Pregnancy: What's Safe? What's Not?
By Dr. Gerard M. DiLeo, MD






In this article:

New Prescription Drugs

Antibiotics

Established Prescription Drugs

Using drugs for uses for which they haven't been officially approved

Alcohol

Cigarettes

Travel

Seatbelts

Vitamins

Fish

Cheese

Sports and Exercise

Hormones

Amusement Park Rides

Painting

Weight Loss Drugs

Other Safety FAQ



Wondering what prescription and over-the-counter drugs are safe during pregnancy? Can you ride aroller coaster or eat brie? Find out what's OK for you and baby and what things you'd be better to pass up.



About 90 percent of the questions patients ask me involve whether something will hurt their babies. Unfortunately, there are only two sources of information regarding harmful substances that are either ingested, worn, or contacted. One is the FDA, which is in charge of approving medicines (and I suppose, food, although I haven't seen any FDA-approved Twinkies yet). Luckily, their stamp is all over prescription drugs and there is an FDA classification of which drugs are harmful or potentially harmful to a developing baby (see below).

The other source of information is the marketplace, where harmful products are removed due to side effects, proven and unproven, and the unbearable costs in defending them in courts. Bendectin is one such drug, a combination of an antihistamine and vitamin B6. Bendectin was exonerated in studies, but the legal challenges became too expensive. Business is business, and Bendectin was voluntarily withdrawn.

If a company even smells trouble, it often will withdraw a product before the lawsuits pile up, because the legal impact on profits will have to be figured into any corporate balance sheet. If Oprah says she is allergic to a certain medicine, the same reaction or side effect will crop up at law offices all over the country.

So while the FDA checks these things out on the front end, it's the marketplace, with its unofficial studies involving millions (that's you, the consumer) that gives a product the final clearance. Consider the FDA-approved, weight-loss drug Redux. Heart valve damage began cropping up after its general release, and Redux is now history.

So is it safe to take new drugs that are FDA approved?

New Prescription Drugs

Although no one can say whether the large studies accepted by the FDA will be corrected by the even larger studies of the population at large, a patient has to rely on some things in this life to get along. It's not much of a problem if you have a cold, but if you have epilepsy and a new drug eliminates an undesirable effect, you will try it. Even though there are episodes that surprised everyone, the FDA is very thorough. (Aspirin would probably have a tough time if judged by the current standards.) Everything boils down to risk vs. benefit.

BOTTOM LINE: If the benefit of a new drug outweighs the risk or, more correctly, the theoretical risk, then it's probably a safe bet. Your doctor makes that call.

Antibiotics

Most of the antibiotics are safe, but there are important exceptions. Tetracycline—a popular prescription for acne—or any version of it can deform a developing baby's teeth and possibly bones. Sulfur drugs taken close to term can affect how bilirubin is handled in your baby, leading to brain damage. Cloramphenicol, leading to the fatal grey baby syndrome, has only been reported when given to a newborn, although that's good enough for a prospective mother not to take it. Quinolones, like Floxin (popularized with Anthrax terrorism) has some disappointing animal studies that earn a warning, although it's been used safely in humans in limited observations. (The data are small in these cases, because it's hard to get pregnant patients to line up for a study to see if a certain drug will hurt their babies.) All of the penicillins seem safe and have a lengthy track record, having been the very first modern antibiotic discovered. Likewise, cephalosporins, like Keflex, are safe. So are erythromycins. My favorite drug for bladder infections, nitrofurantoin (Macrodantin), is not only safe in most cases but also has a low failure rate.

With all of these drugs, if applied to hundreds of millions of persons, one can find truly terrifying side effects here and there. I would say, though, that there's more of a chance of you dying from a sinus infection (which goes on to become pneumonia, sepsis, and death) than having a side effect from an antibiotic that was reported in one out of 500,000 cases.

BOTTOM LINE: There is a large assortment of time-honored safe antibiotics to take for almost any type of infection, and your doctor will know the ones to avoid.

Established Prescription Drugs

The FDA has a categorization of drug risk to the fetus that runs from "Category A" (safest) to "X" (known danger—don't use!):



Category A: Controlled studies in women fail to demonstrate a risk to the fetus in the first trimester (and there is no evidence of a risk in later trimesters), and the possibility of fetal harm appears remote.

Category B: Either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women, or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester (and there is no evidence of a risk in later trimesters).

Category C: Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal or other) and there are no controlled studies in women, or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus.

Category D: There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (e.g., if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective).

Category X: Studies in animals or human beings have demonstrated fetal abnormalities, or there is evidence of fetal risk based on human experience or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant.



An example of a Category X drug is the extremely dangerous anti-acne drug Accutane, which is why women on it need reliable birth control and frequent pregnancy tests if there's any doubt.



Keep in mind that the FDA classifications are very general classifications of very complex interactions between drug, patient, and fetus. They are general guidelines for your doctor and shouldn't be the final say on whether you and your baby are safe. For example, giving a Category C drug to a woman with epilepsy may seem more risky than giving a Category B drug; but if the B drug isn't as effective in controlling seizures, then failure of that drug may force her doctor to use a Category D drug as a rescue.

Using drugs for uses for which they haven't been officially approved

This is called "off-label" use of legitimate drugs. This is not only safe when overseen responsibly by a physician, it's even desirable in many instances. A perfect example of this was the use of Ritodrine for preterm labor. Normally a drug for asthma, it had the same effect on asthma, but also on preterm labor, as another drug, Terbutaline. Both controlled preterm labor and Ritodrine was FDA-approved for this, but Terbutaline wasn't. Terbutaline, however, was ten times cheaper, so it was the one used.



Medicine is an art as well as a science. For particularly troubling conditions in pregnancy, an obstetrician may choose to use a safely established drug in ways for which it wasn't originally designed. This isn't malpractice—it's the art of medicine. The best doctors will think creatively within their art, but then use the science to steer them away from doing any harm.



BOTTOM LINE: Prescription drugs are controlled (that is, the prescription itself) for a reason. These are substances that the government wants dispensed by way of knowledgeable individuals (doctors and pharmacists).



Over-the-counter Drugs—"OTC"



Once again, we're at the mercy of time and the marketplace. Most OTC medicines have been grandfathered into a safe spot in pregnancy. Antacids, laxatives, simple pain medicines, antihistamines, decongestants, and other common remedies are usually safe when they've stood the medical and legal test of time by earning a place on the shelf that any non-medically trained person can choose from. The label will say if a physician should OK it, but this is probably more of legal precaution for the company than a warning of any pending harm.



This is not to say that you should take anything off the shelf with reckless abandon. Combining several of these medicines, staying on any for an unreasonable amount of time, or exceeding the recommended dosage should prompt you to clear this with your obstetrician.



BOTTOM LINE: Most OTC medicines, used according to the directions, are safe. Any alterations in the labeled recommendations should be cleared.



The Rest of the World



Everything else in the world that could be a problem for a developing baby falls into a murky area. Power lines, computer monitors, cell phones, hair dyes, tanning booths, ultrasound (and the list goes on) have all been questioned. The problem is that our technology is advancing at an exponential rate, with truly new things bumping into pregnancy all the time. New pesticides for crops, factory emissions, microwaves—move over. It's a brave, new world, and it just keeps getting busier.



A patient once asked me if using NutraSweet could cause deformities in her baby. Besides telling her no, I also answered that just living in Louisiana was more likely to cause problems in her developing baby than a sweetener used by millions of pregnant women every day. The point here is that you have to live. If you avoided every possible thing that could possibly result in harm, you would never leave the house, unless you were running for your life from toxic mold and radon. Lighten up a little and keep your eyes and ears open to legitimate news items that apply to pregnancy.



Cosmetics, perms, and hair dyes are always a popular worry. The correct answer is that one should minimize exposure to chemicals that aren't necessary to be safe. The reality is that how I define "necessary" and how someone else does may be two different things. For the record, in my twenty-two years of private practice, I've never seen a cosmetic injury to a baby.



Tanning beds—harmless to baby, bad for your skin. Your skin's already stretched, so adding UV thermal injury and dehydration won't help.



BOTTOM LINE: Use common sense; a good rule is that anything that can hurt you may hurt your baby. Items of widespread use which are time-honored without any haunting legacies of horror stories are probably OK, but your doctor will stand by the advice that you should limit unnecessary exposure to chemicals.

Alcohol

Typically, it takes a lot more than an occasional glass of wine to make us obstetricians worry. But since the fetal-alcohol syndrome is so serious, I and all other obstetricians stand by the literature in stating that a safe amount of alcohol has never been officially established.



BOTTOM LINE: Pass on this one until you've finished breastfeeding.





Cigarettes

Don't get me started! Cigarette smoke has over 2,000 chemicals in it. A known poison for your developing baby, each puff constricts nourishment to him or her. Each puff! Every single one. Quit. And if you fail, quit over and over again. Cigarettes are possibly more dangerous than cocaine, but don't do that, either.



BOTTOM LINE: Are you crazy?

Travel

Close to term, but really at any time in pregnancy, you shouldn't be in some mode of transportation in which medical help is several hours or days away. At least on a USA road trip, there's a hospital available every couple of hours. But overnight camping and hiking trips would pose a problem should an emergency develop that required immediate assistance. The same goes for long flights over oceans—airlines aren't equipped to do anything useful in the case of complications of pregnancy. Cruises are worrisome, also.



When you travel, know your due date and your blood type, the two most important things a new doctor would want to know about you.



BOTTOM LINE: Keep civilization available. Know your due date and blood type.





Seatbelts

Use them. The most common reason for fetal death in a car accident is maternal death because of not using seatbelts.



BOTTOM LINE: Use seatbelts, without exception.

Vitamins

The big companies have spent a lot of money on FDA approval and the studies to pursue it, so you can't go wrong staying with a big company's prescription prenatal vitamin. Folic acid is becoming a rising star in pregnancy.



Beware of do-it-yourself multivitamin concoctions that are designed by salespersons at health food stores. They can't do a better job than the big companies, and sometimes too much of a vitamin can be harmful.



BOTTOM LINE: Use the prescription prenatal vitamins; don't use any other herbal or do-it-yourself concoctions, unless prescribed by your obstetrician.

Fish

Mercury exposure can affect a developing baby's brain and nervous system, but this is mainly with non-commercial freshwater fish. In other words, Charlie the Tuna in a can isn't a problem, but the recreational or freelance fisherman's catch of the day could be, and that may apply to many restaurants. The EPA recommends having only a six-ounce portion of fish once a week, but just as there is no safe level of alcohol consumption established, I think the same can apply to a known, nasty toxin like mercury.



For those who really want to eat more fish than this, each state has a website that will report on the levels and toxic risks of the fish in its area.



BOTTOM LINE: Mercury is just too scary to eat fish whenever you want. Obey the EPA's recommendations.

Cheese

We're talking about Listeriosis, a bacterium ingested with certain foods, which can hurt or even cause death in an unborn baby. Although cheese is the most famous culprit, any undercooked meats, unwashed vegetables, unpasteurized milk, or products from unpasteurized milk can give a dose of this infection.



The CDC has an excellent website for all things Listeria at http://www.cdc.gov/ncidod/dbmd/diseaseinfo/listeriosis_g.htm#reducerisk. In general, though, you should cook all animal meat thoroughly. Wash all vegetables and stay away from unpasteurized products. Also, keep your countertops clean. An unwashed vegetable laying on the counter, then washed, then put back on the counter could reclaim the Listeria. Eat deli meats that have been reheated steaming hot.



And here's the cheesy part you've been waiting for: According to the CDC, you should "avoid soft cheeses, like feta, Brie, Camembert, blue-veined cheeses, and Mexican-style cheeses such as queso blanco fresco. Cheeses that may be eaten include hard cheeses, semi-soft cheeses such as mozzarella, pasteurized processed cheese slices and spreads, cream cheese, and cottage cheese."

Sports and Exercise

Any sport that doesn't involve blows or falling down is fine in pregnancy. Exercise is fine, as long as you don't have any pre-pregnancy conditions that would make it dangerous, like heart conditions; as long as you're not high-risk, as with preterm labor; and as long as you proceed in a reasonable way. SCUBA diving, although I have nothing scientific to back this up, would be on my list of things to make me nervous as an obstetrician. There must be a reason no one is pushing pregnant women into hyperbaric oxygen chambers. Also, metabolism is altered such that the usual formulae for oxygen consumption from SCUBA gear may have to be adjusted. Skydiving? As long as you're not so high up that you need oxygen, your parachute has been packed properly of course, and you know how to land, skydiving is OK. (For that one reader out there who skydives while pregnant—this was for you.)



Even with the good news that almost all exercise is fine, even desirable, in pregnancy, any sports that involve sprinting or sudden load demands on joints may be more likely to cause orthopedic injuries then when not pregnant. Your center of gravity is different and progesterone loosens all of your joints, but it's impossible to tell how much impact this will have on a sportsperson.



Horse back riding—another jolting experience. Usually the added discomfort of pregnancy will stop an equestrian before her doctor will.



BOTTOM LINE: Sports—have at it. SCUBA with caution. Don't do kick-boxing. Scratch that one off your list.

Hormones

You have enough hormones already, but there are times when your obstetrician may use more. Micronized progesterone, identical to the same stuff the placenta makes, is used to support first trimester pregnancies that are in danger of miscarriage. There's debate as to whether it does any good, but I for one feel it does no harm. Lately there's been talk of giving it to control preterm labor, because it relaxes muscles. This will probably be an important addition to the management of preterm labor in the near future.



Estrogen isn't given in pregnancy. If you've been taking birth control pills by accident (that is, before you knew you were pregnant), although this has a theoretical risk, I've never seen this hurt a baby. Just don't do it on purpose.



Testosterone and anabolic steroids can hurt your baby, especially if female. Virilization (male-like) effects can occur.



BOTTOM LINE: Progesterone is safe. Other hormones can be harmful unless exposure is minimal and accidental

Amusement Park Rides

Amusement park rides which alter gravity in intensity and in sudden direction changes could theoretically cause placental tearing with horrible consequences. I've never seen a case, but I don't want to, either.

Painting

With the nesting frenzy, the safety of painting always comes up. The biggest risk is in using things like paint thinner on your hands to take the paint off, which exposes you to absorption through your skin. The fumes of the paint aren't a problem in a well-ventilated area, but if they give you a headache, then it's not ventilated well enough.



BOTTOM LINE: Ventilate. Use water-based paints. Avoid paint thinner exposure to hands and skin.

Weight Loss Drugs

Pregnancy isn't the time to try to lose weight. A lot of these OTC drugs have ephedrine in them. These aren't without significant risk and shouldn't be taken.



BOTTOM LINE:Don't use ephedra-containing drugs or any OTC weight loss medicine.



Illegal Drugs



BOTTOM LINE: See "Cigarettes," above.



There are many things, legitimate and illicit, for which there just aren't any studies. In my book, The Anxious Parent's Guide to Pregnancy, I explain something called the babysitter test: Would you hire a babysitter who forced your infant to inhale a lit cigarette? No? Then you shouldn't either. Would you hire a babysitter who gave your infant cocaine, heroin, marijuana, or a stiff drink? Then you shouldn't either. When in doubt, use the babysitter test. It works.

Other Safety FAQ



Is it Safe to get a Suntan While Pregnant?[/b]
Paint Fumes and Birth Defects
Is it Safe to get a Suntan While Pregnant?
Baths and Pregnancy
Marijuana Use in Pregnancy
Diet Drinks and Pregnancy