ICU · Obstetric / pharmacotherapy
ICU Drugs in Pregnancy & Lactation — Safe, Caution & Contraindicated
Also known as Teratogenicity · Drugs in pregnancy · Drugs in lactation · FDA pregnancy categories · PLLR · ACE fetopathy · Fetal warfarin syndrome · Labetalol · LMWH in pregnancy · Pregnancy labelling rule · LactMed · Relative infant dose · Fetal valproate syndrome · Retinoid embryopathy
The ICU drugs in pregnancy: the PLACENTA crosses MOST drugs (the trimester matters — the organogenesis weeks 3 to 10 the highest the teratogenic risk). The SAFE: LMWH (does NOT cross placenta), labetalol (the first-line antihypertensive), penicillins, cephalosporins, macrolides, propofol, noradrenaline, steroids (prednisolone — the 90 per cent metabolised by the placental 11-beta-HSD2), paracetamol, insulin, metformin, magnesium. The CAUTION: aminoglycosides (fetal ototoxicity), benzodiazepines (1st trimester), fluoroquinolones. The CONTRAINDICATED: warfarin (the fetal warfarin syndrome), ACE inhibitors and ARBs (ACE fetopathy — fetal renal damage), valproate (neural tube), isotretinoin, methotrexate, tetracyclines (teeth/bone), lithium. The LACTATION: most ICU drugs compatible (infant dose under 1 per cent); avoid chloramphenicol, amiodarone, lithium, chemotherapy, radioisotopes — check LactMed.
Practise this topic
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- Warfarin, ACE inhibitors/ARBs, valproate, isotretinoin, methotrexate, tetracyclines CONTRAINDICATED in pregnancy
- LMWH does NOT cross placenta — SAFE and preferred for VTE; warfarin crosses → fetal warfarin syndrome
- Maternal hypotension is WORSE for the fetus than any vasopressor — noradrenaline/metaraminol/adrenaline all acceptable
- Treat the MOTHER first — a dead mother = a dead fetus; do not withhold life-saving therapy for fetal drug fear
- Amiodarone, lithium, chemotherapy, radioisotopes AVOID in breastfeeding — most other ICU drugs compatible
- Review EVERY medication at first antenatal contact and ICU admission — ACE inhibitors are commonly prescribed
Meet the patient
A 31-year-old woman at 26 weeks is admitted to your ICU in septic shock from an ESBL pyelonephritis. She is intubated, on noradrenaline, and her regular medications — read off the chart at the bedside — are warfarin for a mechanical mitral valve, ramipril for hypertension, and valproate for juvenile myoclonic epilepsy. Every one of those three drugs is on the contraindicated list, and every one has a safe substitute that must be started tonight.[13]
The question that decides her stay is not which vasopressor or which antibiotic. It is whether you will treat her as aggressively as a non-pregnant patient, or under-dose her out of fear for the fetus. A dead mother is a dead fetus; the fetus survives only if the mother does, so resuscitate her first and review the drug chart second.[1]
References25ShowHide
- [1]Guntupalli KK, Hall N, Karnad DR, et al. Critical illness in pregnancy: part I: an approach to a pregnant patient in the ICU and common obstetric disorders. Chest, 2015.PMID 26020613
- [2]Dinatale M, Roca C, Sahin L, et al. The Importance of Clinical Research in Pregnant Women to Inform Prescription Drug Labeling. Journal of Clinical Pharmacology, 2020.PMID 33274508
- [3]Kaye AB, Bhakta A, Moseley AD, et al. Review of Cardiovascular Drugs in Pregnancy. Journal of Women's Health, 2019.PMID 30407107
- [4]Anderson PO LactMed Update--An Introduction. Breastfeeding Medicine, 2016.PMID 26859061
- [5]ACOG Committee on Practice Bulletins Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstetrics and Gynecology, 2020.PMID 32443079
- [6]Bates SM, Rajasekhar A, Middeldorp S, et al American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy. Blood Advances, 2018.PMID 30482767
- [7]Ngan Kee WD, Khaw KS, Ng FF Comparison of phenylephrine infusion regimens for maintaining maternal blood pressure during spinal anaesthesia for Caesarean section. British Journal of Anaesthesia, 2004.PMID 14977792
- [8]Munk-Olsen T, Liu X, Viktorin A, et al Maternal and infant outcomes associated with lithium use in pregnancy: an international collaborative meta-analysis of six cohort studies. Lancet Psychiatry, 2018.PMID 29929874
- [9]Jentink J, Dolk H, Loane MA, et al Intrauterine exposure to carbamazepine and specific congenital malformations: systematic review and case-control study. BMJ, 2010.PMID 21127116
- [10]Meador KJ, Baker GA, Browning N, et al. Fetal antiepileptic drug exposure and cognitive outcomes at age 6 years (NEAD study): a prospective observational study. Lancet Neurology, 2013.PMID 23352199
- [11]Cooper WO, Hernandez-Diaz S, Arbogast PG, et al Major congenital malformations after first-trimester exposure to ACE inhibitors. New England Journal of Medicine, 2006.PMID 16760444
- [12]Hooton TM, Vecchio M, Iroz A, et al. Effect of Increased Daily Water Intake in Premenopausal Women With Recurrent Urinary Tract Infections: A Randomized Clinical Trial. JAMA Internal Medicine, 2018.PMID 30285042
- [13]Plante LA, Pacheco LD, Louis JM SMFM Consult Series #47: Sepsis during pregnancy and the puerperium. American Journal of Obstetrics and Gynecology, 2019.PMID 30684460
- [14]Ito S Drug therapy for breast-feeding women. New England Journal of Medicine, 2000.PMID 10891521
- [15]Shields AD, Plante LA, Pacheco LD, et al. Society for Maternal-Fetal Medicine Consult Series #67: Maternal sepsis. American Journal of Obstetrics and Gynecology, 2023.PMID 37236495
- [16]Mushambi MC, Kinsella SM, Popat M, et al. Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia, 2015.PMID 26449292
- [17]Yurdakök M Fetal and neonatal effects of anticoagulants used in pregnancy: a review. Turkish Journal of Pediatrics, 2012.PMID 23094528
- [18]Hesse MR, Prins JR, Hooge MNL, et al. Pharmacokinetics and Target Attainment of Antimicrobial Drugs Throughout Pregnancy: Part I-Penicillins. Clinical Pharmacokinetics, 2023.PMID 36662480
- [19]van Runnard Heimel PJ, Schobben AF, Huisjes AJ, et al. The transplacental passage of prednisolone in pregnancies complicated by early-onset HELLP syndrome. Placenta, 2005.PMID 16226134
- [20]Brownfoot FC, Gagliardi DI, Bain E, et al. Different corticosteroids and regimens for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database of Systematic Reviews, 2013.PMID 23990333
- [21]Valent AM, Barbour LA Insulin Management for Gestational and Type 2 Diabetes in Pregnancy. Obstetrics and Gynecology, 2024.PMID 38870526
- [22]Bates SM, Greer IA, Middeldorp S, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 2012.PMID 22315276
- [23]Mehndiratta S, Suneja A, Gupta B, et al. Fetotoxicity of warfarin anticoagulation. Archives of Gynecology and Obstetrics, 2010.PMID 20111969
- [24]Autret-Leca E, Kreft-Jais C, Elefant E, et al. Isotretinoin exposure during pregnancy: assessment of spontaneous reports in France. Drug Safety, 2010.PMID 20635824
- [25]Rowan JA, Hague WM, Gao W, et al. Metformin versus insulin for the treatment of gestational diabetes. New England Journal of Medicine, 2008.PMID 18463376