What over‑the‑counter cold medications are safe for a pregnant woman with upper‑respiratory cold symptoms?

Safe Over-the-Counter Cold Medications During Pregnancy

For pregnant women with upper respiratory cold symptoms, saline nasal rinses and acetaminophen are the safest first-line treatments, followed by intranasal budesonide for persistent congestion, while oral decongestants (pseudoephedrine, phenylephrine) and first-generation antihistamines should be avoided. 1

First-Line Safe Treatments

Saline nasal rinses are the safest and most effective treatment for nasal congestion in pregnancy, with zero fetal risk and no systemic absorption. 1 This should be the initial recommendation for all pregnant women with cold symptoms.

Acetaminophen is the preferred medication for pain and fever control during pregnancy. 1 Use the lowest effective dose for the shortest duration necessary. Fever control is particularly important as maternal hypoxia from severe symptoms poses greater risk than appropriate medication use. 1

Intranasal Corticosteroids for Persistent Symptoms

Modern intranasal corticosteroid sprays—specifically budesonide, fluticasone, and mometasone—are safe for persistent congestion at recommended doses. 2 These have negligible systemic absorption and extensive safety data. 2

• Budesonide has the most extensive pregnancy safety data and is classified as Category B (FDA) and Category A (Australian TGA), making it the preferred intranasal corticosteroid. 1, 3
• Budesonide has not been associated with increased risk of intrauterine growth restriction, preterm delivery, or low birth weight. 3
• Continue budesonide throughout pregnancy at the lowest effective dose to maintain symptom control. 3

Second-Line Options (Use With Caution)

Second-generation antihistamines (cetirizine or loratadine) can be considered for allergic symptoms, but only when symptoms significantly impact quality of life. 1 Cetirizine and loratadine have the most safety data among second-generation agents. 4, 5

First-generation antihistamines like chlorpheniramine have longer safety track records than second-generation agents, though they cause more sedation and anticholinergic effects. 4 However, current guidelines recommend avoiding first-generation antihistamines due to these adverse effects. 1

Medications to Strictly Avoid

Oral decongestants (pseudoephedrine and phenylephrine) should be avoided, especially in the first trimester, due to risk of fetal gastroschisis and maternal hypertension. 1 These have associations with cardiac, ear, gut, and limb abnormalities. 5

First-generation antihistamines (diphenhydramine, chlorpheniramine) should be avoided due to sedative and anticholinergic properties. 1

NSAIDs (ibuprofen, naproxen) and aspirin are contraindicated, particularly after 32 weeks of pregnancy. 1

For Cough Symptoms

If cough is asthma-related, albuterol is the preferred treatment with extensive safety data from over 6,667 pregnant women. 6 Albuterol has more safety evidence than any other short-acting bronchodilator. 2, 6

For non-asthmatic cough, ipratropium bromide may be used as the only recommended inhaled anticholinergic in pregnancy. 1

Critical Clinical Principle

Inadequately controlled respiratory symptoms pose greater risk to the fetus than the medications used to treat them. 1 Maternal hypoxia from severe symptoms is more dangerous than appropriate medication use. 1 Never withhold necessary respiratory medications due to pregnancy concerns. 1

Practical Treatment Algorithm

1. Start with saline nasal rinses for all pregnant women with congestion 1
2. Add acetaminophen for fever or pain 1
3. If congestion persists beyond 3-5 days, add intranasal budesonide 2, 3
4. For allergic symptoms significantly impacting quality of life, consider cetirizine or loratadine 1, 5
5. Avoid all oral decongestants and first-generation antihistamines 1
6. If cough develops, evaluate for asthma or bacterial infection requiring specific treatment 1

Common Pitfalls to Avoid

• Do not recommend oral decongestants even for short-term use in the first trimester. 1, 5
• Do not switch a patient already well-controlled on a different intranasal corticosteroid to budesonide—continue their current medication. 3
• Do not withhold intranasal corticosteroids due to pregnancy concerns when symptoms are persistent. 2
• Do not use combination cold medications that may contain contraindicated ingredients like pseudoephedrine or NSAIDs. 1