Can hydrocortisone or methylprednisolone be used to treat a cough in a pregnant woman in her second trimester?

Can Hydrocortisone or Methylprednisolone Be Used to Treat Cough in a Pregnant Woman in Her Second Trimester?

Hydrocortisone and methylprednisolone can be used during the second trimester of pregnancy when clinically indicated, but systemic corticosteroids should not be used for simple cough treatment—they are reserved for severe, refractory maternal disease or specific medical conditions like severe asthma exacerbations. 1, 2

Key Safety Considerations for Systemic Corticosteroids in Pregnancy

Why These Agents Are Generally Safe When Needed

• Prednisone, prednisolone, hydrocortisone, and methylprednisolone are extensively metabolized by the placenta, with only 10% of the maternal dose reaching the fetus, making them the preferred systemic corticosteroids during pregnancy over dexamethasone or betamethasone 2, 3

• These corticosteroids are not associated with increased rates of major birth defects and can be considered during pregnancy if needed to control active disease 1

• There is no evidence that prednisone, prednisolone, or hydrocortisone are teratogenic in humans (FDA risk category B) 2

Important Dose-Related Risks

However, the EULAR 2025 guidelines emphasize a critical dose threshold:

• Daily doses ≤5 mg prednisone equivalent are associated with low risk 1

• Higher doses used over prolonged periods carry dose-related potential risks including pregnancy-associated osteoporosis, gestational diabetes, serious maternal infections, and preterm birth 1

• The 2025 EULAR recommendations advocate for restrictive use of oral glucocorticoids in pregnant women, with tapering to maintenance doses of ≤5 mg/day when possible 1

When Systemic Corticosteroids Are Appropriate in Pregnancy

Severe Maternal Disease

IV methylprednisolone pulses are considered among the safest options for severe, refractory, or organ- or life-threatening maternal disease during pregnancy 1

Severe Asthma

• For pregnant women with severe asthma, the major benefit of systemic corticosteroids exceeds the possible fetal risk 1

• Albuterol is the preferred short-acting beta-agonist, and inhaled corticosteroids (particularly budesonide) are the preferred long-term control medications 1

• A short course of oral systemic corticosteroids may be necessary before surgery or for severe exacerbations 1

Perioperative Management

• For patients receiving oral systemic corticosteroids within the past 6 months before surgery, give 100 mg hydrocortisone every 8 hours intravenously during the surgical period, with rapid dose reduction within 24 hours after surgery 1

Why Systemic Corticosteroids Should NOT Be Used for Simple Cough

A simple cough in pregnancy does not warrant systemic corticosteroid therapy. The evidence clearly shows:

• Systemic corticosteroids are reserved for controlling active inflammatory disease, severe asthma, or life-threatening maternal conditions—not symptomatic cough relief 1

• The risks of gestational diabetes, infections, preterm birth, and other complications at higher doses outweigh any potential benefit for treating uncomplicated cough 1

Safer Alternatives for Cough in Second Trimester

Inhaled Corticosteroids (If Asthma-Related)

• Budesonide is the preferred inhaled corticosteroid during pregnancy due to extensive safety data (TGA category A, FDA category B) 1

• Inhaled corticosteroids at usual doses have not been associated with increased risk of major malformations, intrauterine growth restriction, preterm delivery, or low birthweight 1

• Use the lowest dose necessary to maintain asthma control 1

Other Considerations

• Non-selective NSAIDs with short half-life (e.g., ibuprofen) can be used in the lowest effective dose for short duration (7-10 days) in the second trimester, but must be discontinued after gestational week 28 1

Common Pitfalls to Avoid

• Do not use dexamethasone or betamethasone for maternal conditions, as these cross the placenta more readily and are intended for fetal lung maturation 2, 3

• Do not prescribe systemic corticosteroids for simple symptomatic relief when the underlying condition does not warrant anti-inflammatory therapy 1

• Do not forget stress-dose coverage during labor and delivery in patients on chronic corticosteroid therapy (100 mg hydrocortisone IV at onset of active labor) 2

• Infants born to mothers who received substantial doses of corticosteroids during pregnancy should be carefully observed for signs of hypoadrenalism 4, 5

Clinical Algorithm for Decision-Making

1. Identify the underlying cause of cough (asthma, upper respiratory infection, gastroesophageal reflux, etc.)

2. If asthma-related: Use inhaled corticosteroids (budesonide preferred) at the lowest effective dose 1

3. If severe asthma exacerbation: Short course of oral prednisone/prednisolone may be justified, as uncontrolled asthma poses greater risk than corticosteroid exposure 1

4. If non-asthma related cough: Avoid systemic corticosteroids entirely; treat underlying cause with pregnancy-compatible alternatives 6

5. If systemic corticosteroids are truly needed: Use prednisone, prednisolone, hydrocortisone, or methylprednisolone (not dexamethasone/betamethasone), at the lowest effective dose for the shortest duration 1, 2, 3