Misoprostol (Cytotec) is Absolutely Contraindicated During Pregnancy
Misoprostol (Cytotec) is the medication that is contraindicated during pregnancy among the options listed. This prostaglandin E1 analog carries an FDA black box warning specifically prohibiting its use for NSAID-induced ulcer prophylaxis in pregnant women due to its potent abortifacient properties. 1
Why Misoprostol is Contraindicated
FDA Black Box Warning and Mechanism
Misoprostol administration to pregnant women can cause abortion, premature birth, birth defects, and uterine rupture. The FDA explicitly states that misoprostol should NOT be taken by pregnant women to reduce the risk of NSAID-induced ulcers. 1
The drug's mechanism as a prostaglandin E1 analog causes cervical ripening and powerful uterotonic effects, making it highly effective at terminating pregnancies across all trimesters. 2, 3
Uterine rupture has been specifically reported when misoprostol was administered in pregnant women, particularly when used to induce labor or abortion beyond the eighth week of pregnancy. 1
Teratogenic Effects When Pregnancy Continues
Beyond its abortifacient properties, misoprostol is associated with specific teratogenic effects if the pregnancy continues after exposure, including limb defects and Möbius syndrome. 3
Healthcare providers must recognize these associated teratogenic effects and provide thorough consultation before prescribing this medication, especially regarding risks if abortion fails. 3
Strict Prescribing Requirements (If Ever Used in Women of Childbearing Age)
The FDA mandates that if misoprostol must be prescribed to a woman of childbearing potential for ulcer prophylaxis, ALL of the following conditions must be met: 1
- Patient must be at high risk of complications from gastric ulcers associated with NSAID use OR at high risk of developing gastric ulceration
- Negative serum pregnancy test within 2 weeks prior to beginning therapy
- Patient is capable of complying with effective contraceptive measures
- Patient has received both oral AND written warnings about the hazards
- Therapy begins only on the second or third day of the next normal menstrual period
Why the Other Options Are NOT Contraindicated
Pantoprazole (Protonix) - Safe in Pregnancy
Proton pump inhibitors, including pantoprazole, are not associated with increased risk of congenital malformations, premature births, stillbirths, spontaneous abortions, or low birth weight. 4
PPIs can be used throughout pregnancy when clinically indicated for GERD or ulcer prophylaxis.
Famotidine (Pepcid) - Safe in Pregnancy
H2-receptor antagonists like famotidine have an established safety profile in pregnancy with no evidence of teratogenicity.
These medications are commonly used for acid suppression throughout all trimesters without contraindication.
Sucralfate (Carafate) - Safe in Pregnancy
Sucralfate acts locally in the gastrointestinal tract with minimal systemic absorption, making it one of the safest options for ulcer treatment during pregnancy.
It can be used throughout pregnancy without restriction.
Clinical Bottom Line
For pregnant patients requiring NSAID-induced ulcer prophylaxis, use pantoprazole, famotidine, or sucralfate—NEVER misoprostol. 1 The abortifacient and teratogenic properties of misoprostol make it absolutely contraindicated for this indication during pregnancy, as explicitly stated in FDA labeling and multiple clinical guidelines. 1, 2, 3
If a woman of childbearing age requires chronic NSAID therapy with ulcer prophylaxis, counsel her about pregnancy risks and ensure effective contraception if misoprostol is being considered, or preferentially choose alternative gastroprotective agents that are pregnancy-compatible. 1