Is prednisone (corticosteroid) safe to use during pregnancy?

Is Prednisone Safe in Pregnancy?

Yes, prednisone is considered low risk and safe to use during pregnancy when clinically indicated, with the lowest effective dose recommended to control maternal disease. 1, 2

Evidence-Based Safety Profile

Prednisone and prednisolone are not associated with increased major birth defects and can be used during pregnancy when needed to control active disease. 2 This recommendation is supported by multiple high-quality guidelines, including the American Association for the Study of Liver Diseases (2021), which explicitly states that prednisone is considered low risk in both pregnancy and lactation. 1

The reassuring safety data comes from a large nationwide cohort study of nearly 52,000 pregnancies with first-trimester corticosteroid exposure, which showed no increased risk of congenital malformations. 1 This directly contradicts older literature that reported increased orofacial clefts, making the more recent and larger study the definitive evidence. 1

Prednisone has a built-in protective mechanism: it is metabolized in the placenta by 11-beta-hydroxylase, providing some fetal protection from systemic exposure. 2

Dose-Dependent Risk Stratification

The safety of prednisone is highly dose-dependent, requiring careful attention to dosing:

Low-Risk Dosing:

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

Higher-Risk Dosing:

• 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 2
• Research data confirms that higher prednisone doses are associated with reduced gestational age at delivery (approximately 2.3-2.6 weeks shorter) 3

Clinical Management Algorithm

Initial Dosing:

• Start with the lowest effective dose, typically 10-20 mg/day, and adjust to maintain disease control 2
• Use the lowest effective dose for the shortest duration needed 1

Timing Considerations:

• First-trimester use carries the greatest theoretical risk of teratogenicity, though recent large studies show no increased malformation risk 1
• After the first trimester, short bursts of corticosteroids may be used more liberally, especially if maternal disease (such as severe asthma exacerbation) poses greater risk 1
• Avoid aggressive tapering in the last weeks before delivery, as some conditions may worsen 2

Monitoring Requirements:

• Screen for gestational diabetes, particularly in women on glucocorticoid therapy 2
• Monitor blood pressure closely, as corticosteroids can exacerbate hypertension 2
• Increased surveillance for preeclampsia is warranted 2
• Monitor for pregnancy-specific complications: hyperglycemia, osteoporosis, excessive weight gain, and psychosis 2

Delivery Management:

• 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 2

Important Caveats and Pitfalls

Avoid Common Errors:

• Do not withhold necessary prednisone therapy due to pregnancy concerns—uncontrolled maternal disease poses greater risk to both mother and fetus than appropriate prednisone use 1, 4
• Do not confuse prednisone with mycophenolic acid (MPA) products, which are absolutely contraindicated in pregnancy due to high risk of congenital malformations 1
• Consultation with the patient's obstetrician is recommended when using corticosteroids, particularly for conditions less severe than life-threatening disease 1

Glucocorticoid-Sparing Strategies:

• If corticosteroid therapy is ineffective or causes significant side effects, consider alternative therapies 2
• Combining pregnancy-compatible immunosuppressive agents (azathioprine, hydroxychloroquine, cyclosporine, tacrolimus) may allow for glucocorticoid dose reduction 2

Lactation:

• Prednisone is considered low risk during lactation and breastfeeding is not contraindicated 1, 4
• Very little corticosteroid ingested by the mother enters breast milk 5

Long-Term Offspring Outcomes:

• Reassuringly, research shows that low-dose prednisone exposure in utero (average 6 mg daily) does not increase insulin resistance in offspring at approximately 7 years of age 6
• Prednisone use or RA disease activity in pregnant women had no influence on body composition of prepubertal offspring 7

FDA Classification:

• The FDA classifies corticosteroids as Pregnancy Category C, meaning animal studies show adverse effects but there are no adequate well-controlled studies in pregnant women 8
• However, this classification is outdated compared to current guideline recommendations that explicitly endorse prednisone use when clinically indicated 1, 2