Clinical Review

What you need to know about medication safety in pregnancy

OBG Manag. 2007 November;19(11):66-82

References

Reference

1. American College of Obstetricians and Gynecologists. Teratology. ACOG Educational Bulletin #236. Washington, DC: ACOG; 1997.

2. Splinter M, Nightingale B, Sawgraves R, Rayburn W. Medication use during pregnancy by women delivering at a tertiary university hospital. South Med J. 1997;90:498-502.

3. Physician’s Desk Reference. 61st ed. Montvale, NJ: Medical Economics; 2007.

4. Briggs GG, Freeman RK, Yaffee FJ. Drugs in Pregnancy and Lactation: Reference Guide to Fetal and Neonatal Risk. 7th ed. Baltimore: Williams & Wilkins; 2005.

5. Briggs GG, Freeman RK, Yaffee FJ. ReproTox Database. Vol. 13. No. 1. Bethesda, Md: Reproductive Toxicology Center; 2000.

6. Heinonen OP, Sloan ED, Shapiro S. Birth Defects and Drugs in Pregnancy. Boston: John Wright PSG; 1973.

7. Reproductive Toxicology Center. Bethesda, Md. Available at http://reprotox.org. Accessed Oct. 5, 2007.

8. PDR for Nonprescription Drugs, Dietary Supplements, and Herbs. 28th ed. Montvale, NJ: Medical Economics; 2007.

<b>How selected drugs affect the human fetus and breastfed infant</b><cs cn="1" a="l"> <cs cn="2" a="l"> <cs cn="3" a="l"> <cs cn="4" a="l"> </cs></cs></cs></cs><row><entry v="t">DRUG</entry> <entry v="t">FIRST-TRIMESTER EFFECTS</entry> <entry v="t">EFFECTS DURING SECOND AND THIRD TRIMESTER</entry> <entry v="t">SAFETY DURING BREASTFEEDING</entry></row><row><entry cs="4">ANALGESICS</entry></row><row><entry v="t">Acetaminophen</entry> <entry v="t">None known</entry> <entry v="t">Hepatotoxicity/nephrotoxicity</entry> <entry v="t">Safe</entry></row><row><entry v="t">Ibuprofen</entry> <entry v="t">Gastroschisis (?)</entry> <entry v="t">Closure of ductus</entry> <entry v="t">Small amount passed; no other information</entry></row><row><entry v="t">Narcotics</entry> <entry v="t">None known</entry> <entry v="t">Depression, withdrawal</entry> <entry v="t">Not recommended if dosing is repetitive</entry></row><row><entry v="t">Salicylates</entry> <entry v="t">None known</entry> <entry v="t">Prolonged pregnancy and labor, hemorrhage, altered hemostasis, intracranial hemorrhage</entry> <entry v="t">Use with caution; may have adverse effects in newborn</entry></row><row><entry cs="4">ANESTHETICS</entry></row><row><entry v="t">General</entry> <entry v="t">Anomalies (?), abortion (?)</entry> <entry v="t">Depression</entry> <entry v="t"> </entry></row><row><entry v="t">Local</entry> <entry v="t">None known</entry> <entry v="t">Bradycardia, seizures</entry> <entry v="t"> </entry></row><row><entry cs="4">ANTI-ASTHMATICS</entry></row><row><entry v="t">Metaproterenol, salmeterol, albuterol</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">No information available</entry></row><row><entry v="t">Terbutaline</entry> <entry v="t">None known</entry> <entry v="t">Tachycardia, hypothermia, hypocalcemia, hypoglycemia, and hyperglycemia</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Theophylline</entry> <entry v="t">None known</entry> <entry v="t">Jitteriness, tachycardia</entry> <entry v="t">May produce jitteriness, poor feeding, vomiting, cardiac arrhythmias</entry></row><row><entry cs="4">ANTICOAGULANTS</entry></row><row><entry v="t">Warfarin</entry> <entry v="t">Nasal hypoplasia, ophthalmic abnormalities, epiphyseal stippling</entry> <entry v="t">Hemorrhage, stillbirth</entry> <entry v="t">Safe</entry></row><row><entry v="t">Heparin, low molecular weight</entry> <entry v="t">None known</entry> <entry v="t">Hemorrhage (?), stillbirth (?)</entry> <entry v="t">Safe</entry></row><row><entry cs="4">ANTICONVULSANTS</entry></row><row><entry v="t">Barbiturates</entry> <entry v="t">Malformations (?)</entry> <entry v="t">Bleeding, withdrawal</entry> <entry v="t">Not recommended</entry></row><row><entry v="t">Carbamazepine, oxcarbazepine</entry> <entry v="t">Craniofacial, neural tube (?)</entry> <entry v="t">Bleeding, withdrawal, growth restriction</entry> <entry v="t">Probably safe</entry></row><row><entry v="t">Clonazepam</entry> <entry v="t">None known</entry> <entry v="t">Withdrawal, depression</entry> <entry v="t">Not recommended (potential for apnea, cyanosis, or hypotonia); serum levels should be monitored</entry></row><row><entry v="t">Ethosuximide</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Gabapentin</entry> <entry v="t">Unknown</entry> <entry v="t">None known</entry> <entry v="t">Unknown</entry></row><row><entry v="t">Phenytoin*</entry> <entry v="t">Craniofacial abnormalities, mental retardation, hypoplasia of phalanges</entry> <entry v="t">Hemorrhage, depletion of vitamin K-dependent clotting factors</entry> <entry v="t">Probably safe</entry></row><row><entry v="t">Primidone</entry> <entry v="t">Orofacial clefts</entry> <entry v="t">Hemorrhage, depletion of vitamin K-dependent clotting factors, intrauterine growth restriction</entry> <entry v="t">May produce significant adverse effects in infants; use with caution</entry></row><row><entry v="t">Trimethadione*</entry> <entry v="t">Mental retardation, facial dysmorphogenesis, cardiovascular effects</entry> <entry v="t">Hemorrhage, depletion of vitamin K-dependent clotting factors, intrauterine growth restriction</entry> <entry v="t">No information available</entry></row><row><entry v="t">Valproic acid*</entry> <entry v="t">Spina bifida, facial dysmorphogenesis</entry> <entry v="t">Perinatal distress, behavioral abnormalities</entry> <entry v="t">Safe</entry></row><row><entry cs="4">ANTI-EMETICS</entry></row><row><entry v="t">Diphenhydramine</entry> <entry v="t">None known, clefting unlikely</entry> <entry v="t">None known</entry> <entry v="t">Safe, but may cause drowsiness</entry></row><row><entry v="t">Doxylamine (with pyridoxine)</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Unknown; probably sedating</entry></row><row><entry v="t">Meclizine</entry> <entry v="t">None known</entry> <entry v="t">Retrolental fibrosis in premature infant</entry> <entry v="t">Unknown</entry></row><row><entry v="t">Metoclopramide</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Potential central nervous system effects</entry></row><row><entry v="t">Ondansetron</entry> <entry v="t">Unknown</entry> <entry v="t">Unknown</entry> <entry v="t">Unknown</entry></row><row><entry v="t">Promethazine</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Scopolamine</entry> <entry v="t">None known</entry> <entry v="t">Fetal heart rate changes</entry> <entry v="t">Compatible</entry></row><row><entry cs="4">ANTIBACTERIALS</entry></row><row><entry v="t">Aminoglycosides</entry> <entry v="t">None known</entry> <entry v="t">Nephrotoxic (?), ototoxic (?)</entry> <entry v="t">Depends on level of exposure and renal function of infant</entry></row><row><entry v="t">Azithromycin</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Cephalosporins</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Probably Compatible</entry></row><row><entry v="t">Chloramphenicol</entry> <entry v="t">None known</entry> <entry v="t">Vascular collapse</entry> <entry v="t">Contraindicated</entry></row><row><entry v="t">Ciprofloxacin</entry> <entry v="t">Toxic to developing cartilage (?)</entry> <entry v="t">Toxic to developing cartilage (?)</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Clindamycin</entry> <entry v="t">Unknown</entry> <entry v="t">Unknown</entry> <entry v="t">Compatible, but potential modification of bowel flora, interference with culture interpretation after fever work-up in infants</entry></row><row><entry v="t">Erythromycin</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Isoniazid</entry> <entry v="t">Malformations (?)</entry> <entry v="t">Behavioral abnormality</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Metronidazole</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Use with caution because of mutagenic and carcinogenic effects in some species; abstain from breastfeeding for 12–24 hours after single dose</entry></row><row><entry v="t">Nitrofurantoin</entry> <entry v="t">None known</entry> <entry v="t">Hemolysis (?)</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Penicillins</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Rifampin</entry> <entry v="t">Risk of malformation not greater than in general population</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Sulfonamides</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Generally Compatible, but avoid in infants with hyperbilirubinemia, premature infants, and infants with G6PD deficiency</entry></row><row><entry v="t">Tetracyclines</entry> <entry v="t">None known</entry> <entry v="t">Stained deciduous teeth (enamel hypoplasia)</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Trimethoprim</entry> <entry v="t">Cleft palate, micrognathia, limb shortening</entry> <entry v="t">Unknown</entry> <entry v="t">Compatible</entry></row><row><entry cs="4">ANTIFUNGALS</entry></row><row><entry v="t">Amphotericin-B</entry> <entry v="t">Unknown</entry> <entry v="t">Unknown</entry> <entry v="t">Unknown</entry></row><row><entry v="t">Fluconazole</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry cs="4">ANTIRETROVIRALS</entry></row><row><entry v="t">Class of drugs in general</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Contraindicated (HIV)</entry></row><row><entry cs="4">ANTIVIRALS</entry></row><row><entry v="t">Acyclovir</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Interferon</entry> <entry v="t">None known</entry> <entry v="t">Intrauterine growth restriction (?)</entry> <entry v="t">Likely safe</entry></row><row><entry cs="4">CANCER CHEMOTHERAPY</entry></row><row><entry v="t">Alkylating agents</entry> <entry v="t">Abortion, anomalies</entry> <entry v="t">Hypoplastic gonads, growth restriction and delay</entry> <entry v="t">Contraindicated</entry></row><row><entry v="t">Antimetabolites <list type="bullet"> <item><para>Folic acid analogues (methotrexate)</para></item> <item><para>Purine analogues</para></item> <item><para>Pyrimidine analogues (cytosine arabinoside, 5-fluorouracil)</para></item> </list></entry> <entry v="t"><list type="bullet"> <item><para>Abortion, intrauterine growth restriction, cranial anomalies</para></item> <item><para>Same as above</para></item> <item><para>Same as above</para></item></list></entry> <entry v="t"><list type="bullet"> <item><para>Hypoplastic gonads, growth restriction and delay</para></item> <item><para>Same as above, plus transient anemia</para></item> <item><para>Same as above</para></item></list></entry> <entry v="t"><list type="bullet"> <item><para>Contraindicated</para></item> <item><para>Contraindicated</para></item> <item><para>Contraindicated</para></item></list></entry></row><row><entry v="t">Antibiotics <list type="bullet"> <item><para>Actinomycin</para></item> <item><para>Vinca alkaloids (vincristine)</para></item></list></entry> <entry v="t"><list type="bullet"> <item><para>Abortion, intrauterine growth restriction, cranial anomalies</para></item> <item><para>Same as above</para></item></list></entry> <entry v="t"><list type="bullet"> <item><para>Hypoplastic gonads, growth restriction and delay</para></item> <item><para>Same as above</para></item></list></entry> <entry v="t"><list type="bullet"> <item><para>Contraindicated</para></item> <item><para>Contraindicated</para></item></list></entry></row><row><entry cs="4">CARDIOVASCULAR DRUGS</entry></row><row><entry v="t">ACE inhibitors</entry> <entry v="t">None known</entry> <entry v="t">Oliguria, skull defects, death</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Adenosine</entry> <entry v="t">None known</entry> <entry v="t">No effects on fetal heart rate</entry> <entry v="t">Unknown</entry></row><row><entry v="t">Beta-sympathomimetics</entry> <entry v="t">None known</entry> <entry v="t">Tachycardia, hypothermia, hypocalcemia, hypoglycemia, and hyperglycemia</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Calcium channel blockers</entry> <entry v="t">Unknown</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Digitalis</entry> <entry v="t">None known</entry> <entry v="t">Lower heart rate</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Hydralazine</entry> <entry v="t">Skeletal defects (?)</entry> <entry v="t">Tachycardia, thrombocytopenia, fetal distress</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Methyldopa</entry> <entry v="t">None known</entry> <entry v="t">Hemolytic anemia, tremor, hypotension</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Propranolol, labetalol</entry> <entry v="t">Unknown</entry> <entry v="t">Lower heart rate, intrauterine growth restriction (?), hypoglycemia, respiratory distress</entry> <entry v="t">Compatible; hypoglycemia (?)</entry></row><row><entry v="t">Reserpine</entry> <entry v="t">None known</entry> <entry v="t">Lethargy, respiratory distress</entry> <entry v="t">Unknown</entry></row><row><entry cs="4">COLD AND COUGH PREPARATIONS</entry></row><row><entry v="t">Antihistamines</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Reduced milk (?); drowsiness</entry></row><row><entry v="t">Cough suppressants</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Decongestants</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Dextromethorphan</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">No information</entry></row><row><entry v="t">Expectorants</entry> <entry v="t">Fetal goiter (?)</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Loratadine</entry> <entry v="t">Likely none</entry> <entry v="t">Likely none</entry> <entry v="t">Compatible</entry></row><row><entry cs="4">DIURETICS</entry></row><row><entry v="t">Furosemide</entry> <entry v="t">Unknown</entry> <entry v="t">Death from sudden hypoperfusion, electrolyte imbalance</entry> <entry v="t">Found to suppress lactation</entry></row><row><entry v="t">Thiazides</entry> <entry v="t">None known</entry> <entry v="t">Thrombocytopenia, hypokalemia, hyperbilirubinemia, hyponatremia</entry> <entry v="t">Compatible</entry></row><row><entry cs="4">FERTILITY DRUGS</entry></row><row><entry v="t">Clomiphene</entry> <entry v="t">Meiotic nondisjunction (?), neural tube defects (?)</entry> <entry v="t">Unknown</entry> <entry v="t">No data available</entry></row><row><entry cs="4">GASTROINTESTINAL AGENTS</entry></row><row><entry v="t">Bisacodyl</entry> <entry v="t">Unknown</entry> <entry v="t">Unknown</entry> <entry v="t">No reports of adverse effects</entry></row><row><entry v="t">Cholestyramine</entry> <entry v="t">None known</entry> <entry v="t">None known, but fat-soluble vitamins are depleted</entry> <entry v="t">Unknown</entry></row><row><entry v="t">Colestipol</entry> <entry v="t">Unknown</entry> <entry v="t">Unknown, but minimal absorption</entry> <entry v="t">No data available</entry></row><row><entry v="t">Docusate</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">H2-histamine receptor blockers</entry> <entry v="t">None known</entry> <entry v="t">Anti-androgen effect (cimetidine)</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Magnesium hydroxide (Milk of Magnesia)</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Mineral oil</entry> <entry v="t">Decreased maternal vitamin absorption</entry> <entry v="t">Decreased maternal vitamin absorption</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Proton pump inhibitors</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Unknown</entry></row><row><entry v="t">Sulfasalazine</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Caution with ill infants</entry></row><row><entry cs="4">HORMONES</entry></row><row><entry v="t">Androgens*</entry> <entry v="t">Virilization of female fetus</entry> <entry v="t">Adrenal suppression</entry> <entry v="t">No adverse effects reported</entry></row><row><entry v="t">Corticosteroids</entry> <entry v="t">Orofacial cleft in animals, not in humans</entry> <entry v="t">No adverse effects in humans</entry> <entry v="t">No data available</entry></row><row><entry v="t">Danazol</entry> <entry v="t">Virilization of female fetus (?)</entry> <entry v="t">None known</entry> <entry v="t">No information available</entry></row><row><entry v="t">Estrogens</entry> <entry v="t">Cardiovascular anomalies (?)</entry> <entry v="t">None known</entry> <entry v="t">No reported adverse effects</entry></row><row><entry v="t">Progestins</entry> <entry v="t">Limb and cardiovascular anomalies (?), VACTERL syndrome (?), masculinization of female fetus (?)</entry> <entry v="t">None known</entry> <entry v="t">No reported adverse effects</entry></row><row><entry cs="4">DIABETES CARE</entry></row><row><entry v="t">Glucagon</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Glyburide</entry> <entry v="t">None known</entry> <entry v="t">Not thought to cross the placenta in significant amounts; no neonatal hypoglycemia</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Insulin</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Safe</entry></row><row><entry v="t">Metformin</entry> <entry v="t">None known</entry> <entry v="t">Neonatal hypoglycemia</entry> <entry v="t">Unknown</entry></row><row><entry v="t">Sulfonylureas</entry> <entry v="t">Anomalies (?)</entry> <entry v="t">Suppressed insulin secretion</entry> <entry v="t">Compatible</entry></row><row><entry cs="4">MIGRAINE REMEDIES</entry></row><row><entry v="t">Ergotamine</entry> <entry v="t">None known</entry> <entry v="t">May stimulate contractions</entry> <entry v="t">Use with caution</entry></row><row><entry v="t">Sumatriptan</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry cs="4">PSYCHOACTIVE DRUGS, ANTIDEPRESSANTS</entry></row><row><entry v="t">Amphetamine</entry> <entry v="t">Inconsistent; likely none</entry> <entry v="t">Reduced weight</entry> <entry v="t">Contraindicated</entry></row><row><entry v="t">Benzodiazepines</entry> <entry v="t">Facial dysmorphism (?)</entry> <entry v="t">Depression, floppy infant, hypothermia, withdrawal</entry> <entry v="t">Some concern about central nervous system toxicity with long-term use</entry></row><row><entry v="t">Fluoxetine</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Symptoms of colic</entry></row><row><entry v="t">Hydroxyzine</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">No information</entry></row><row><entry v="t">Lithium</entry> <entry v="t">Facial clefts; cardiovascular anomaly</entry> <entry v="t">Lithium toxicity (neurologic and hepatic dysfunction)</entry> <entry v="t">Contraindicated</entry></row><row><entry v="t">Meprobamate</entry> <entry v="t">Cardiac anomalies (?), major malformations (?)</entry> <entry v="t">None known</entry> <entry v="t">Unknown</entry></row><row><entry v="t">Phenothiazines</entry> <entry v="t">None known</entry> <entry v="t">Muscle rigidity, hypothermia, tremor</entry> <entry v="t">Unknown</entry></row><row><entry v="t">Sedatives</entry> <entry v="t">None known</entry> <entry v="t">Depression, slow learning</entry> <entry v="t">Not recommended</entry></row><row><entry v="t">Thalidomide*</entry> <entry v="t">Phocomelia in 20% of cases</entry> <entry v="t">None known</entry> <entry v="t">No information</entry></row><row><entry v="t">Tricyclics</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Unknown/caution</entry></row><row><entry v="t">Zolpiden</entry> <entry v="t">Unknown</entry> <entry v="t">Withdrawal or floppy infant (?)</entry> <entry v="t">Compatible</entry></row><row><entry cs="4">RADIOLABELED DIAGNOSTICS</entry></row><row><entry v="t">Albumin</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">No information available</entry></row><row><entry v="t">I131 (diagnostic)</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Not recommended during exposure; may continue 24 hours after exposure</entry></row><row><entry v="t">Technetium</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Not recommended during exposure; may continue 24 hours after exposure</entry></row><row><entry cs="4">SMOKING CESSATION</entry></row><row><entry v="t">Bupropion</entry> <entry v="t">Likely none</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Nicotine</entry> <entry v="t">Spontaneous abortion (?)</entry> <entry v="t">Impaired growth (?)</entry> <entry v="t">Consistent with passive smoking</entry></row><row><entry cs="4">THYROID MEDICATION</entry></row><row><entry v="t">I131 (therapeutic)</entry> <entry v="t">Goiter, abortion, anomalies</entry> <entry v="t">Goiter, airway obstruction, hyperthyroid, mental retardation</entry> <entry v="t">Contraindicated</entry></row><row><entry v="t">Methimazole</entry> <entry v="t">Aplasia cutis (?), goiter</entry> <entry v="t">Goiter, airway obstruction, hyperthyroid, mental retardation, aplasia cutis (?)</entry> <entry v="t">Compatible, but monitor fetal thyroid function</entry></row><row><entry v="t">Propylthiouracil</entry> <entry v="t">Goiter</entry> <entry v="t">Same as above</entry> <entry v="t">Safe, but monitor baby’s thyroid status</entry></row><row><entry v="t">Thyroid USP</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Thyroxine</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry cs="4">TOCOLYTICS</entry></row><row><entry v="t">Beta-sympathomimetics</entry> <entry v="t">None known</entry> <entry v="t">Tachycardia, hypothermia, hypocalcemia, hypoglycemia, hyperglycemia</entry> <entry v="t">—</entry></row><row><entry v="t">Indomethacin</entry> <entry v="t">None known</entry> <entry v="t">Oligohydramnios (>48 hours of use)</entry> <entry v="t">—</entry></row><row><entry v="t">Magnesium sulfate</entry> <entry v="t">None known</entry> <entry v="t">Hypermagnesemia, respiratory depression</entry> <entry v="t">—</entry></row><row><entry v="t">Nifedipine</entry> <entry v="t">Unknown</entry> <entry v="t">None known</entry> <entry v="t">—</entry></row><row><entry cs="4">VACCINATIONS</entry></row><row><entry v="t">Influenza</entry> <entry v="t">None known</entry> <entry v="t">Passive immunization</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Pneumovaccine</entry> <entry v="t">None known</entry> <entry v="t">Passive immunization</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Tetanus toxoid</entry> <entry v="t">None known</entry> <entry v="t">Passive immunization</entry> <entry v="t">Compatible</entry></row><row><entry cs="4">VAGINAL PREPARATIONS</entry></row><row><entry v="t">Antifungal agents</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Podophyllin</entry> <entry v="t">Mutagenesis (?)</entry> <entry v="t">Central nervous system effects (?)</entry> <entry v="t">Contraindicated</entry></row><row><entry cs="4">VITAMINS (high dose)</entry></row><row><entry v="t">A</entry> <entry v="t">Urogenital and craniofacial anomalies (?)</entry> <entry v="t">None known</entry> <entry v="t">No data available</entry></row><row><entry v="t">C</entry> <entry v="t">None known</entry> <entry v="t">Scurvy after delivery</entry> <entry v="t">Compatible</entry></row><row><entry v="t">D</entry> <entry v="t">Supravalvular aortic stenosis (?)</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">E</entry> <entry v="t">Unknown</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">K</entry> <entry v="t">Unknown</entry> <entry v="t">Hemorrhage, if deficiency</entry> <entry v="t">Compatible</entry></row><row><entry cs="4">“STREET” DRUGS</entry></row><row><entry v="t">Cocaine</entry> <entry v="t">Placental abruption, vascular disruption, urinary tract anomalies</entry> <entry v="t">Withdrawal, placental abruption, vascular disruption, growth restriction</entry> <entry v="t">Contraindicated</entry></row><row><entry v="t">Heroin</entry> <entry v="t">None known</entry> <entry v="t">Depression, withdrawal, growth restriction</entry> <entry v="t">Contraindicated</entry></row><row><entry v="t">LSD</entry> <entry v="t">None known</entry> <entry v="t">Withdrawal, behavioral effects</entry> <entry v="t">Contraindicated</entry></row><row><entry v="t">Marijuana</entry> <entry v="t">None known</entry> <entry v="t">Behavioral effects, growth restriction</entry> <entry v="t">Contraindicated</entry></row><row><entry v="t">Methadone</entry> <entry v="t">None known</entry> <entry v="t">Withdrawal, growth restriction</entry> <entry v="t">Contraindicated</entry></row><row><entry v="t">Methamphetamine</entry> <entry v="t">None known</entry> <entry v="t">Withdrawal, growth restriction</entry> <entry v="t">Contraindicated</entry></row><row><entry v="t">Pentazocine</entry> <entry v="t">None known</entry> <entry v="t">Withdrawal, growth restriction</entry> <entry v="t">Contraindicated</entry></row><row><entry v="t">Phencyclidine</entry> <entry v="t">None known</entry> <entry v="t">Withdrawal, neurobehavioral effects, growth restriction</entry> <entry v="t">Contraindicated</entry></row><row><entry cs="4">OTHER DRUGS</entry></row><row><entry v="t">Azathioprine</entry> <entry v="t">Abortion</entry> <entry v="t">Anemia, thrombocytopenia, lymphopenia, growth retardation</entry> <entry v="t">Not recommended</entry></row><row><entry v="t">Bromocriptine</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Caffeine</entry> <entry v="t">Anomalies (?) in high doses, abortion (?)</entry> <entry v="t">Jitteriness</entry> <entry v="t">Not recommended</entry></row><row><entry v="t">Immune gamma globulin</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">Compatible</entry></row><row><entry v="t">Isotretinoin*</entry> <entry v="t">Central nervous system, cardiac, facial anomalies</entry> <entry v="t">Stillbirth, mental retardation (?)</entry> <entry v="t">Contraindicated</entry></row><row><entry v="t">Misoprostol</entry> <entry v="t">Abortion; variety of anomalies (cranium, limb, oral cleft); Mobius sequence</entry> <entry v="t">None with low dose for cervical ripening; placental abruption</entry> <entry v="t">Contraindicated, especially if diarrhea occurs</entry></row><row><entry v="t">Spermicides</entry> <entry v="t">None known</entry> <entry v="t">None known</entry> <entry v="t">No information</entry></row><row><entry cs="4">* Proven teratogen.</entry></row><row><entry cs="4">Unknown=no studies to investigate fetal effects; none known=no malformations reported in human studies or no consistent malformations in animal studies; (?)=conflicting information</entry></row><row><entry cs="4">Source: Reprotox data from humans, last reviewed in 2006.</entry></row>

Most drugs enter breast milk

The amount of drug that an infant consumes from breast milk depends on the medication’s chemical properties as well as the dosage, frequency, and duration of exposure.² Contraindications and cautions are usually either theoretical or based on findings from case reports that often conflict or confuse. In theory, it is safer for the mother to take the medication just after infant feeding or just before the infant’s longest sleep period.

The TABLE also lists the effects of drugs in the breastfed human infant. Again, the information comes from the Reprotox database, access to which requires a subscription. For additional information, try the free LactMed site at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT.

Nearly all drugs are excreted in breast milk, usually in small amounts (often less than 5% of the weight-adjusted maternal daily dose). The amount of drug or metabolite in an infant’s serum also is determined by the volume of breast milk, age of the infant, and other exposures.

Prescribing strategies for your pregnant patient

Avoid prescribing multiple medications, if possible, and choose “safe” drugs from among the options in categories that include a number of teratogenic medications, such as anticonvulsants.

Determine the best method to monitor therapy. For example, use a peak flow meter for asthma, a portable blood pressure monitor for hypertension, and so on.

Focus on keeping the patient healthy. The healthiest mother is most likely to deliver the healthiest infant.

Keep the underlying disorder in mind, as well as the drug, when choosing a drug.

Know which drugs are clearly linked to birth defects. These include phenytoin, warfarin, alcohol, methotrexate, diethylstilbestrol, cis-retinoic acid, valproic acid, and carbamazepine.

Pay special attention to the first trimester. Too little is known about the first-trimester effects of the vast majority of drugs for them to be considered safe.

Suspect a drug-related effect

A medication may be the cause in any newborn manifesting signs of anemia, hepatitis, hepatotoxicity, hepatorenal dysfunction, and hyperbilirubinemia. This includes breastfed infants. An adverse drug-related effect should also be suspected when an infant exhibits signs of jaundice, floppiness, jitteriness, poor suck, diarrhea, or growth restriction.