What are the safest cough and cold medications for pregnant women?

Best Cough and Cold Medicines for Pregnant Women

For pregnant women with cough and cold symptoms, saline nasal rinses are the safest first-line treatment, followed by acetaminophen for fever/pain, and inhaled albuterol for cough related to bronchospasm—while oral decongestants (pseudoephedrine, phenylephrine) and first-generation antihistamines should be avoided entirely. 1

First-Line Safe Treatments

Nasal Congestion

• Saline nasal rinses are the safest and most effective treatment for nasal congestion in pregnancy, with zero systemic absorption and no fetal risk 1
• Intranasal corticosteroid sprays (budesonide preferred) are safe for persistent congestion with minimal systemic absorption 1
• Budesonide has the most safety data during pregnancy and is classified as Category A by the Australian TGA 2

Fever and Pain

• Acetaminophen is the preferred medication for pain and fever control during pregnancy 1
• Use at the lowest effective dose for the shortest possible time 1, 3
• While acetaminophen is considered safest, emerging data suggest potential associations with neurodevelopmental outcomes, so use only when needed with no safer alternative available 3

Cough

• Albuterol (salbutamol) is the preferred treatment for asthma-related or bronchospasm-related cough in pregnancy, with extensive safety data from over 6,667 pregnant women showing no increased risk of structural anomalies 4, 1
• Albuterol is classified as Category A by the Australian TGA, indicating compatibility during pregnancy 4
• For acute symptoms: 2-4 puffs via metered-dose inhaler as needed 4
• Ipratropium bromide may be used for non-asthmatic cough as the only recommended inhaled anticholinergic in pregnancy 1

Second-Line Treatments (Use With Caution)

Cough Suppressants

• Dextromethorphan can be considered for persistent cough, with human studies showing no increased rate of major malformations above baseline (2.3% vs 2.8% in controls) 5
• FDA labeling advises asking a health professional before use if pregnant 6
• Use only when necessary and for shortest duration 6

Expectorants

• Guaifenesin has limited pregnancy data but FDA labeling advises consulting a health professional before use if pregnant 7
• Should be reserved for cough with excessive mucus production 7

Antihistamines

• Second-generation antihistamines (cetirizine, loratadine) can be considered for allergic symptoms only when symptoms significantly impact quality of life 1
• These are preferred over first-generation antihistamines due to less sedation and anticholinergic effects 1

Medications to AVOID

Oral Decongestants

• Pseudoephedrine and phenylephrine are contraindicated, especially in the first trimester, due to risk of fetal gastroschisis and maternal hypertension 1
• Despite widespread use (15% of pregnant women use pseudoephedrine), these pose significant risks 8

First-Generation Antihistamines

• Diphenhydramine and chlorpheniramine should be avoided due to sedative and anticholinergic effects 1
• Use has appropriately decreased over time as safer alternatives became available 8

NSAIDs

• Aspirin, ibuprofen, and naproxen are contraindicated, especially after 32 weeks gestation, due to risk of fetal complications 1
• Despite this, 18% of pregnant women still use ibuprofen 8

Critical Clinical Principles

Risk-Benefit Balance

• Inadequately controlled respiratory symptoms pose a greater risk to the fetus than appropriate medication use 1
• Maternal hypoxia from severe symptoms is more dangerous than the medications used to treat them 1
• Uncontrolled respiratory disease increases risk of perinatal mortality, preeclampsia, preterm birth, and low birth weight 4

When to Escalate Care

• If albuterol is needed more than twice weekly, this signals inadequate control requiring controller therapy (inhaled corticosteroids, preferably budesonide) 4
• Cough lasting more than 7 days requires evaluation for asthma, bacterial infection, or other serious causes 1, 7, 6
• Never withhold necessary respiratory medications due to pregnancy concerns 1

Common Pitfalls to Avoid

• Do not recommend combination OTC products that contain multiple unnecessary ingredients, including alcohol, which is present in many liquid formulations 9
• Do not use influenza antivirals (amantadine, rimantadine, zanamivir, oseltamivir) without clear indication, as these should only be used if potential benefit justifies potential risk to the fetus 2
• Do not assume all "natural" remedies are safe—stick to evidence-based treatments with known safety profiles 1
• Approximately 5% of persons of European ethnicity lack the ability to metabolize dextromethorphan normally, leading to rapid toxic levels 10