?

Medication Safety During Pregnancy

Most medications that control maternal disease are safer to continue during pregnancy than allowing the underlying condition to remain uncontrolled, which poses greater risks to both mother and fetus. 1

Safe Medications Throughout Pregnancy

Pain and Fever Management

• Acetaminophen (paracetamol) is the safest analgesic option across all trimesters and should be first-line for pain or fever, though use the lowest effective dose for the shortest duration necessary 1, 2
• Acetaminophen does not cause premature ductus arteriosus closure or oligohydramnios, unlike NSAIDs 2
• Limit use to less than 28 days when possible, as prolonged exposure (particularly in second/third trimesters) is associated with 20-30% increased risk of neurodevelopmental effects including ADHD and autism spectrum conditions 2

Respiratory Medications

• Albuterol (salbutamol) is the preferred short-acting beta-agonist throughout all trimesters with extensive safety data 1
• Budesonide is the preferred inhaled corticosteroid based on reassuring data from over 52,000 first-trimester exposures showing no increased malformation risk 1
• Beclomethasone and other inhaled corticosteroids are also compatible with 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
• Cyclosporine and tacrolimus should be used at the lowest effective dose with trough level monitoring 1

Gastrointestinal Medications

• Mesalamine, ursodeoxycholic acid, cholestyramine, rifampin, and S-adenosyl-L-methionine are safe options 1
• Histamine H2 blockers and proton pump inhibitors have not demonstrated significant fetal effects 3

Limited-Use Medications

• NSAIDs (particularly ibuprofen) can be used short-term (7-10 days maximum) ONLY during the second trimester (weeks 14-27) at the lowest effective dose 1, 2
• NSAIDs are strictly contraindicated in the first trimester and after gestational week 28 due to risks of oligohydramnios, premature ductus arteriosus closure, and increased risk of gastroschisis/small intestinal atresia 1, 2
• Low-dose aspirin (100-162 mg/day) starting at 12-16 weeks gestation reduces preeclampsia risk and is an exception to the NSAID restriction 1

Absolutely Contraindicated Medications

Teratogenic Medications - Discontinue Before Conception

• Methotrexate (discontinue 1-3 months before conception) - proven teratogen causing miscarriage and major birth defects 1
• Mycophenolate (discontinue 1.5 months before conception) - causes miscarriage and major birth defects 1
• Cyclophosphamide (discontinue 3 months before conception) - proven teratogen 1

Cardiovascular Medications

• ACE inhibitors and angiotensin receptor blockers (including valsartan) must be stopped at conception - cause fetal renal dysplasia, oligohydramnios, pulmonary hypoplasia, intrauterine growth restriction, and ossification disorders 4, 1
• Warfarin and other vitamin K antagonists - cause coumarin-embryopathy and bleeding complications 4, 1
• Statins should be avoided throughout pregnancy - harmlessness not proven and temporary interruption poses no disadvantage to mother 4, 1

Newer Immunomodulatory Agents

• Tofacitinib, filgotinib, upadacitinib, ozanimod, and etrasimod are contraindicated during conception, pregnancy, and lactation due to serious malformations found in animal studies 4

Other Contraindications

• Chronic diuretic use is not recommended due to restricted maternal plasma volume 1
• Oral decongestants combined with acetaminophen should be avoided in the first trimester due to increased risk of gastroschisis and small intestinal atresia 2

Advanced Therapies and Biologics

• Vedolizumab and ustekinumab continuation during pregnancy is not associated with adverse maternal or fetal outcomes and should be continued to minimize relapse risk 4
• When advanced therapy continues during pregnancy, postpone live vaccinations (including BCG) for the infant for the first 12 months 4
• Non-live vaccinations should follow the standard schedule 4
• Breast feeding while on biological therapy does not confer additional risk; vaccination decisions should be based on in utero exposure only 4

Critical Principles

Disease Control Priority

• Uncontrolled maternal disease often poses greater risks to both mother and fetus than appropriate medication use 1
• Discontinuing necessary medications can lead to disease flares with worse outcomes than medication exposure 1
• Failing to treat significant symptoms (especially fever or respiratory distress) may pose greater risks than appropriate medication use 5

Imaging Considerations

• Minimize radiation exposure and prefer ultrasound and MRI 4
• Avoid gadolinium as part of MR enterography during pregnancy 4

Postpartum Considerations

• Medicines that are low risk in pregnancy are also low risk in breastfeeding and should be continued 4
• Breast feeding is the preferred method and does not affect the course of inflammatory bowel disease 4
• Insulin requirements drop dramatically after delivery and need immediate reassessment 1

Common Pitfalls to Avoid

• Do not rely solely on pharmaceutical manufacturer instructions, which are often overly cautious due to legal concerns rather than evidence-based risk 4
• Do not discontinue effective disease-controlling medications without weighing the risk of disease flare against theoretical medication risks 1
• Do not use NSAIDs after 28 weeks under any circumstances 1, 2
• Do not assume all medications in the same class have equal safety profiles - specific agents within classes have more pregnancy data (e.g., budesonide over other inhaled corticosteroids) 1