What are the recommended medications for a pregnant woman in her second trimester experiencing a cough?

Recommended Medications for Cough in Second Trimester of Pregnancy

For pregnant women in the second trimester with cough, albuterol is the preferred first-line treatment if the cough is asthma-related (with wheezing, shortness of breath, or chest tightness), while ipratropium bromide is recommended for non-asthmatic cough, as inadequate symptom control poses greater risk to the fetus than these medications. 1

Initial Assessment: Determine the Cause

The critical first step is identifying whether the cough is asthma-related or non-asthmatic 1:

• Asthma-related cough presents with wheezing, shortness of breath, chest tightness, or a history of asthma 1
• Non-asthmatic cough may be post-infectious (following recent upper respiratory infection with persistent dry cough) or related to other causes 1
• Consider gastroesophageal reflux as a potential exacerbating factor 2

Treatment Based on Etiology

For Asthma-Related Cough (First-Line)

Albuterol is the preferred medication due to extensive safety data showing no evidence of fetal injury 3, 1:

• Dosing: 2-4 puffs via metered-dose inhaler every 4-6 hours as needed 3, 1
• Alternative: 2.5 mg via nebulizer every 20 minutes for 3 doses, then every 1-4 hours as needed 2
• Albuterol is classified as pregnancy category A with extensive reassuring data 3

If daily controller medication is needed (rescue inhaler used more than twice weekly), budesonide is the preferred inhaled corticosteroid 3, 1:

• Budesonide has the most reassuring pregnancy data among inhaled corticosteroids 3
• Other inhaled corticosteroids (beclomethasone, fluticasone) may be continued if the patient was well-controlled pre-pregnancy, as switching formulations may jeopardize control 3

For Non-Asthmatic Cough (First-Line)

Ipratropium bromide is the only recommended inhaled anticholinergic for cough suppression in pregnancy 1:

• Dosing: 4-8 puffs via MDI as needed, or 0.25 mg via nebulizer every 20 minutes for 3 doses, then every 2-4 hours as needed 1
• Effective for post-infectious cough in controlled trials 1

Simple Non-Pharmacological Measures (Always Appropriate)

Home remedies should be offered first for acute viral cough 3, 2:

• Honey and lemon is the simplest, cheapest, and safest initial recommendation 3, 2
• Menthol inhalation (menthol crystals or proprietary capsules) provides short-term cough suppression 3, 2
• Adequate hydration supports immune function 1

Second-Line Pharmacological Options

Dextromethorphan (Use with Caution)

Dextromethorphan can be considered for short-term use when first-line approaches are insufficient 2:

• A controlled study of 184 pregnant women found no increased risk of major malformations (2.3% vs 2.8% in controls) 4
• FDA labeling states "ask a health professional before use" if pregnant 5
• Use the lowest effective dose for the shortest duration 2
• Maximum cough suppression occurs at 60 mg, though typical over-the-counter doses are subtherapeutic 3
• Caution: Avoid combination products containing other ingredients like paracetamol at higher doses 3

First-Generation Antihistamines

Sedating antihistamines may be useful specifically for nocturnal cough 3, 2:

• These suppress cough but cause drowsiness 3
• Reserve for nighttime use when sedation is acceptable 3

For Allergic Rhinitis Contributing to Cough

Second-generation antihistamines are preferred if allergic rhinitis is contributing 2:

• Loratadine or cetirizine are the preferred agents 2
• Intranasal corticosteroids, particularly budesonide, are safe and effective 6

Critical Medications to AVOID

Oral decongestants must be avoided, especially in the first trimester, but caution extends throughout pregnancy 1, 6:

• Associated with potential cardiac, ear, gut, and limb abnormalities 1

Codeine and pholcodine are NOT recommended 3:

• No greater efficacy than dextromethorphan but significantly greater adverse effects 3
• Opioids have concerning side effect profiles including respiratory depression, constipation, and neonatal withdrawal syndrome 7

Antibiotics have no role unless bacterial sinusitis or pertussis is confirmed 1:

• Do not use empirically for viral post-infectious cough 1

Essential Safety Principles

The most dangerous error is withholding necessary respiratory medications due to pregnancy concerns 1:

• Inadequate control of respiratory symptoms poses greater risk to the fetus than the medications used to treat them 3, 1
• Uncontrolled asthma is associated with increased maternal and fetal morbidity 3

Monitor for adequate symptom control 2:

• Frequent rescue medication use (more than twice weekly) indicates need for controller therapy 2
• Monthly evaluations are recommended for pregnant women with asthma 2

When to Escalate Care

Immediate evaluation is warranted for 1:

• Hemoptysis (coughing up blood)
• Significant breathlessness
• Prolonged fever with systemic illness
• Symptoms persisting beyond 3 weeks without improvement

Consider alternative diagnoses if cough persists beyond 8 weeks 1.

Common Pitfalls to Avoid

• Do not assume all cough is benign - persistent symptoms require investigation for alternative diagnoses 1
• Do not use combination over-the-counter products indiscriminately - these may contain multiple unnecessary ingredients and increase medication exposure 2
• Do not prescribe antibiotics empirically for viral post-infectious cough 1
• Do not use NSAIDs beyond 32 weeks gestation due to risk of premature ductus arteriosus closure 6