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Pharmacotherapy during pregnancy

Last updated: July 21, 2023

Summarytoggle arrow icon

Pharmacotherapy during pregnancy is an important concern for a medical professional because there are only a limited number of drugs that can be safely administered during this period. Many drugs can cause harm to the fetus in the form of defects in organogenesis, growth retardation, and functional deficits. The aim of drug selection in this period is to prescribe an agent that effectively alleviates the mother's medical complaints while ensuring the safety of the unborn fetus. This article provides a brief overview of drugs that can be used for common conditions in pregnant women. It also lists the substances that should be avoided during pregnancy.

Antibiotics during pregnancytoggle arrow icon

Drugs of choice

Drugs to avoid

Overview of antibiotics to avoid during pregnancy [1][2][3]
Harmful side effects
Tetracycline
Aminoglycoside
Trimethoprim/sulfonamide combinations
Chloramphenicol
  • Gray baby syndrome: a syndrome associated with chloramphenicol accumulation in the body, leading to ashen gray color of the skin, cardiovascular collapse, and abdominal distention
Clarithromycin
  • Embryotoxic
Fluoroquinolones

“Teethracycline:” teeth discoloration with tetracycline.
“A mean guy stepped on baby's ear:” Aminoglycoside can cause ototoxicity.

Other medical therapy during pregnancytoggle arrow icon

Antihypertensives

Drugs of choice

“Moms Love Healthy Newborns:” Methyldopa, Labetalol, Hydralazine, Nifedipine are safe to use during pregnancy.

Drugs to avoid

Overview of antihypertensives to avoid during pregnancy [4][5]
Harmful side effects
Diuretics
ACE inhibitors [6]
Angiotensin-receptor blockers
Atenolol

Antifungals

Drugs of choice

Drugs to avoid

Overview of antifungals to avoid during pregnancy [8]
Harmful side effects

Ketoconazole, flucytosine, and griseofulvin
Itraconazole, fluconazole (> 300 mg)
Iodides

Antivirals

Drugs of choice

Drugs to avoid

Overview of antivirals to avoid during pregnancy [9][10][11][12][13]
Harmful side effects
Efavirenz [14]

Ribavirin
Interferon α
Ribavirin and interferon α combination
Didanosine and stavudine combination
Nevirapine

Nevirapine should not be used as first-line therapy if avoidable!

Anticoagulants

Drugs of choice

Drugs to avoid

Overview of anticoagulants to avoid during pregnancy [15][16]
Drugs to avoid Harmful side effects

Warfarin
Phenprocoumon
Non-vitamin K oral anticoagulants (apixaban, rivaroxaban, dabigatran)
  • The data available do not suggest a high risk of embryopathy, but, because of significant data gaps, they are to be avoided in pregnancy.

“Don't Warry, be Heppy:” warfarin should be replaced with heparin during pregnancy.

Analgesics

Drugs of choice

Drugs to avoid

Overview of analgesics to avoid during pregnancy [17]
Harmful side effects
NSAIDs (in the second and third trimesters)
Metamizole

Thyroid agents

Drugs of choice

Drugs to avoid

Overview of thyroid agents to avoid during pregnancy [18]
Harmful side effects
Radioiodine therapy (absolutely contraindicated)

Methimazole (first trimester)

Carbimazole

Thiamazole

Antiepileptics

Drugs of choice

Individualized treatment based on seizure type and most tolerated drug

Drugs to avoid

Overview of antiepileptics to avoid during pregnancy [2][19][20]
Harmful side effects

Phenytoin

Carbamazepine
Valproate

Antiemetics during pregnancy [21]

Other drug classes to avoid during pregnancy [2][19][20]

Overview of other drugs to avoid during pregnancy
Drugs to avoid Harmful effects
Steroid therapy (especially as antiallergenics)
  • Reduced birth weight
  • Increased risk of preeclampsia
  • Increased risk of oral and lip clefts
Oral antidiabetic agents
Methotrexate
Cholestyramine
  • Fetal and maternal hemorrhage

Lithium
Antineoplastic drugs (specifically antifolate metabolites and alkylating agents)
Isotretinoin and excessive intake of vitamin A (> 8,000 IU vitamin A per day as retinol/retinyl esters)
  • High risk of miscarriage
  • Multiple congenital malformations, including cardiac anomalies, facial cleft, and skeletal abnormalities
Misoprostol
5α-reductase inhibitor
Antacids

Calcium carbonate

Magnesium hydroxide
  • Inhibition of uterine contractions [25]
  • Might delay the onset of lactation [26]

“IsoTERATinoin” is a TERrible TERATogen.”

First-generation antihistamines (e.g., chlorpheniramine) may be used as antiallergenics during pregnancy. Second-generation antihistamines (e.g., loratadine, fexofenadine, cetirizine) may be considered if chlorpheniramine is not tolerated. Loratadine is the best-studied second-generation antihistamine. [27]

Type 2 diabetes during pregnancy or gestational diabetes requires insulin therapy!

Referencestoggle arrow icon

  1. Podymow T, August P. Update on the use of antihypertensive drugs in pregnancy. Hypertension. 2008; 51 (4): p.960-969.doi: 10.1161/HYPERTENSIONAHA.106.075895 . | Open in Read by QxMD
  2. Cauldwell M, Dos Santos F, Steer PJ, Swan L, Gatzoulis M, Johnson MR. Pregnancy in women with congenital heart disease. BMJ. 2018; 360: p.k478.doi: 10.1136/bmj.k478 . | Open in Read by QxMD
  3. Kubota-Sjogren Y, Nelson-Piercy C. Fulminant antenatal pulmonary oedema in a woman with hypertension and superimposed preeclampsia.. BMJ case reports. 2015; 2015.doi: 10.1136/bcr-2015-212751 . | Open in Read by QxMD
  4. Cooper WO, Hernandez-diaz S, Arbogast PG, et al. Major congenital malformations after first-trimester exposure to ACE inhibitors. N Engl J Med. 2006; 354 (23): p.2443-2451.doi: 10.1056/NEJMoa055202 . | Open in Read by QxMD
  5. King CT, Rogers PD, Cleary JD, Chapman SW. Antifungal therapy during pregnancy. Clin Infect Dis. 1998; 27 (5): p.1151-1160.
  6. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. https://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0. Updated: October 26, 2016. Accessed: February 22, 2017.
  7. Kang SH, Chua-gocheco A, Bozzo P, Einarson A. Safety of antiviral medication for the treatment of herpes during pregnancy. Can Fam Physician. 2011; 57 (4): p.427-428.
  8. Recommendations for Obstetric Health Care Providers Related to Use of Antiviral Medications in the Treatment and Prevention of Influenza. https://www.cdc.gov/flu/professionals/antivirals/avrec_ob.htm. Updated: November 3, 2016. Accessed: February 22, 2017.
  9. Ribavirin. https://aidsinfo.nih.gov/drugs/28/ribavirin/138/professional. Updated: November 1, 2017. Accessed: October 24, 2018.
  10. Peginterferon Alfa-2b (HCV). https://aidsinfo.nih.gov/drugs/487/peginterferon-alfa-2b--hcv-/0/professional. Updated: May 1, 2018. Accessed: October 24, 2018.
  11. Chersich MF, Urban MF, Venter FW, et al. Efavirenz use during pregnancy and for women of child-bearing potential. AIDS Res Ther. 2006; 3: p.11.doi: 10.1186/1742-6405-3-11 . | Open in Read by QxMD
  12. $Practice Advisory on Low-Dose Aspirin and Prevention of Preeclampsia: Updated Recommendations.
  13. Beyer-Westendorf J, Marten S, Michalski F. Outcome of Noac Exposure during Pregnancy (and the problem of event reporting). Blood. 2015; 126 (23): p.1125.
  14. Babb M, Koren G, Einarson A. Treating pain during pregnancy. Can Fam Physician. 2010; 56 (1): p.25, 27.
  15. Azizi F, Amouzegar A. Management of hyperthyroidism during pregnancy and lactation. Eur J Endocrinol. 2011; 164 (6): p.871-876.doi: 10.1530/eje-10-1030 . | Open in Read by QxMD
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  19. Quinlan JD, Hill DA. Nausea and vomiting of pregnancy. Am Fam Physician. 2003; 68 (1): p.121-128.
  20. Auffret M, Bernard-Phalippon N, Dekemp J, et al. Misoprostol exposure during the first trimester of pregnancy: Is the malformation risk varying depending on the indication?. Eur J Obstet Gynecol Reprod Biol. 2016; 207: p.188-192.doi: 10.1016/j.ejogrb.2016.11.007 . | Open in Read by QxMD
  21. Hirshburg JM, Kelsey PA, Therrien CA, Gavino AC, Reichenberg JS. Adverse Effects and Safety of 5-alpha Reductase Inhibitors (Finasteride, Dutasteride): A Systematic Review.. The Journal of clinical and aesthetic dermatology. 2016; 9 (7): p.56-62.
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  30. Schaefer C, Peters PWJ, Miller RK. Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment. Elsevier ; 2015

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