Medication safety and drug exposure in pregnancy

Medications and drug safety information for pregnant women that should be known by the pharmacy doctors.

Introduction

Although some medicines are considered safe during pregnancy, the effects of other medicines on your unborn baby are unknown. Certain medicines can be most harmful to a developing baby when taken during the first three months of pregnancy, often before a woman even knows she is pregnant.

Pain medications

Acetaminophen is analgesic drug of choice for pain during pregnancy. Avoid aspirin during pregnancy, unless needed for specific indications. Use other NSAIDs cautiously during first and second trimesters (Pregnancy Category B), avoid use in third trimester (Pregnancy Category D). Periconceptional opiate analgesics may be associated with increased risk for malformations. For further information, see note on "Analgesics during pregnancy and lactation".

Psychiatric medications

Antidepressants

If patient suicidal or psychotic, aggressively treat depression; try to avoid antiepileptic mood stabilizers in first trimester if possible. Single medication at higher dose favored over multiple medications. For pregnant patients with depression but not currently using antidepressants, consider treating with antidepressant if patient is willing to take medicine, there is no concern for psychiatric comorbidities, and patient has failed psychotherapy alone (choice of antidepressant should be individualized). For pregnant patients with current or recent major depressive disorder taking antidepressants, continuation may be appropriate or trial of medication taper (with additional psychotherapy as needed) may be considered if asymptomatic.

Anxiolytics

Anxiolytics options for anxiety disorders during pregnancy include benzodiazepines and antidepressants. Mood stabilizers require monitoring and may be associated with congenital malformations. Typical (first generation) antipsychotics are first-line treatment for psychotic disorders in pregnant women as available evidence suggests minimal risks for neonatal toxicity and teratogenicity

Antimicrobials

Antibiotics

Most antibiotics are considered safe during pregnancy. For further information, see note on "Antibiotics use in pregnancy". Also see note on "Oral antibiotics that should be used or avoided during pregnancy".

Antiviral medications

For pregnant women with confirmed or suspected influenza antiviral medication recommended as soon as possible and treatment should not wait for laboratory confirmation. Antivirals include:

Neuraminidase inhibitors, oseltamivir (Tamiflu), zanamivir (Relenza) which are active against influenza A and B. Oseltamivir and zanamivir are Pregnancy Category C medications that can be taken during any trimester of pregnancy. Oseltamivir generally considered preferred antiviral in pregnancy. Zanamivir may be preferred in pregnancy by some providers due to low systemic absorption; however respiratory complications such as bronchoconstriction with use must be considered.
Amantadine and rimantadine, which are active against influenza A only - are not recommended for treatment or prophylaxis of currently circulating influenza A due to resistance.

Antihypertensive medications

Chronic or mild-to-moderate hypertension during pregnancy. First-line agents include labetalol, nifedipine, and methyldopa AND second-line agent is thiazide diuretics. Options for urgent control of acute severe hypertension include labetalol, nifedipine, and hydralazine. For further information, see note on "Which anti-hypertensives are safe to use during pregnancy?".

Antiepileptic drugs

Discuss risks of antiepileptic drugs (AEDs) with women and girls of childbearing potential (including girls likely to need treatment into childbearing years), including risk fetal malformations. If possible, consider avoiding valproate and AED polytherapy during first trimester to reduce major congenital malformations and avoid throughout pregnancy to prevent reduced cognitive outcomes. Topiramate may increase risk for cleft lip and palate.

Lowest risk agents in women of child-bearing potential (lower teratogenic potential) are lamotrigine and levetiracetam (Tiratam).
Moderate risk agents in women of child-bearing potential (moderate teratogenic potential) are Carbamazepine (Tegretol), oxcarbazepine (Trileptal) and phenytoin
Highest risk agents in women of child-bearing potential (high teratogenic potential) is valproic acid (Depakene).

Other conditions

First-line treatment for acute migraine consists of acetaminophen and metoclopramide. Consider glatiramer in women with multiple sclerosis who become pregnant

For inflammatory bowel disease. 5-aminosalicylates and corticosteroids are considered first-line treatment for inflammatory bowel disease during pregnancy, depending on disease phenotype and activity. Treat acute flairs appropriately, usually with anti-tumor necrosis factor antibodies (anti-TNF), and without delay to prevent maternal and fetal complications.
Gastroesophagealreflux disease (GERD). Antacids containing aluminum, magnesium, and calcium are first-line pharmacologic treatment of heartburn and acid reflux in pregnancy. Histamine H2-receptor blockers recommended in pregnant women whose symptoms cannot be controlled with lifestyle modification and antacids. See notes on "Gastrointestinal agents during pregnancy and breastfeeding" AND "Dyspepsia and gastro-esophageal reflux during pregnancy".
Venous thromboembolism. For prevention and treatment of venous thromboembolism in pregnancy, subcutaneous enoxaparin or low-molecular-weight heparin (LMWH) recommended over unfractionated heparin (UFH).

References

Medicine Guidelines for Pregnancy. Cleveland Clinic. Available at: https://my.clevelandclinic.org/health/drugs/4396-medicine-guidelines-during-pregnancy
Larimore WL, Petrie KA. Drug use during pregnancy and lactation. Prim Care. 2000;27(1):35-53.
ACOG Committee on Practice Bulletins--Obstetrics. ACOG Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists number 92, April 2008 (replaces practice bulletin number 87, November 2007). Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol. 2008;111(4):1001-1020.