(1)
Department of Family Medicine, University of California, Riverside, Riverside, CA, USA
Key Points
1.
All medications should be viewed with caution in pregnancy.
2.
Management of medication use in pregnancy ideally begins with adequate preconception counseling and prepregnancy planning.
3.
Medications used in pregnancy require clear identification of indication for use, duration of treatment, expected outcome, and signs or symptoms requiring early termination of their use.
4.
When in doubt consultation with an expert in maternal–fetal medicine is strongly recommended.
Background
With the exception of prenatal vitamins and possibly iron supplementation, all medications should be used with caution during pregnancy. Although clinical experience with many medications in pregnancy is quite extensive and the safety and efficacy is reasonably established, pregnancy represents a unique challenge in medication assessment. It would not be ethical, under most circumstances, to randomize pregnant patients to receive increasing doses of medications to assess safety and efficacy of a medication known to produce or suspected of producing harm in pregnancy. This limits the degree to which safety can be categorically stated for the use of any medication in pregnancy. Many medications once thought to be safe in pregnancy have subsequently been shown to be harmful. Other medications originally thought to be harmful have been shown to have beneficial effects when used for specific medically indicated purposes.
Many medications can and should be used in pregnancy for a variety of legitimate medical indications. Although it is beyond the scope of this chapter to discuss in detail the use of all medications in pregnancy, a few general guidelines can be offered. Texts exist that detail the risks and benefits of many available medications. Such a text should be a routine part of every obstetrical provider’s library. When doubt exists concerning the indications for or the safety or efficacy of any medication, consultation with an expert in maternal–fetal medicine is strongly recommended.
General Principles of Medication Use in Pregnancy
The three general principles are as follows:
1.
Chronic medications should be reviewed to assess safety and efficacy.
2.
The risk of not treating (or treating less effectively) an identified disease (acute or chronic) should be weighed against the risks of the proposed treatment.
3.
All medications used in pregnancy require clear identification of indication for use, duration of treatment, expected outcomes, and signs or symptoms that require early termination of use.
Chronic Medical Conditions
Some patients have chronic medical conditions that predate pregnancy. The management of many of these conditions will include the use of medication. Although it is always important to consider safety and efficacy when using medications, with the onset of pregnancy these considerations become considerably more complex. Ideally, a consideration of the impact of pregnancy on the medical condition as well as the impact of the medical condition on pregnancy would occur prior to pregnancy. For some patients, this leads to a recommendation to delay pregnancy until the medical condition can be more adequately controlled. In other circumstances, it may lead to a recommendation to avoid pregnancy altogether.
Under many circumstances (both planned and unplanned), however, management of pregnancy will overlap with management of chronic medical conditions and their associated medications. The first consideration should be for the safety of the mother. Disease processes that are life threatening to the mother may require continuation of treatment even if pregnancy is continued. The provider should explore treatment alternatives with equal efficacy and better established safety profiles when possible. When safer alternatives are not available, providers should discuss with patients the potential risks of continuing the pregnancy while simultaneously continuing the use of the required medication versus the potential risks of terminating medication use for the duration of pregnancy. Patients must be given sufficient information to make an informed decision concerning their health and the health of their developing fetus, especially during the critical period of organogenesis early in pregnancy. In all circumstances providers and patients must make individualized treatment decisions based on the medical conditions of the specific patient.
Acute Medical Conditions
Pregnant patients are vulnerable to all the acute medical conditions of nonpregnant patients. Medical decisions concerning the treatment of acute medical conditions that arise during pregnancy must follow the same general guidelines as those for chronic conditions. Will the medical condition adversely affect the pregnancy? Will treatment of the condition ameliorate or eliminate these potential effects? Will the proposed treatment adversely affect the pregnancy? Are there safer or more well-established alternative treatment options? What are the likely consequences of not treating the medical condition? What are the potential consequences of not treating the medical condition?
As with the treatment of chronic medical conditions, it is critical that both providers and patients have sufficient information concerning the risks and benefits of treatment options to make informed, individualized decisions. When providers cannot adequately answer these questions, patients should be referred to a provider with sufficient expertise to provide more complete information.
Acute Obstetrical Conditions
Pregnancy may be accompanied by a variety of complications that require consideration of medication use. The same general principles apply and the same questions must be answered. When these complications are relatively common, much established data may exist to guide providers and patients in their decision-making process. When the complications are less common, consultation may be required.
Therapeutic Categories and Considerations
Any drug used during pregnancy should be checked for safety prior to use. Keeping in mind the general considerations just given, the following recommendations may be considered:
1.
When antibiotics are indicated consider penicillin, cephalosporins (except cefotetan), clindamycin, and macrolides. Avoid sulfa drugs (contraindicated in the first and third trimester), quinolones, tetracyclines, and aminoglycosides (ototoxic, may be indicated for severe Gram-negative infections).
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