Is prednisone (corticosteroid) safe to use during pregnancy?

Is Prednisone Safe During Pregnancy?

Yes, prednisone is generally safe during pregnancy when used at appropriate doses to control active maternal disease, though it should be used at the lowest effective dose for the shortest duration necessary. 1, 2

Evidence-Based Safety Profile

Teratogenicity and Fetal Risk

• Prednisone and prednisolone are not associated with increased major birth defects and can be used during pregnancy when needed to control active disease 1
• The FDA classifies prednisone as Pregnancy Category C, noting that while animal studies show teratogenic effects (increased cleft palate in mice, rats, and rabbits), adequate human studies demonstrate clinical safety 3
• Multiple clinical experiences suggest no abnormalities in children of mothers treated with usual doses of prednisone throughout pregnancy 4, 5
• Prednisone is metabolized in the placenta by 11-beta-hydroxylase, providing some fetal protection, though high doses may still affect the fetus 1

Dose-Dependent Risk Stratification

Low-dose therapy (≤10 mg/day):

• Daily doses ≤5 mg prednisone are associated with low risk 2
• Low-dose prednisone (10-20 mg/day) is considered effective and safe for maternal use 1
• The American College of Rheumatology conditionally recommends continuing low-dose glucocorticoid treatment (≤10 mg daily) during pregnancy if clinically indicated 1

Higher-dose therapy (>5 mg/day):

• Doses >5 mg/day carry dose-related risks including gestational diabetes, pregnancy-associated osteoporosis, serious maternal infections, and preterm birth 2
• The American College of Rheumatology strongly recommends tapering higher doses to <20 mg daily, adding pregnancy-compatible glucocorticoid-sparing agents if necessary 1
• Women taking glucocorticoids should be screened for gestational diabetes mellitus 1

Clinical Management Algorithm

Prescribing Principles

• Start with the lowest effective dose (typically 10-20 mg/day) and adjust to maintain hemostatic control 1
• Avoid aggressive tapering in the last weeks before delivery, as thrombocytopenia may worsen 1
• Monitor closely for pregnancy-specific complications: hypertension, hyperglycemia, osteoporosis, excessive weight gain, and psychosis 1

Peripartum Considerations

• Women receiving oral steroids ≥7.5 mg daily for at least 2 weeks require stress-dose hydrocortisone intravenously during active labor and cesarean section to prevent maternal hypothalamic-pituitary-adrenal axis suppression 2
• Women taking >5 mg prednisolone daily for more than 3 weeks are at increased risk of adrenal suppression and require consideration of increased glucocorticoid dosing at delivery, and during intercurrent infection, vomiting, or hyperemesis gravidarum 1

Postpartum Management

• Monitor platelet count after delivery and taper corticosteroids slowly to avoid rapid decline and ensure maternal mental state stability 1
• Breastfeeding is safe, as clinically insignificant amounts of prednisone enter breast milk 5, 6

Important Caveats and Pitfalls

Maternal Monitoring Requirements

• Screen for gestational diabetes, particularly in women on glucocorticoid therapy 1
• Monitor blood pressure closely, as corticosteroids can exacerbate hypertension 1
• Increased surveillance for preeclampsia is warranted 1

Neonatal Considerations

• Infants born to mothers receiving substantial doses should be carefully observed for signs of hypoadrenalism 3
• Rare cases of transient fetal adrenal suppression have been reported, requiring nursery monitoring 5
• Premature rupture of amniotic membranes and low birthweight babies may occur 4

Alternative Considerations

• If corticosteroid therapy is ineffective or causes significant side effects, IVIg should be considered as an alternative 1
• Combining pregnancy-compatible immunosuppressive agents (azathioprine, hydroxychloroquine, cyclosporine, tacrolimus) may allow for glucocorticoid dose reduction 1, 6

Critical Distinction

• Prednisone and prednisolone are preferred over betamethasone and dexamethasone for maternal disease control, as the latter cross the placenta more readily and are reserved for fetal indications (lung maturation) 4