The List of Safe Drugs During Pregnancy & Lactation

7/29/2019 The List of Safe Drugs During Pregnancy & Lactation

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RGUHS J Pharm Sci | Vol 3 | Issue 1 | JanMar, 2013 21

Review Artcle

www.rjps.in

Safe Drugs During Pregnancyand Lactation

S.B. Puranik1, Imran Khan*1, Mohit Joshi2 and Mahvash Iram3

1Biocon Limited Bangalore, 2Srinivas College of Pharmacy Mangalore, 3Al-Ameen College of Pharmacy,

Hosur road Bangalore, Karnataka, India-560027

Received Date : 11-12-2012

Revised Date : 15-02-2013

Accepted Date : 28-02-2013

DOI: 10.5530/rjps.2013.1.4

Address for

correspondence

Mr. Imran Ahmad Khan

Biocon India Ltd,

20th KM, Hosur Road,

Electronic City,

Bangalore- 560100,

Karnataka (India)

Tel. 011-91- 9900434646E-mail:

[email protected]

ABSTRACT

Pregnancy is the carrying of one or more offspring, known as a fetus or embryo, inside the womb of a female.

Lactation describes the secretion of milk from the mammary glands, the process of providing milk to the young,

and the period of time that a mother lactates to feed her young one. This process occurs in all female mammals, in

humans it is commonly referred to as breastfeeding or nursing. This paper summarizes the factors determining fetal

damage and lists the problems associated with some drugs frequently encountered during Pregnancy and Lactation.

Keywords: Pregnancy, lactation, safe drugs, fetal damage.

INTRODUCTION

Pregnancy is the carrying of one or moreoffspring, known as a fetus or embryo, insidethe womb of a female. Lactation describesthe secretion of milk from the mammaryglands, the process of providing milk to the

young, and the period of time that a motherlactates to feed her young one. This processoccurs in all female mammals, in humans itis commonly referred to as breastfeeding ornursing. Medical scientists divide 40 weeksof pregnancy into 3 trimesters. The rst tri-mester is for weeks 012; the second is for1328 weeks, and the third for weeks 2940.1The hazards of exposing the human fetus todrugs have become increasingly apparent inthe last 15 years, during the time when drugusage has steadily increased. Even though a

direct cause-and-effect relationship betweencertain commonly used drugs and fetal dis-orders or malformations has been difcult

to establish, the principle of avoidance ofall but essential medications in pregnancyand in the potentially pregnant has becomeincreasingly important. This paper summa-rizes the factors determining fetal damageand lists the problems associated with somedrugs frequently encountered in practice.2

Drugs that a pregnant woman takes canaffect the fetus in several ways. They canact directly on the fetus causing damageor abnormal development leading to birthdefects or death. Drugs can also alter thefunction of the placenta usually by constrict-

ing blood vessels and reducing the blood sup-ply of oxygen and nutrients to the fetus frommother and thus resulting in a baby that isunderweight and underdeveloped. Moreoverthey can cause the muscles of the uterus tocontract forcefully; indirectly injuring thefetus by reducing the blood supply or trig-gering pre-term labor and delivery.3 Womenoverestimate the risk of drug use and otherexposures during pregnancy. Perception ofrisk may impact a womans decision to takea needed drug during pregnancy manifesting

various other complications. There is a pau-city of research on this topic in the literature.Therefore, it is important for health careproviders to use evidence-based informa-tion, to reduce unnecessary anxiety, and toensure safe and appropriate treatment duringpregnancy.4 This article is a summary regard-ing fetal and neonatal risk of prescriptiondrugs, over-the counter medications, vita-mins and vaccines.5 Survey has conrmed


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S.B. Puranik. et al.: Pregnancy and Lactation......

22 RGUHS J Pharm Sci | Vol 3 | Issue 1 | JanMar, 2013

that at present, some drugs are often more widely usedin pregnancy than is justied by the knowledge available.6

Database available for the information

A Motherisk symposium on establishing benchmarksfor the evaluation of medications during pregnancywas held on May 10, 2006, under the auspices of the

Canadian Society of Pharmacology and Therapeutics.From that symposium came a consensus on the needfor collection and analysis of data on fetal safety andongoing post-marketing surveillance, which in turnled to the establishment of Case Med-Pregnancy-theCanadian Alliance for Safe and Effective Medicationduring Pregnancy and Breastfeeding.7

Safefetus.com is a complete database of worldwidemedications (generic & trade) providing information onthe drugs indications, fetal risk, breastfeeding risk, dur-ing pregnancy, according to the FDA.8

The latest edition is the resource for any practicing Obste-

trician/Gynecologist, family physician, midwife, or phar-macist who prescribes medicinal products to or evaluatesenvironmental or occupational exposures in women whoare or may become pregnant. Based on the highly success-ful German editions of this reference, the up-to-date druglistings have been revised into a handy pocket guide colortabbed for quick access to important information.9 Anti-biotics were the most dispensed prescribed drug duringpregnancy, and the proportion of women lling prescrip-tions with antibiotics increased further during the lactatingperiod reaching almost 14%. The most prescribed antibi-otic drugs were -lactam and penicillins. Similar ndings

were reported in a Norwegian10 and a German11 study.12

Fifth edition of Drugs in Pregnancy and Lactation,

by Briggs GG, Freeman RK, Yaffee SJ is the source whichcontains information on drug effects during both preg-nancy and lactation. The monographs are comprehensiveand up to date and include information from sources thatare difcult for practicing physicians to locate.13

The need for further information on drug utilization pat-terns during pregnancy in different countries was assessedby reviewing literature. The resulting prole, from 13 identi-ed studies, was that, pregnant women used an average of

4.7 drugs. The most commonly ingested medications werevitamins and iron preparations (almost all women), analge-sics, antiemetics and antacids. However, important variables(such as date of surveillance; country; size of involved pop-ulation; habits; physiopathological and demographic char-acteristics), differently taken into account in each selectedstudy, made it impossible to construct a comprehensive,detailed, up-to-date picture about drug utilization duringpregnancy. The evaluation conrmed the need for and value

of systematic permanent surveillance of drug utilization inpregnancy, so as to avoid the use of data obtained in widely

differing contexts, times, and methods, in a eld where

knowledge is often based on scanty information.14 Thisanalysis of a large nation-wide cohort of pregnant womenshowed that during pregnancy drugs were prescribed tomost women, even when vitamins, minerals, iodide and ironwere omitted. Magnesium and iron seemed to have beenover-prescribed. On the other hand, the ofcial recommen-

dation for iodide substitution, to prevent thyroid diseases inmother and child, was insufciently implemented. In ouropinion, regular analysis of prescription data can identifypotential harmful therapies and focal points where guide-lines are needed and can check their implementation.15

How drugs act on fetus

Medications should be avoided by all women who areor might become pregnant. While some medications areknown to be harmful when taken during pregnancy, thesafety of most medications taken by pregnant womenhas been difcult to determine. The effects depend on

many factors, viz. How much medication was taken,when during the pregnancy the medication was taken,other health conditions a woman might have and othermedications a woman takes.16

Some of the fetuss blood vessels are contained in tinyhair like projections (villi) of the placenta that extendinto the wall of the uterus. The mothers blood passesthrough the space surrounding the villi (intervillousspace). Only a thin membrane (placental membrane)separates the mothers blood in the intervillous spacefrom the fetuss blood in the villi. Drugs in the mothersblood can cross this membrane into blood vessels in the

villi and pass through the umbilical cord to the fetus. Theprocess of drug transfer is shown in Figure 1.17

Most drugs that go into the body will also go into the milk,so before any medication is taken, consideration of its effecton baby and whether or not it has any effects on lactationneeds to be done. While most medications are safe to takewhile breastfeeding, its wise to talk to the doctor before tak-ing. Some drugs do not harm the baby, but may affect themilk volume by suppressing the milk-making hormones.On the other hand, some conditions (i.e., hypothyroidism)

Figure 1: Drug transfer to Fetus through Umbilical cord.


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can interfere with ability to make milk, and medications totreat the problem will improve milk production. There arethree issues to consider when considering taking medica-tion while breastfeeding viz. is the drug needed, will thedrug affect baby, will the drug affect ability to make milk.18

More than 90% of pregnant women take prescrip-tion or nonprescription (over-the-counter) drugs or

use social drugs (such as tobacco and alcohol) or illicitdrugs at some time during pregnancy. In general, drugs,

unless absolutely necessary, should not be used dur-ing pregnancy because many can harm the fetus. About2 to 3% of all birth defects result from the use of drugsother than alcohol. Drugs that a pregnant woman takesduring pregnancy can affect the fetus in several ways, viz.they can act directly on the fetus, causing damage, abnormaldevelopment (leading to birth defects), or death, they canalter the function of the placenta, usually by causing blood

vessels to constrict and thus reducing the supply of oxy-gen and nutrients to the fetus from the mother. Sometimesthe result is a baby that is underweight and underdevel-oped, they can cause the muscles of the uterus to contractforcefully, indirectly injuring the fetus by reducing its bloodsupply or triggering preterm labor and delivery. Concernabout the safety of foreign compounds administered to

pregnant women has been increasingly evident since tha-lidomide. The direct response to this misadventure led tothe promulgation of the drug regulations of 1962 in theUnited States. According to these regulations, a drug mustbe demonstrated to be safe and effective for the conditionsof use prescribed in its labeling, including dosage level andpatient populations for whom the drug is intended.19

Over the years, far too many women have been wronglytold they had to stop breastfeeding. The decision aboutcontinuing breastfeeding when the mother takes a drug,

Table 1: List of Safe Drugs during Pregnancy and Lactation20

Sl. No. Name of the Drug Category

1. Acetaminophen Used for pain relief

2. Acyclovir and valacyclovir Antiviral for herpes infections

3. Antacids Used to treat upset stomachs

4. Bupivacaine A local anesthetic

5. Caffeine A stimulant

6. Clotrimazole Used to treat yeast and fungal infections

7. Cephalosporins Antibiotics for lung, ear, skin, urinary tract, throat, and bone infections

8. Contraceptives (progestin-only) Used for birth control

9. Corticosteroids Used to treat inammation of joints and other conditions

10. Decongestant nasal sprays Used to treat stuffy noses

11. Digoxin Used to treat heart problems

12. Erythromycin Used for skin and respiratory infections

13. Fexofenadine Antihistamine for allergies and hay fever

14. Fluconazole Used to treat yeast infections

15. Hepar in and Low molecular weight hepar ins

(enoxaparin, dalteparin, tinzaparin)

Used to prevent blood from clotting

16. Ibuprofen Used for pain relief

17. Inhalers, bronchodilators, and corticosteroids Used for asthma

18. Insulin For diabetes; dosage required may drop up to 25 percent during lactation

19. Laxatives, bulk-forming and stool softening Used to treat constipation

20. Lidocaine A local anesthetic

21. Loratadine Antihistamine for allergies and hay fever

22. Magnesium sulfate Used to treat preeclampsia and eclampsia

23. Methyldopa Used to treat high blood pressure

24. Methylergonovine (short courses) Used to prevent or control bleeding after childbirth

25. Metoprolol A beta-blocker used to treat high blood pressure26. Miconazole Used to treat yeast infections

27. Nifedipine Used for high blood pressure and Reynauds syndrome of the nipple

28. Penicillins Used to treat bacterial infections

29. Propranolol A beta blocker used to treat heart problems, and high blood pressure

30. Theophylline Used to treat asthma and bronchitis

31. Tretinoin Cream used for acne

32. Elotroxin Used to treat thyroid problems

33. Vaccines (except smallpox and yellow fever)

34. Vancomycin An antibiotic

35. Verapamil Used for high blood pressure

36. Warfarin Used to treat or prevent blood clots


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Table 2: List of Probably Safe Drugs in Usual Doses20


1. ACE inhibitors Used to treat high blood pressure

2. Anticholinergic agents Used to treat intestinal and gall bladder spasms; may reduce milk supply

3. Anticonvulsants Used for seizures and mood disorders

4. Antihistamines May reduce milk supply and cause infant drowsiness or fussiness

5. Antituberculars Used to treat tuberculosis

6. Azathioprine Used to suppress the immune system following organ transplants

7. Barbiturates (except Phenobarbital) For sedation and tension headaches

8. Bupropion For depression

9. Clindamycin Used to treat abdominal and vaginal infections

10. Oral decongestants Used to treat congestion associated with colds or allergies; often reduces milk supply

11. Ergonovine (short course) Used to treat uterine bleeding. May reduce milk supply.

12. Fluconazole Antifungal

13. Gadolinium Contrast agent for MRI studies

14. Haloperidol Used to treat psychosis

15. Histamine H2

blockers Used to treat stomach problems

16. Labetalol Used for high blood pressure; caution with preterm babies

17. Hydrochlorothiazide (low doses) Diuretic for high blood pressure

18. Lorazepam Used to treat anxiety

19. Methimazole Used for hyperthyroidism; less than 20 mg/day is probably safe

20. Metoclopramide Used for gastrointestinal problems and to increase milk supply

21. Midazolam Sedative used in anesthesia

22. Naproxen Used for pain relief; okay if baby is at least 1 month old

23. Oxazepam Used to treat anxiety

24. Paroxetine Used to treat depression

25. Phenothiazines antipsychotic and antihistaminic

26. Propofol Sedative used in anesthesia

27. Propylthiouracil (PTU) Used to treat hyperthyroidism

28. Quinidine Used to treat heartbeat irregularities

29. Quinolone antibacterials Treatment of urinary tract infections

30. Salicylates (occasional use) Used for pain relief

31. Sertraline Used to treat depression

32. Spironolactone Used to treat high blood pressure

33. Sumatriptan Used to treat migraines

34. Tetracyclines < 14 days Used to treat acne and urinary tract infections

35. Trazodone Used for depression and sleep

36. Tricyclic antidepressants (avoid doxepin) Used to treat depression; nortriptyline preferred

37. Verapamil Used for high blood pressure

Table 3: List of Potentially Hazardous Drugs in Usual Doses20


1. Acebutolol A beta blocker used to treat high blood pressure and abnormal heart rhythms.

2. Atenolol A beta blocker used to treat high blood pressure and abnormal heart rhythms.

3. Antihistamine/decongestant combinations Used to treat colds and allergies; may reduce milk supply

4. Benzodiazepines Used to treat anxiety and for sleep (lorazepam, oxazepam preferred)

5. Chlorthalidone Diuretic used to treat high blood pressure; may reduce milk supply

6. Citalopram Antidepressant; can cause infant drowsiness

7. Clonidine Used to treat high blood pressure, may reduce milk supply

8. Contraceptives (estrogen-containing) Used for birth control; may reduce milk supply

9. Doxepin Used to treat depression

10. Ergotamine Used to treat migraines

11. Ethosuximide Used to treat epilepsy

12. Fluorescein IV Used to diagnose retinal problems

13. Fluoxetine Used to treat depression

14. Iodinated contrast media Used to examine kidneys; withhold breastfeeding temporarily

15. Lamotrigine Used for seizures and mood disorders

(Continued)


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Table 3: (Continued)


16. Lithium (monitor infant serum levels) Used to treat bipolar disease

17. Metronidazole An antibiotic used to treat some intestinal and genital infections

18. Nadolol A beta blocker used to treat high blood pressure and heart problems

19. Narcotics, especially meperidine in addicts and

high doses with newborns

Used for pain (one tablet every six hours maximum; watch for drowsiness)

20. Nefazodone Used for depression

21. Nicotine Smoking can reduce milk supply

22. Nitrofurantoin Used to treat urinary tract infections (safe if the baby is at least 1 month old)

23. Phenobarbital, anticonvulsant doses Sedative and anticonvulsant

24. Piroxicam Used to treat arthritis and pain

25. Primidone Used to treat seizures

26. Reserpine Used to treat hypertension

27. Sotalol Used to treat heart problems

28. Thiazide diuretics, long-acting or high doses For high blood pressure or edema; high dose may reduce milk supply

29. Venlafaxine Used to treat depression

Table 4: List of Drugs not Safe to take in Usual Doses in Pregnancy and Lactation20


1. Amantadine Used to treat the u or Parkinsons disease2. Amiodarone Used to treat heart problems

3. Antilipemics (excluding resins) Used to lower the level of cholesterol in the blood

4. Antineoplastic agents Used to treat cancer

5. Aspirin (large doses) Used to treat arthritis

6. Cocaine Narcotic Analgesic

7. Chlorampenicol Used to treat serious infections

8. Clozapine Used to treat schizophrenia

9. Dipyrone (dipironain Mexican drugs) Used for pain and inammation

10. Gold Salts Used to treat arthritis

11. Iodide products Used for douching or as an expectorant

12. Iodine, radioactive Used to diagnose and treat hyperthyroidism

13. Lipid-lowering drugs Used to lower the level of fats in the blood

14. Metamizole (Dipyrone) Analgesic/anti-inammatory

15. Salicyclates, large doses Used to treat arthritis

Table 5: Problems Associated with Commonly Used Drugs

Sl. No. Category Examples Problem

1. Anti- anxiety drug Diazepam When the drug is taken late in pregnancy, depression,

irritability, shaking, and exaggerated reexes in the

newborn

2. Antibiotics Chloramphenicol Gray baby syndrome

In women or fetuses with glucose-6-phosphate

dehydrogenase (G6PD) deciency, the breakdown of red

blood cells

Fluoroquinolones (such as ciprooxacin,

ooxacin, levooxacin, and noroxacin)

Possibility of joint abnormalities (seen only in animals)

Kanamycin Damage to the fetuss ear, resulting in deafness(ototoxicity)

Nitrofurantoin In women or fetuses with G6PD deciency, the breakdown

of red blood cells

Streptomycin Damage to the fetuss ear, resulting in deafness(ototoxicity)

Sulfonamides (such assulfasalazine and

trimethoprim-sulfamethoxazole )

When the drugs are given late in pregnancy, jaundice and

possibly brain damage in the newborn (much less likely

with sulfasalazine)

In women or fetuses with G6PD deciency, the breakdown

of red blood cells

Tetracycline Slowed bone growth, permanent yellowing of the teeth,

and increased susceptibility to cavities in the baby

Occasionally, liver failure in the pregnant woman

(Continued)


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3. Anticoagulants Heparin When the drug is taken for a long time, osteoporosis and a

decrease in the number of platelets in the pregnant woman

Warfarin Birth defects

Bleeding problems in the fetus and the pregnant woman

4. Anticonvulsants Carbamazepine Some risk of birth defects

Bleeding problems in the newborn, which can be prevented

if pregnant women take vitamin K orally every day fora month before delivery or if the newborn is given an

injection of vitamin K soon after birth

Phenytoin & Phenobarbital Same as those for carbamazepine

Trimethadione Increased risk of miscarriage in the woman

High (70%) risk of birth defects, including a cleft palate and

defects of the heart, face, skull, hands, or abdominal organs

Valproate Some (1%) risk of birth defects, including a cleft palate and

defects of the heart, face, skull, spine, or limbs

Angiotensin-converting enzyme (ACE)

inhibitors

When the drugs are taken late in pregnancy, kidney

damage in the fetus, a reduction in the amount of uid

around the developing fetus (amniotic uid), and defects of

the face, limbs, and lungs

5. Antihypertensive Beta-blockers When some beta-blockers are taken during pregnancy, a

slowed heart rate and low blood sugar level in the fetusand possibly slowed growth

Thiazide diuretics A decrease in the levels of oxygen, sodium, and potassium

and in the number of platelets in the fetuss blood

Slowed growth

Actinomycin Possibility of birth defects (seen only in animals)

6. Chemotherapy

drugs

Busulfan Birth defects such as underdevelopment of the lower jaw,

cleft palate, abnormal development of the skull bones,

spinal defects, ear defects, and clubfoot

Slowed growth

Chlorambucil, Cyclophosphamide,

Mercaptopurine & Methotrexate

Same as those with busulfun

Vincristine & Vinblastine Possibility of birth defects (seen only in animals)

7. Mood-stabilizing

drug

Lithium Birth defects (mainly of the heart), lethargy, reduced muscle

tone, poor feeding, underactivity of the thyroid gland, and

nephrogenic diabetes insipidus in the newborn

8. Non-steroidal

anti-inammatory

drugs (NSAIDs)

Aspirin and other salicylates

Ibuprofen, Naproxen

When the drugs are taken in large doses, a delay in the

start of labor, premature closing of the connection between

the aorta and artery to the lungs (ductus arteriosus),

jaundice, and (occasionally) brain damage in the fetus and

bleeding problems in the woman during and after delivery

and in the newborn

When the drugs are taken late in pregnancy, a reduction in

the amount of uid around the developing fetus

9. Oral anti-

hyperglycemic

drugs

Chlorpropamide & Tolbutamide A very low level of sugar in the blood of the newborn

Inadequate control of diabetes in the pregnant woman

When the drug is taken early in pregnancy by a woman with

type 2 diabetes, possibility of increased risk of birth defects

10. Sex hormones Danazol & Synthetic progestin (but not thelow doses used in oral contraceptives)

When this drug is taken very early in pregnancy,masculinization of a female fetuss genitals, sometimes

requiring surgery to correct

Diethylstilbestrol (DES) Abnormalities of the uterus, menstrual problems, and an

increased risk of vaginal cancer and complications during

pregnancy in daughters

Abnormalities of the penis in sons

11. Skin treatments Etretinate Birth defects, such as heart defects, small ears, and

hydrocephalus (sometimes called water on the brain)

Isotretinoin Same as those for etretinate

Mental retardation

Risk of miscarriage

(Continued)


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12. Thyroid drugs Methimazole An enlarged or underactive thyroid gland in the fetus

Scalp defects in the newborn

Propylthiouracil An enlarged or underactive thyroid gland in the fetus

Radioactive iodine Destruction of the thyroid gland in the fetus

When the drug is given near the end of the 1st trimester,

very overactive and enlarged thyroid gland in the fetus

Triiodothyronine An overactive and enlarged thyroid gland in the fetus13. Vaccines (live

virus)

Vaccine for German measles (rubella) and

chickenpox (varicella)

Potential infection of the placenta and developing fetus

Vaccines for measles, mumps, polio, or

yellow fever

Potential but unknown risks

Table 6: Drugs Category Based on AAP22

Lactation Risk Categories Pregnancy Risk Categories

L1 (safest)

L2 (safer)

L3 (moderately safe)

L4 (possibly hazardous)

L5 (contraindicated)

A (controlled studies show no risk)

B (no evidence of risk in humans)

C (risk cannot be ruled out)

D (positive evidence of risk)

X (contraindicated in pregnancy)

for example, is far more involved than whether the babywill get any in the milk. It also involves taking into con-sideration the risks of not breastfeeding, for the mother,the baby and the family, as well as society. On the otherhand, it should be taken into consideration that somebabies may refuse to take the bottle completely, so thatthe advice to stop is not only wrong, but often impracti-

cal as well. On top of that it is easy to advise the motherto pump her milk while the baby is not breastfeeding,but this is not always easy in practice and the mothermay end up painfully engorged. So it is necessary toknow which drugs are safe for consumption duringpregnancy and lactation or the alternatives for that drug.

Medications are grouped into 1 of 5 categories based onthe potential for producing birth defects. The categories

are A, B, C, D and X. Generally speaking, drugs that fallinto either class A or B are considered safe and are routinelyused. There may be exceptions.21 The American Academyof Pediatrics has given a selected list of some approveddrugs by them for the use in breastfeeding mothers (AAPlist revised 8/04). This list is for general information only.They have classied these drugs in following categories.22

Table 7: List of Commonly Used Drugs during Pregnancy & Lactation Based on Risk Category22

Generic Name Pregnancy Risk Category Lactation Risk Category

Analgesics

Acetaminophen B L1Colchicine D L4

Nefopam NR

Non-Steroidal Anti-Infammatory Drugs (NSAIDs)

Azapropazone (apazone) L2

Dipyrone (banned in the US & UK) NR

Flufenamic acid NR

Ibuprofen B (1st, 2nd trim.) D (3rd trim.) L1

Indomethacin B (1st, 2nd trim.) D (3rd trim.) L3

Ketorolac B (1st, 2nd trim.) D (3rd trim.) L2

Mefenamic acid NR

Naproxen B L3, L4 (for chronic use)

Phenylbutazone NR

Piroxicam B L2

Suprofen NR

Tolmetin C L3

Narcotic Analgesic

Butorphanol B (1st, 2nd trim.), D (3rd trim.) L3

Codeine C L3

Fentanyl B L2

Meperidine BL2

L3 (if used early postpartum)

Methadone & Morphine B L3

Propoxyphene C L2

(Continued)


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Anesthetics

Halothane & Lidocaine C L2

Methohexital B L3

Thiopental C L3

Antacids and gastrointestinal drugs

Cimetidine (Antacid) B L2Cisapride (GI tract stimulant) C L2

Domperidone (used for nausea & vomiting, stimulates

lactation) L1

Antibiotic

Amoxicillin B L1

Aztreonam B L2

Cefadroxil, Cefazolin, Cefoxitin & Ceftazidime B L1

Cefotaxime B L2

Cefprozil C L1

Ceftriaxone B L2

Ciprooxacin C L3

Clindamycin B L3

Erythromycin B L1, L3 early postnatal

Gentamicin & Ooxacin C L2

Kanamycin D L2

Fleroxacin, Moxalactam & Sulbactam NR

Nitrofurantoin B L2

Penicillin B L1

Streptomycin D L3

Carbamazepine & Sulsoxazole C L2

Tetracycline D L2

Ticarcillin B L1

Trimethoprim/sulfamethoxazole C L3

Anticoagulant

Bishydroxycoumarin (dicumarol) NR

Warfarin D L2

Anticonvulsant

Ethosuximide C L4

Magnesium sulfate B L1

Phenytoin & Valproic acid D L2

Antifungal

Fluconazole & Ketoconazole C L2

Antihistamine

Dexbrompheniramine maleate with d-isoephedrine NR

Fexofenadine C L2

Loratadine B L1

Terfenadine NR

Triprolidine C L1

AntiviralAcyclovir C L2

Interferon-alpha C L2

Arthritis Medication

Gold salts C L5

Asthma Medication

Dyphylline & Theophylline C L3

Terbutaline B L2

Contraceptives/Hormones

Estradiol X L3 (may interfere with milk production)

Clogestone NR

(Continued)




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Contraceptive pill with estrogen/progesterone X L3 (may interfere with milk production)

Levonorgestrel & Norethynodrel X L2

Medroxyprogesterone D L1, L4 (if used rst 3 days postpartum)

Progesterone L3

Anti-Tussive

Codeine C L3

Noscapine NR

Decongestants

Pseudoephedrine C L3 (for acute use), L4 (for chronic use)

Diabetes Medication

Note: Insulin has not been reviewed by the AAP. Pregnancy risk category = B; Lactation r isk category = L1.

Tolbutamide D L3

Anti-Diarrheal

Loperamide B L2

Note: Pepto-Bismol & Kaopectate (bismuth subsalicylate is the active ingredient in both) are not recommended for routine use by

nursing mothers, due to the association of salicylates with Reyes syndrome in children.

Diuretics

Acetazolamide C L2

Bendroumethiazide D L4 (may inhibit lactation)Chlorothiazide & Chlorthalidone D L3

Hydrochlorothiazide & Spironolactone D L2

Galactagogues

Domperidone L1

Antiarrhythmic/Antihypertensive/Cardiac Stimulant

Antiarrhythmics

Disopyramide & Quinidine C L2

Flecainide & Procainamide C L3

Mexiletine B L2

Antihypertensive

Captopril D L3 (if used after 30 days)

Diltiazem/Diltiazem HCL C L3

Enalapril/Enalapril Maleate C (1st trim.), D (2nd, 3rd trim.) L2Hydralazine, Labetalol & Methyldopa C L2

Minoxidil C L2 (topically), L3 (orally)

Nadolol C L4

Nifedipine C L2

Oxprenolol NR

Propranolol, Timolol & Verapamil C L2

Sotalol B L3

Cardiac Stimulants

Digoxin C L2

Laxatives

Cascara/Cascara Sagrada C L3

Danthron NR

Magnesium sulfate B L1Senna L3

Anti-Malarial

Chloroquine C L3

Hydroxychloroquine C L2

Pyrimethamine C L4

Quinine D L2

Diagnostic agents

Diatrizoate NR

Fluorescein C L3

Gadopentetic (Gadolinium) C L2

(Continued)




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Iohexol, Metrizoate & Metrizamide B L2

Iopanoic acid D L2

Migraine Medication

Sumatriptan C L3

Sedatives

Chloral hydrate C L3

Methyprylon (withdrawn from use in US & Canada) NR

Bromide D L5

Secobarbital D L3

Sleep Aids

Zolpidem/Zolpidem Tartrate B L3

Steroids

Prednisone, Prednisolone & Methylprednisolone [high

dosage methylprednisolone]C L2

Thyroid

Carbimazole & active metabolite of carbimazole

(Methimazole)D L3

Propylthiouracil D L2

Thiouracil NR

Levothyroxine A L1

Tuberculosis

Cycloserine & Isoniazid C L3

Ethambutol B L2

Rifampin C L2

Vitamins

B-1 (thiamin) NR

B-12 (Cyanocobalamin) A L1

B-6 (pyridoxine) A L2; L4 in high doses (may inhibit lactation)

D, vitamin A L3 (do not overdose)

Folic acid A (1st, 2nd trim.), C (3rd trim.) L1

K-1, vitamin (Phytonadione) C L1

Riboavin/B2

A L1

Miscellaneous

Acitretin (Anti-psoriasis) NR

Alcohol/Ethanol D L3

Allopurinol C L2

Antimony NR

Atropine (Anticholinergic, drying agent) C L3

Azapropazone/apazone (Antirheumatic) L2

Baclofen (muscle relaxant) C L2

Barbiturate NR

Caffeine B L2

Carbetocin (Antihemorrhagic) NR

Chloroform NR

Cisplatin (Anti-cancer) D L4

Dapsone (Antileprosy) C L4

Hydroxychloroquine (Antirheumatic, lupus) C L2

Iodine & Iodides (povidone-iodine, e.g., in a vaginal

douche) NR

Ivermectin (Antiparasitic) C L3

Nalidixic acid (Urinary Anti-infective) B L4

Norsteroids NR

Pyridostigmine (Muscle stimulant) C L2

Scopolamine (Motion sickness) C L3

Sulfapyridine NR

Timolol (glaucoma med) D L3

*NR: Not Reviewed. This drug has not yet been reviewed by the AAP.




11/11



CONCLUSION

Drugs should be avoided by all women who are ormight become pregnant. While some medications areknown to be harmful when taken during pregnancy, thesafety of most medications taken by pregnant womenhas been difcult to determine. The effects depend on

many factors, viz. How much medication was taken,

when during the pregnancy the medication was taken,other health conditions a woman might have and othermedications a woman takes?Some of the fetuss bloodvessels are contained in tiny hair like projections (villi)of the placenta that extend into the wall of the uterus.The mothers blood passes through the space surround-ing the villi (intervillous space). Only a thin membrane(placental membrane) separates the mothers bloodin the intervillous space from the fetuss blood in thevilli. Drugs in the mothers blood can cross this mem-brane into blood vessels in the villi and pass through theumbilical cord to the fetus. Most drugs that go into the

body will also go into the milk, so before any medicationis taken, consideration of its effect on baby and whetheror not it has any effects on lactation must be made.

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Documents

The List of Safe Drugs During Pregnancy & Lactation