The clinical content of preconception care: the use of medications and supplements among women of reproductive age.

Abstract

The use of prescription and over-the-counter medications and dietary supplements are common among women of reproductive age. For medications, little information about the teratogenic risks or safety is available, as pregnant women are traditionally excluded from clinical trials, and premarketing animal studies do not necessarily predict the effects of treatment in human pregnancy. Even less is typically known about the effects of dietary supplements on pregnancy outcomes, as they are not held to the same rigorous safety and efficacy standards as prescription medications. Congenital anomalies associated with medication use are potentially preventable, because they are linked with modifiable maternal exposures during the period of organogenesis. However, as women of reproductive age experience acute and chronic conditions that can result in adverse outcomes for the woman and her offspring, the benefits of use of a particular medication before or early in pregnancy may outweigh the risks. Resources and principles outlined in this article will aid healthcare providers in selecting appropriate medication regimens for women of reproductive age, particularly those with chronic health conditions, those who are planning a pregnancy, and those who may become pregnant.

Full text

Page 1

The clinical content of preconception care:
the use of medications and supplements
among women of reproductive age
Anne L. Dunlop, MD, MPH; Paula M. Gardiner, MD, MPH; Cynthia S. Shellhaas, MD, MPH;
M. Kathryn Menard, MD, MPH; Melissa A. McDiarmid, MD, MPH
M
tive age is common. A survey of women
giving birth in Oklahoma1reports that
the average number of medications
taken during pregnancy ranged from
1.6-2.9 (excluding vitamin and mineral
supplements), depending on the trimes-
ter. The same survey reported that 54%
of all products consumed in pregnancy
were over-the-counter (OTC) medica-
tions. Another source estimates that
morethan80%ofpregnantwomentake
OTC or prescription drugs during preg-
nancy.2National surveys among women
of reproductive age document that
are planning a pregnancy, and those who may become pregnant.
Key words: medication, preconception, prescription, teratogen
edication usage among pregnant
women and women of reproduc-
chronic conditions often requiring the
ongoing administration of medications
for maintenance are not uncommon
among women of reproductive age.3As
maternal age and body mass index in-
crease, it is likely that an even greater
proportion of women who are planning
a pregnancy or who could become preg-
nant will have chronic diseases that ne-
cessitate prescription medications.
Presently, congenital anomalies are
among the leading causes of infant mor-
talityintheUnitedStates.4Itisestimated
that approximately 10-15% of congeni-
tal anomalies are due to teratogenic ma-
ternal exposures. Congenital anomalies
caused by teratogenic exposures, such as
certain medications, are considered pre-
ventable, as they are linked with modifi-
able maternal exposures during the pe-
riod of organogenesis.5It follows that
maternal avoidance of teratogenic expo-
sureswouldminimizecongenitalanom-
alies. However, as women of reproduc-
tive age and those who are pregnant
experience acute and chronic health
conditions that must be medically man-
aged,inmanyinstancesavoidanceofmed-
icationsisneitherpossiblenoradvisable.
The benefits of medication use during
pregnancy are not restricted to the re-
covery of maternal health, but extend to
the protection of the fetus in many in-
stances. Poorly controlled diabetes mel-
litus is teratogenic, whereas the appro-
priate management of diabetic pregnant
women can prevent diabetic embryopa-
thy.6Uncontrolled asthma can decrease
oxygen in the fetal blood, possibly im-
pairing fetal growth and survival.7Un-
controlled high blood pressure increases
the risks of placental problems and fetal
growth retardation.8The treatment of
infectious diseases of the reproductive
tract can significantly reduce the preva-
lence of preterm birth and its effects.1,9
For all pregnant women infected with
HIV, the Center for Disease Control
(CDC) recommends the drug zidovu-
dine (AZT) to minimize perinatal trans-
mission.10The periconceptional use of
folic acid can prevent most neural tube
defects11and a considerable number of
congenitalanomaliesofthecardiovascu-
FromtheDepartmentofFamilyand
PreventiveMedicine(DrDunlop),Emory
UniversitySchoolofMedicine,Atlanta,GA;
theDepartmentofFamilyMedicine(Dr
Gardiner),BostonUniversityMedical
Center,Boston,MA;theDivisionof
Maternal-FetalMedicine,Departmentof
ObstetricsandGynecology(DrShellhaas),
TheOhioStateUniversityCollegeof
MedicineandDirectorforBureauofChild
andFamilyHealthServices,StateofOhio,
OH;theDepartmentofObstetricsand
Gynecology(DrMenard),Universityof
NorthCarolinaatChapelHill,ChapelHill,
NC;andtheUniversityofMaryland,
OccupationalHealthProgram(Dr
McDiarmid),Baltimore,MD.
Received June 17, 2008; accepted July 29,
2008.
Reprints not available from the authors.
Conflict of Interest: Anne L. Dunlop, MD, MPH;
Paula M. Gardiner, MD, MPH; Cynthia S.
Shellhaas, MD, MPH; M. Kathryn Menard, MD,
MPH; and Melissa A. McDiarmid, MD, MPH
have no conflict of interest including grants,
honoraria, advisory board membership, or
share holdings.
0002-9378/$34.00
© 2008 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2008.07.065
The use of prescription and over-the-counter medications and dietary supplements are
common among women of reproductive age. For medications, little information about the
teratogenic risks or safety is available, as pregnant women are traditionally excluded from
clinical trials, and premarketing animal studies do not necessarily predict the effects of
treatment in human pregnancy. Even less is typically known about the effects of dietary
supplements on pregnancy outcomes, as they are not held to the same rigorous safety
and efficacy standards as prescription medications. Congenital anomalies associated with
medication use are potentially preventable, because they are linked with modifiable
maternal exposures during the period of organogenesis. However, as women of repro-
ductive age experience acute and chronic conditions that can result in adverse outcomes
for the woman and her offspring, the benefits of use of a particular medication before or
early in pregnancy may outweigh the risks. Resources and principles outlined in this
article will aid healthcare providers in selecting appropriate medication regimens for
women of reproductive age, particularly those with chronic health conditions, those who
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Page 2

lar system, urinary tract, and limb
deficiencies.12,13
Teratogenicity is a complex process
and is dependent on the timing of the
exposure in relation to the gestational
age, the dose, and route of administra-
tion. The developmental stage of the
conceptusisparticularlycriticalindeter-
mining teratogencity. For example, after
24 weeks’ gestation, the antibiotic tetra-
cycline can cause permanent staining of
the offspring’s teeth. During the second
and third trimesters, angiotensin-con-
verting enzyme (ACE) inhibitors can
damage the fetal kidneys. The period of
greatest sensitivity to most teratogenic
exposuresistheperiodoforganogenesis,
from 18-60 days postconception (ap-
proximately 4.5-11 weeks after the last
menstrual period).14Exposures after the
period of organogenesis usually do not
result in structural anomalies, although
there are exceptions. Rather, teratogenic
exposures during the fetal period (after
60 days postconception) typically result
ingrowthrestrictionorfunctionaldisor-
ders of the central nervous system, kid-
neys, or other organs.
The dose and route of administration
oftheagentareotherimportantfeatures
of potential teratogenicity. Teratogenic
effects occur only when the dose of an
agent exceeds a threshold.15Higher
dosesandchronicexposuresareofmore
concern than lower doses and single ex-
posures. A teratogenic effect is less likely
with the use of dermal agents with min-
imal systemic absorption. Finally, the
way in which the woman or offspring
metabolize an agent is influenced by ge-
notype, which ultimately determines the
effective “dose” of the exposure. Pro-
cesses relevant to medication processing
that are influenced by genotype include
metabolism, receptor binding, drug dis-
tribution, placental transport, and cellu-
lar sensitivity. In addition, physiologic
changes that occur during pregnancy
and affect the pharmacokinetics and/or
pharmacodynamics include: changes in
body weight and body composition; de-
layedgastricemptyingandgastrointesti-
nal transit time; expanded plasma vol-
ume;increasedcardiacoutputandblood
flow to the uterus, kidneys, skin, and
mammary glands; decreased plasma al-
bumin; increased glomerular filtration
rate; and changes in the activity of he-
patic enzymes.16It may be necessary to
adjust the dosage and/or frequency of
medication used during pregnancy.
For most medications, little informa-
tion about teratogenic risk or safety is
available at the time of marketing, as
pregnant women are traditionally ex-
cludedfromclinicaltrials.Premarketing
animalstudiesdonotnecessarilypredict
the effects of treatment in human preg-
nancy.Medicationsforwhichtherewere
false-negative animal teratology studies
include captopril, enalapril, carbima-
zole, methimazole, and misoprostol. Al-
though comparably more research has
been performed on hypertension, de-
pression,andotherconditionsthatcom-
monly occur in women of reproductive
age, no areas can be considered well-
studied in pregnancy. A review con-
ducted in 2001 concluded that there was
notenoughinformationtoassesstheter-
atogenic risk or safety during pregnancy
of more than 90% of prescription medi-
cations approved by the US Food and
Drug Administration (FDA) in the pre-
vious20years.17Gapsininformationare
even more substantial for OTC and di-
etary supplements.
Given the above, it can be difficult for
health care providers and women to de-
cide whether to use a given medication
during pregnancy as well as for women
who are planning to or who could be-
comepregnant.Thedecisionmustbein-
dividualized according to the woman
andheruniquecircumstances,consider-
ing the balance of risks, benefits, and ef-
ficacyoftreatmentformotherandfetus.
There are resources available to aid
healthcareprovidersandwomenintheir
medical decision-making. The US FDA
uses a risk classification system for med-
ications based on data from human and
animal studies to help interpret the risks
associated with use of medications dur-
ing pregnancy.18The current FDA clas-
sification system uses the letters A, B, C,
D, and X for the 5 categories (Table 1).
Drugsforwhichthereisevidenceoffetal
risk but “the potential benefits from the
use of the drug in pregnant women may
be acceptable despite its potential risks”
are classified as class D. Drugs that are
“contraindicated in women who are or
may become pregnant” are classified as
class X. Critics of the FDA classification
system argue that the risk categories are
limited in that they do not indicate the
TABLE 1
FDA classification of medication safety during pregnancy
CategoryDescription
A Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities.
................................................................................................................................................................................................................................................................................................................................................................................
B Animal studies have revealed no evidence of harm to the fetus; however, there are no adequate and well-controlled studies in
pregnant women; or animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women
have failed to demonstrate a risk to the fetus.
................................................................................................................................................................................................................................................................................................................................................................................
CAnimal studies have shown an adverse effect and there are no adequate and well-controlled studies in pregnant women; or no
animal studies have been conducted and there are no adequate and well-controlled studies in pregnant women.
................................................................................................................................................................................................................................................................................................................................................................................
DStudies, adequate well-controlled or observational, in pregnant women have demonstrated a risk to the fetus. However, the benefits
of therapy may outweigh the potential risk.
................................................................................................................................................................................................................................................................................................................................................................................
XStudies, adequate well-controlled or observational, in animals or pregnant women have demonstrated positive evidence of fetal
abnormalities. The use of the product is contraindicated in women who are or may become pregnant.
................................................................................................................................................................................................................................................................................................................................................................................
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risk based on time during gestation in
which the medication is used and that
the letters imply a gradation of risk that
does not necessarily exist. In actuality,
category X reflects a benefit-risk judg-
ment, but drugs in this category may be
no more toxic than those in categories C
orD.Anunderstandingofboththevalue
and limitations of the FDA categories of
risk is necessary for counseling women
of reproductive age who have taken or
may need to take a given medication. In
response to criticism of the current sys-
tem of classification, the FDA has pro-
posed to amend its regulations concern-
ing the format and content of the
“Pregnancy,” “Labor and delivery,” and
“Nursing mothers” subsections of the
“Use in Specific Populations” section of
thelabelingforhumanprescriptiondrug
and biological products. Specifically, the
FDAisproposingtorequirethatlabeling
includes a summary of the risks of using
adrugduringpregnancyandlactation,a
discussion of the data supporting that
summary,andrelevantclinicalinforma-
tion to help health care providers make
prescribingdecisions
women about the use of drugs during
pregnancy and/or lactation. The pro-
posal would eliminate the current preg-
nancy categories A, B, C, D, and X.19
There are several additional resources
that healthcare providers may utilize.
The textbook Drugs in Pregnancy and
Lactation20includesafetalrisksummary
containing a review of literature about a
particular drug to provide more data for
decision making by the prescribing
health care provider. Complete and up-
to-date information regarding medica-
tion teratogenic risks can be found on
the online REPRORISK system (www.
reprotox.org), available from Micro-
medex, which contains periodically up-
dated, scientifically reviewed resources.
Inaddition,theOrganizationofTeratol-
ogy Information Specialists has compiled
“fact sheets” on various prescription
and OTC medications and supplements
(available at http://otispregnancy.org/
otis_fact_sheets.asp).
More details about preconception
considerations for various prescription
and OTC medications and supplements
are found below.
and counsel
Prescription medications
A recent study finds that 1 of every 13
visits made to ambulatory practices by
womenofreproductiveageresultsinthe
prescription of a potentially teratogenic
(classDorX)medication.Thesamesur-
vey found that contraceptive counseling
was provided on less than 20% of visits
thatdocumenteduseofapotentialterat-
ogen by a woman of reproductive age,
and that women using low-risk drugs
(class A or B) received contraceptive
counselingasfrequentlyaswomenusing
potential teratogens. A table of medica-
tions generally accepted to be contrain-
dicated in the preconception period and
pregnancy is found in Table 2. A more
complete listing of potential teratogens
(class D or X) is found as an appendix in
the article by Schwarz et al.21
Recommendationsbyothergroups
Several professional organizations have
issued recommendations regarding the
use of drugs related to their specialty in
pregnancy. Specifically, there are estab-
lished practice guidelines for use of
medications to manage diabetes,22hy-
pertension,23seizure disorders,24thyroid
disorders,25disorders requiring anticoag-
ulation,26asthma,27gastrointestinaldisor-
ders,28tuberculosis,29sexuallytransmitted
infections including HIV,9,10migraine
headaches,30the management of acne
using isotretinoin, and psychiatric and
psychologic disorders (including de-
pression and bipolar disorders).31,32Re-
cently,theFDAhaschangedthelabeling
of paroxetine (Paxil) from class C to D
basedontheresultsofrecentstudiessug-
gestingthatthedrugincreasestheriskof
birth defects, particularly heart defects,
when women take it during the first 3
months of pregnancy.33
Recommendation. All women of re-
productive age should be screened for
the use of teratogenic medications and
should receive counseling about the po-
tential impact of chronic health condi-
tions and medications on pregnancy
outcomes for mother and child. When-
ever possible, potentially teratogenic
medications should be switched to safer
medications before conception. For
womenwithchronicconditionswithse-
rious morbidity (to mother and infant),
thefewestnumberandlowestdosagesof
essential medications that control ma-
ternal disease should be used. For
women not desiring pregnancy, a plan
for contraception should be addressed
and initiated. Strength of recommenda-
tion: A; quality of evidence: II-2.
OTC medications
Commonly used OTC medications
among women of reproductive age in-
cludeanalgesics;cough,cold,andallergy
remedies; and remedies for gastrointes-
tinal upset.34,35The safety of commonly
used examples of these OTC medica-
tions are given in Table 3.
Relatedrecommendations
byothergroups
As part of a preconception care visit, the
American College of Obstetricians and
Gynecologists (ACOG) recommends
that women inform their health care
provider of their use of OTC medica-
tions. The ACOG also recommends that
women who are pregnant talk to their
doctor before using any OTC medica-
tion during pregnancy.
Recommendation. Health care provid-
ers should educate women of reproduc-
tiveageabouttheneedtodiscusstheuse
of OTC medications with their provider
when planning a pregnancy. Women
should be specifically advised not to use
aspirin if they are planning a pregnancy
or become pregnant. Strength of recom-
mendation: A; quality of evidence: III.
Dietary Supplements
The 1994 Dietary Supplement Health
andEducationAct(DSHEA)defineddi-
etary supplements (DSs) as vitamin,
mineral,herb/botanical,aminoacid,en-
zyme, protein, probiotic, glandular, or
hormone-like substances. Various na-
tional surveys have estimated that
18-52% of the US population uses di-
etarysupplementsandmanywomenuse
dietary supplements before and during
pregnancy.36-38In the United States, di-
etary supplements are not regulated in
the same way as prescription medica-
tions and do not necessarily undergo
clinicaltrialsforsafetyandefficacy,espe-
cially in pregnancy. However, concerns
about safety, effectiveness, quality con-
trol, contamination, adverse events, and
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interactions with medications have been
raisedintheliteratureaboutdietarysup-
plements.39Although many health care
professionals will recommend certain
dietary supplements before and during
pregnancy (eg, folate, iron, and cal-
cium), the safety and efficacy of many
dietary supplements (eg, botanicals and
weight loss products) has not been
well established before or during preg-
nancy.40Most of the data available have
been based on case reports, animal stud-
ies, and retrospective studies. Clinical
trialsevaluatingthesafetyandefficacyof
dietary supplements before and during
pregnancyareneededespeciallyforvita-
minD,fishoil,andbotanicalproducts.It
is critical that all health care profession-
alsasktheirpatientswhatvitamins,min-
erals, herbs, traditional remedies, and
otherdietarysupplementstheyareusing.
Recommendationsbyothergroups
Health Canada has reported that at this
time there is not enough scientific infor-
mation about the safety of various herbs
and herbal products to recommend their
general use during pregnancy and lacta-
tion. Women should use these products
cautiously, and critically examine any in-
formationabouttheirproposedbenefits.41
Recommendation. Health care provid-
ers should educate women of reproduc-
tiveageabouttheneedtodiscusstheuse
of dietary supplements before preg-
nancy, including herbs, weight loss
products, and sport supplements, and
should caution women about the un-
known safety profile of many supple-
ments. High-quality and prescription-
quality dietary supplements should be
encouraged. Strength of recommenda-
tion: A; quality of evidence: II-C.
Conclusion
Giventhewidespreaduseofprescription
and OTC medications and dietary sup-
plements—including herbs, weight loss
products, and sport supplements—
among women of reproductive age, the
growing prevalence of women with
chronic conditions during their repro-
ductive years, and the unknown safety
profileorknownriskofteratogenicityof
many medications and supplements,
health care providers should educate
women of reproductive age about the
TABLE 2
Medications contraindicated (class X) in pregnancy
Agent
Angiotensin-converting enzyme inhibitors (antihypertensive),
and angiotension II receptor blockers
................................................................................................................................................................................................................................................................................................................................................................................
HMG-CoA reductase inhibitors (statins) A range of abnormalities has been reported for exposures during the 4th-9th
week of gestation.
................................................................................................................................................................................................................................................................................................................................................................................
Androgens and testosterone derivativesCause masculinization of female fetus.
................................................................................................................................................................................................................................................................................................................................................................................
Carbamazapine (anticonvulsant)Risk of fetal death, mental retardation, and malformed hearts, genitals, cleft
palates, and arteries. Should be switched to another, less teratogenic agent
before conception whenever possible. Use should be reserved only for cases
where benefit outweighs risk.
................................................................................................................................................................................................................................................................................................................................................................................
Coumadin derivativesRisk of bone and cartilage deformities, mental retardation, and vision problems.
Should be switched to heparin before conception whenever possible.
................................................................................................................................................................................................................................................................................................................................................................................
Folic acid antagonistsRisk of spontaneous abortion and malformations.
................................................................................................................................................................................................................................................................................................................................................................................
Leflunomide, thalidomide Risk of limb deformities. Use only with strict pregnancy prevention protocols.
................................................................................................................................................................................................................................................................................................................................................................................
Lithium (antidepressant)Associated with increased risk of cardiovascular anomalies.
................................................................................................................................................................................................................................................................................................................................................................................
Phenytoin (anticonvulsant) Risk of fetal hydantoin syndrome, including intrauterine growth restriction with
small head circumference, dysmorphic facies, orofacial clefts, cardiac defects,
and distal digital hypoplasia. Use should be reserved only for when benefit
outweighs risk.
................................................................................................................................................................................................................................................................................................................................................................................
Streptomycin and kanamycin (antiinfective) Risk of ototoxicity.
................................................................................................................................................................................................................................................................................................................................................................................
Tetracycline (antiinfective) Risk to developing bones and teeth causing discoloration of teeth and skeletal
abnormalities.
................................................................................................................................................................................................................................................................................................................................................................................
Valproic acid (anticonvulsive) Risk of central nervous system dysfunction, spina bifida, development delay,
intrauterine growth retardation, and cardiac anomalies. Should be switched to
another, less teratogenic agent before conception whenever possible. If benefit
of use outweighs risk, should be administered in 3-4 divided doses and should
not be combined with carbamazapine and phenobarbitol.
................................................................................................................................................................................................................................................................................................................................................................................
Isotretinoin, known as Accutane (antiacne) Elevated risk of spontaneous abortion and many anomalies.
................................................................................................................................................................................................................................................................................................................................................................................
Information from Briggs et al.19
................................................................................................................................................................................................................................................................................................................................................................................
Dunlop.Theclinicalcontentofpreconceptioncare:theuseofmedicationsandsupplementsamongwomenofreproductiveage.AmJObstetGynecol2008.
Comments
May cause kidney abnormalities in fetus when used in 2nd or 3rd trimesters.
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needtodiscusstheuseofallmedications
and supplements with their health care
provider, particularly if they are plan-
ning a pregnancy or could become preg-
nant. Numerous resources exist to aid
health care providers in selecting appro-
priate medications that balance the risk
andbenefit(forboththewomanandany
offspring she may conceive) of using
particular medications while planning a
pregnancy or during pregnancy.
In medically managing the chronic and
acute health conditions women may face
while planning a pregnancy, it is useful to
classifymedicationsaseither“essential”or
“nonessential.” Essential medications are
those necessary to treat diseases with seri-
ous morbidity for the women and/or her
fetus. Nonessential medications are those
used to treat conditions without serious
morbidity.Ingeneral,thegoalsofprecon-
ception medical management include the
following42:
1. Identify the pattern of medica-
tion and supplement use before
conception.
2. Counsel women with chronic condi-
tions about the potential impact of
the condition and its various treat-
ments on the health of the woman
and the fetus. Provide preconception
counseling of women for whom
drugs are essential to allow them to
make informed decisions regarding
theavoidanceortimingofpregnancy.
3. Establisheffective
chronicconditionsbeforeconception.
4. Manageall chronic
andacute illnesses
pregnancy.
5. Counsel women to avoid the use of
nonessential medications, including
prescription (eg, isotretinoin for
acne) and OTC medications and di-
etary or herbal supplements.
6. Avoid the use of medications with
highteratogenicriskwhenequallyef-
fectivetreatmentswithlowerrisksare
available, for example, warfarin (an
treatmentfor
conditions
throughout
TABLE 3
FDA classification of common over-the-counter medications
FDA Class
by Trimester
Analgesics
................................................................................................................................................................................................................................................................................................................................................................................
AcetominophenB/B/B NonnarcoticPain reliever of choice.
................................................................................................................................................................................................................................................................................................................................................................................
AspirinD/D/D Salicylate Not recommended except for specific indications; associated with increased
perinatal mortality, neonatal hemorrhage, decreased birth weight, prolonged
gestation and labor, and possible teratogenicity.
................................................................................................................................................................................................................................................................................................................................................................................
Ibuprofen
Ketoprofen
Naproxen
B/B/D
NSAID
hypertension of the newborn infant, fetal nephrotoxicity, and periventricular
hemorrhage.
................................................................................................................................................................................................................................................................................................................................................................................
Cough and cold remedies
................................................................................................................................................................................................................................................................................................................................................................................
ChlorpheniramineB AntihistamineAntihistamine of choice.
................................................................................................................................................................................................................................................................................................................................................................................
PseudoephedrineB DecongestantOral decongestant of choice; possible association with gastroschisis.33
................................................................................................................................................................................................................................................................................................................................................................................
GuaifenesinCExpectorantPossible increased risk of neural tube defects.
................................................................................................................................................................................................................................................................................................................................................................................
DextromethorphanC AntitussiveAppears to be safe in pregnancy.
................................................................................................................................................................................................................................................................................................................................................................................
DiphenhydramineB AntihistaminePossible oxytocin-like effects at high dosages.
................................................................................................................................................................................................................................................................................................................................................................................
ClemastineB AntihistamineUnknown safety profile.
................................................................................................................................................................................................................................................................................................................................................................................
Gastrointestinal remedies
................................................................................................................................................................................................................................................................................................................................................................................
Aluminum hydroxide/
Magnesium hydroxide
................................................................................................................................................................................................................................................................................................................................................................................
Calcium carbonateCAntacidAppears to be safe in pregnancy.
................................................................................................................................................................................................................................................................................................................................................................................
SimethiconeCAntiflatulantAppears to be safe in pregnancy.
................................................................................................................................................................................................................................................................................................................................................................................
CimetadineBAntihistamine Preferred after antacids; generally regarded as safe.
................................................................................................................................................................................................................................................................................................................................................................................
RanitidineBAntihistamine Preferred after antacids; generally regarded as safe.
................................................................................................................................................................................................................................................................................................................................................................................
NizatidineCAntihistamine Not recommended because of adverse animal studies.
................................................................................................................................................................................................................................................................................................................................................................................
FamotidineB AntihistamineProbably safe; data needed.
................................................................................................................................................................................................................................................................................................................................................................................
FDA, Food and Drug Administration.
Adapted with permission from “Over the Counter Medications in Pregnancy,” June 15, 2003, American Family Physician.43
................................................................................................................................................................................................................................................................................................................................................................................
Dunlop.Theclinicalcontentofpreconceptioncare:theuseofmedicationsandsupplementsamongwomenofreproductiveage.AmJObstetGynecol2008.
Drug name Drug ClassUse in Pregnancy
B/B/D
B/B/D
NSAID
NSAID
Avoid in 3rd trimester; associated with oligohydramnios, premature closure
of the fetal ductus arteriosus with subsequent persistent pulmonary
B AntacidAppears to be safe in pregnancy.
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