Medication Safety During Pregnancy — What's Safe, What to Avoid

Acetaminophen (Tylenol) is considered the safest over-the-counter pain reliever during pregnancy and is the first-line recommendation for headaches, body aches, fever, and mild to moderate pain. It has been used extensively during pregnancy for decades, and major medical organizations including ACOG continue to support its use at recommended doses (no more than 3,000mg per day, though many providers prefer a limit of 2,000mg).

NSAIDs (non-steroidal anti-inflammatory drugs) — including ibuprofen (Advil, Motrin) and naproxen (Aleve) — should generally be avoided during pregnancy. In the first trimester, some studies suggest a small increased risk of miscarriage. In the third trimester (especially after 20 weeks), NSAIDs can cause premature closure of the ductus arteriosus (a critical fetal blood vessel), reduced amniotic fluid levels (oligohydramnios), and kidney problems in the fetus. The FDA issued a specific warning in 2020 against NSAID use after 20 weeks of pregnancy.

Aspirin in standard doses should be avoided for the same reasons as other NSAIDs. However, low-dose aspirin (81mg daily) is actually recommended for some women at high risk of preeclampsia — this is a specific medical indication prescribed by your provider, typically starting between weeks 12-16.

For migraines, acetaminophen combined with caffeine (in moderate amounts) is generally the first approach. Your provider may also recommend magnesium supplementation for migraine prevention. For severe migraines that don't respond to acetaminophen, your provider may prescribe specific medications after weighing benefits and risks.

Always check the active ingredients in combination products (cold medicines, PM formulations) — many contain multiple medications, some of which may not be safe during pregnancy.

Dealing with allergies, colds, or congestion during pregnancy is frustrating because many go-to medications require a second thought. Here's what the evidence says about common options.

Antihistamines for allergies: loratadine (Claritin) and cetirizine (Zyrtec) are considered first-line safe options during pregnancy. Both are second-generation antihistamines with extensive safety data and minimal drowsiness. Diphenhydramine (Benadryl) is also considered safe but causes drowsiness and is typically used at bedtime or for acute allergic reactions. Chlorpheniramine is another safe option.

For nasal congestion, saline nasal spray and nasal irrigation (like a neti pot with sterile water) are the safest first-line options. Nasal steroid sprays (budesonide/Rhinocort is the most studied in pregnancy) are safe for ongoing use. Pseudoephedrine (Sudafed) should generally be avoided in the first trimester due to a small risk of abdominal wall defects, and used only briefly in the second and third trimesters if needed — it can also raise blood pressure. Phenylephrine (in many 'PE' formulations) has poor oral absorption and limited evidence in pregnancy.

For coughs, dextromethorphan (found in Robitussin DM and Delsym) is considered safe after the first trimester. Guaifenesin (an expectorant in Mucinex) is generally acceptable, though data is limited in the first trimester. Honey is a surprisingly effective and completely safe cough suppressant — studies show it performs comparably to dextromethorphan for nighttime cough.

For sore throats, throat lozenges, warm salt water gargles, and acetaminophen are all safe. Avoid lozenges containing menthol in large quantities or herbal ingredients that haven't been studied in pregnancy.

General rule: use the minimum effective dose for the shortest time necessary. Read all labels carefully and avoid multi-symptom combination products — treat only the specific symptoms you have.

Digestive complaints are among the most common pregnancy symptoms, and fortunately most have safe treatment options.

For heartburn and acid reflux, calcium carbonate antacids (Tums) are the first-line option — they also provide supplemental calcium. Famotidine (Pepcid) is considered safe for more persistent heartburn that doesn't respond to antacids. Ranitidine (Zantac) was previously recommended but was withdrawn from the market due to contamination concerns. Omeprazole (Prilosec) and other proton pump inhibitors (PPIs) are generally reserved for severe cases — they're not considered harmful, but the evidence base is smaller, so providers often try H2 blockers first. Avoid sodium bicarbonate-based antacids (baking soda, Alka-Seltzer) due to their high sodium content, which can cause fluid retention.

For nausea and vomiting, the first-line treatment is the combination of vitamin B6 (pyridoxine, 25mg three times daily) and doxylamine (Unisom SleepTabs, 12.5mg). This combination — previously sold as Diclegis — has the most extensive safety data of any pregnancy anti-nausea treatment. Ginger in standardized capsules (250mg four times daily) is backed by clinical evidence. For moderate nausea, your provider may prescribe dimenhydrinate (Dramamine) or meclizine. For severe cases (hyperemesis gravidarum), ondansetron (Zofran), metoclopramide, or IV fluids may be necessary.

For constipation, the safety hierarchy is: dietary fiber first (psyllium husk/Metamucil is safe), then osmotic laxatives (polyethylene glycol/Miralax has a strong safety profile), then stool softeners (docusate sodium/Colace). Stimulant laxatives like senna or bisacodyl should be used only occasionally and with provider guidance, as they can theoretically stimulate uterine contractions. Mineral oil should be avoided as it can interfere with nutrient absorption.

For diarrhea, loperamide (Imodium) is considered safe after the first trimester for short-term use. Focus on hydration and electrolyte replacement. Bismuth subsalicylate (Pepto-Bismol) should be avoided due to its salicylate (aspirin-like) component.

One of the most critical — and misunderstood — medication decisions during pregnancy involves chronic conditions. The instinct to stop all medications 'for the baby's safety' can actually be more dangerous than continuing treatment. Uncontrolled chronic conditions pose significant risks to both mother and baby.

Depression and anxiety: untreated prenatal depression is associated with preterm birth, low birth weight, postpartum depression, and impaired mother-infant bonding. SSRIs, particularly sertraline (Zoloft) and fluoxetine (Prozac), have been extensively studied in pregnancy. While they do cross the placenta, the absolute risks to the baby are small, and most research shows these medications are compatible with healthy pregnancies. Paroxetine (Paxil) is the one SSRI typically avoided due to a small increased risk of cardiac defects. Never stop antidepressants abruptly — work with your provider to either continue, adjust, or taper gradually.

Epilepsy: uncontrolled seizures during pregnancy carry serious risks including fetal injury, placental abruption, and maternal death. Most anti-epileptic drugs have some risk — valproic acid (Depakote) carries the highest risk of birth defects and should be avoided if possible. Lamotrigine (Lamictal) and levetiracetam (Keppra) are generally considered the safest options. If you have epilepsy and are planning pregnancy, work with your neurologist in advance to optimize your medication regimen. High-dose folic acid (4mg daily) is recommended.

Asthma: uncontrolled asthma reduces oxygen delivery to the baby and increases the risk of preeclampsia, preterm birth, and low birth weight. Most asthma medications — including inhaled corticosteroids (budesonide is the most studied), short-acting beta-agonists (albuterol), and long-acting beta-agonists — are considered safe and should be continued. Budesonide is the preferred inhaled corticosteroid during pregnancy because it has the most safety data. The rule is simple: the risk of an asthma attack far exceeds the risk of asthma medication.

The same principle applies to thyroid conditions, autoimmune diseases, and hypertension — work closely with your provider to find the safest effective treatment rather than stopping medication entirely.

'Natural' does not mean safe — this is one of the most important distinctions to understand during pregnancy. Herbal supplements are not regulated by the FDA the same way medications are, meaning their purity, potency, and safety are not guaranteed. Many herbal products contain active compounds that can cross the placenta, stimulate uterine contractions, or interact with other medications.

Herbal products with some evidence supporting safety include ginger (the most studied — effective for nausea at doses up to 1,000mg daily, with a reassuring safety profile), peppermint tea (safe in normal food/beverage amounts for digestive discomfort), chamomile tea (generally considered safe in moderate amounts, though very large doses are not well-studied), and raspberry leaf tea (traditionally used to prepare for labor in the third trimester — limited evidence suggests it may shorten the second stage of labor, but start only after 32 weeks and with provider approval).

Herbal products to avoid during pregnancy include black cohosh and blue cohosh (can stimulate uterine contractions and cause preterm labor), dong quai (has estrogenic effects and may cause uterine contractions), pennyroyal (toxic and can cause miscarriage — even small amounts are dangerous), large doses of parsley, sage, or oregano oil (concentrated forms may stimulate the uterus), St. John's wort (interacts with many medications and has insufficient pregnancy safety data), ephedra/ma huang (stimulant that can raise blood pressure and heart rate), kava (associated with liver damage and has no pregnancy safety data), and high-dose vitamin A supplements (doses above 10,000 IU daily are teratogenic).

Essential oils also require caution. While diffusing lavender or peppermint oil is generally considered safe, ingesting essential oils or applying concentrated oils directly to the skin is not recommended during pregnancy. Some oils — including clary sage, rosemary, and cinnamon bark — may stimulate contractions.

Before taking any supplement, ask your provider. Bring the actual product (or a photo of the label) so they can review the specific ingredients and dosages.

Evaluating medication safety during pregnancy requires nuance — it's rarely a simple yes or no. The old FDA pregnancy letter categories (A, B, C, D, X) were replaced in 2015 by the Pregnancy and Lactation Labeling Rule (PLLR), which requires more detailed narrative descriptions of risks, human data, and animal data. This is more informative but also more complex to interpret.

Key principles to understand: no medication is proven 100% safe in pregnancy — ethical constraints prevent randomized controlled trials in pregnant women. Most safety data comes from registries that track outcomes in women who took medications during pregnancy, animal studies (which don't always translate to humans), and retrospective observational studies. The absence of evidence of harm is not the same as evidence of safety, but for many commonly used medications, decades of real-world use provide substantial reassurance.

The risk-benefit calculation always includes two sides: the risk of the medication to the baby versus the risk of the untreated condition to both mother and baby. For example, the small theoretical risk of an SSRI is often far outweighed by the well-documented risks of untreated depression during pregnancy.

When discussing medications with your provider, share your complete medication list (including supplements, vitamins, and occasional OTC use), ask specific questions like 'What are the known risks of this medication during pregnancy?' and 'What are the risks of not treating this condition?', don't rely on internet searches or pregnancy apps for medication safety — these are often overly cautious and can cause unnecessary alarm, and ask about the timing — some medications are only risky during specific developmental windows.

Reliable resources to discuss with your provider include MotherToBaby (mothertobaby.org) — a free service run by teratology information specialists who can answer medication questions by phone or chat, LactMed (for breastfeeding safety), and the Organization of Teratology Information Specialists (OTIS) pregnancy registries.

The most important takeaway: never stop a prescribed medication without talking to your provider first. Abrupt discontinuation can be dangerous for both chronic conditions and the baby.