Is Vistaril (hydroxyzine) safe to use during the 3rd trimester of pregnancy?

Hydroxyzine (Vistaril) Should Be Avoided During the Third Trimester of Pregnancy

Hydroxyzine is not recommended for use during the third trimester of pregnancy due to inadequate human safety data, risk of neonatal withdrawal syndrome, and availability of safer alternatives. 1

Evidence-Based Contraindications

The American Academy of Allergy, Asthma, and Immunology explicitly recommends against hydroxyzine use throughout pregnancy, including the third trimester, citing insufficient human safety data and potential fetal risks. 1 This represents the most current and authoritative guidance on this specific medication.

Neonatal Withdrawal Risks

A critical concern with third-trimester hydroxyzine exposure is neonatal withdrawal syndrome. 1 Infants exposed to hydroxyzine near delivery can develop:

• Irritability 1
• Tremors 1
• Other withdrawal symptoms requiring neonatal monitoring 1

This risk is particularly relevant in the third trimester when the medication is used close to delivery, as the neonate must metabolize and clear the drug after birth without continued maternal support.

Safer Alternative Medications

For Nausea and Vomiting

If hydroxyzine was being considered for pregnancy-related nausea:

• Metoclopramide is recommended as a safer first-line option 1
• Ondansetron is also considered safer than hydroxyzine 1

For Allergic Conditions

If hydroxyzine was being used for allergies or pruritus:

• Cetirizine (Category B) has a better safety profile in pregnancy 1
• Loratadine (Category B) is also preferred over hydroxyzine 1

These second-generation antihistamines have more robust safety data and are specifically recommended by the American Academy of Allergy, Asthma, and Immunology as alternatives to hydroxyzine during pregnancy. 1

Clinical Decision Algorithm

When a pregnant patient in the third trimester needs symptom control:

1. Identify the indication - Is hydroxyzine being used for nausea, anxiety, allergies, or pruritus? 1

2. Switch to safer alternatives immediately:

   • For nausea: Use metoclopramide or ondansetron 1
   • For allergies/pruritus: Use cetirizine or loratadine 1

3. If hydroxyzine has already been used: Counsel the patient about neonatal withdrawal risks and ensure pediatric team is aware for appropriate neonatal monitoring at delivery 1

Critical Pitfalls to Avoid

Do not assume hydroxyzine is safe simply because it is commonly prescribed for nausea or anxiety in non-pregnant patients. The lack of adequate human safety data and documented neonatal withdrawal syndrome make it inappropriate for third-trimester use when safer alternatives exist. 1

Do not continue hydroxyzine "because the patient is already on it." The third trimester represents the highest risk period for neonatal withdrawal, making medication switching particularly important even late in pregnancy. 1