Management of Cold and Flu During Pregnancy

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Congestion

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Cough and Sore Throat

Headache/Body aches/ Fever

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Sleep Aids

COVID-19

Influenza (Flu)

Respiratory Syncytial Virus (RSV)

Supplements

Cold and Flu Prevention

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Hand sanitization and washing, as well as the use of masks may be considered as first line strategies for preventing cold and flu. It is recommended to spend at least 20 seconds scrubbing your hands when washing. See “supplement” section for additional information on commonly used supplements for cold and flu prevention and/or treatment.

Congestion

• May be considered throughout pregnancy:
  • Oxymetazoline: Human studies do not show a risk of birth defects with oxymetazoline nasal spray, but there is not enough data to show that there is no risk. Oxymetazoline may be preferred to drugs that are taken by mouth, which may be more likely to reach the baby, or to drugs with less data in pregnant humans. If benefits outweigh risk of treatment, oxymetazoline use should be short-term (less than 3 days).
• Non-medication options: increasing fluid intake to thin mucus and assist sinuses in draining, sinus rinses (Neti-pot), nasal strips, or a cool-mist humidifier may be helpful and are considered safe for use during pregnancy.
• May be considered in the 2nd/3rd trimester:
  • Guaifenesin: Most data do not suggest an increased risk of birth defects with guaifenesin use during pregnancy, but one study found an association between first trimester use and risk of hernia in offspring. Use may be considered if benefits of treatment are greater than risk to the fetus, especially after the first trimester.
  • Phenylephrine: Phenylephrine causes blood vessels to become narrower, which may decrease blood flow from the mom to the fetus. In 2023 the FDA released a statement stating that orally administered phenylephrine is not effective as a nasal decongestant. Nasal phenylephrine may be helpful without significant absorption. Human studies of oral use suggest a risk of birth defects throughout pregnancy, which may be higher in the first-trimester when major organs and body systems begin to form. Risk of use may outweigh benefit, especially in the first trimester. Short-term use (< 3 days) may be considered in the 2nd or 3rd trimester if benefit outweighs risk of treatment.
  • Pseudoephedrine: Pseudoephedrine causes blood vessels to become narrower, which may decrease blood flow from the mom to the fetus. Birth defects have been observed during the first trimester, when major organs and body systems begin to form. Short-term use (< 3 days) may be considered in the 2nd or 3rd trimester if benefit outweighs risk of treatment.

Cough and Sore Throat

• May be considered throughout pregnancy:
  • Benzocaine: Lozenges and cough drops may contain benzocaine. Human data does not show a risk of birth defects with benzocaine treatment during the first few months of pregnancy or throughout pregnancy. Consideration may be given to using benzocaine if treatment benefit is greater than risk to the baby.
  • Dextromethorphan: Dextromethorphan is a common ingredient in cough medications. It does not appear to be associated with an increased risk of birth defects based on available data. If the benefits of use are greater than risk to the baby, non-alcohol-containing dextromethorphan products are preferred.
  • Non-medication options: warm salt water gargle
• Not preferred due to limited data:
  • Benzonatate: Benzonatate is a prescription cough medication. Safe use of benzonatate during pregnancy has been described, but there is minimal data on the safety of benzonatate during pregnancy. Other medications with more evidence for safety during pregnancy may be more ideal. The benefits of benzonatate use should be weighed against potential risk to the baby.
  • Menthol: Menthol is contained in some cough drops and lozenges. There is limited data on the safety of menthol during pregnancy. Other medications with more data for safety during pregnancy may be preferred. Menthol should only be used if benefits are greater than the potential risk to the fetus.
  • Phenol: Phenol may be found in cough drops and lozenges. There is limited data on the safety of phenol during pregnancy and phenol is absorbed when given by mouth, applied to the skin, and inhaled, making it possible for phenol to reach the baby. Other medications with more data for safety during pregnancy may be preferred. Phenol should only be used if benefits are greater than the potential risk to the fetus.

Head/Body Aches and Fever

• May be considered throughout pregnancy:
  • Acetaminophen: Using acetaminophen during the early stages of pregnancy may slightly increase the risk of birth defects, particularly when higher dosages are used. Using normal amounts of acetaminophen for a short period of time is not thought to greatly increase the chance of serious birth defects. If the benefits of using acetaminophen during pregnancy are greater than the potential risks to the baby, short-term use could be considered.
• May be considered during the first trimester:
  • Regular strength aspirin, ibuprofen, and naproxen: Some data suggest that these medications could increase risk of miscarriage, particularly when taken around the time of conception or when used long-term. There may also be a slightly increased risk of an intestinal condition in the baby with use during the first-trimester. Use of these medications after the first 20 weeks of pregnancy has been associated with a decrease in the amount of fluid that surrounds the fetus. This can result in issues with the joints, lungs, or death of the fetus. Fetal kidney failure and heart issues have also been described with use during the second half of pregnancy. Short-term use of low doses of these medications may be considered before week 20 of pregnancy if benefits of use outweigh risk to the fetus. Use is not advised after 20 weeks. If use is deemed medically necessary, close monitoring is warranted.

Sleep Aids

• May be considered throughout pregnancy:
  • Doxylamine: Doxylamine is sometimes found in cold medications. It is also a preferred medication for the treatment of nausea and vomiting of pregnancy when used in combination with pyridoxine (vitamin B6); and because of this, there is substantial experience with this medication in pregnancy. Evidence suggests that this combination is not associated with an increased risk of birth defects. While most available safety data are for use of the combination, rather than doxylamine alone, it is believed that the risk of birth defects with doxylamine alone is unlikely, given the relative, limited risk of the combination. Short-term use may be considered during pregnancy if benefits of treatment outweigh risk to the baby.
  • Melatonin: Given that melatonin is a hormone that is produced naturally by the body, it is not expected to pose a large risk to the baby if taken at standard dosages during pregnancy. In fact, small studies of melatonin supplementation in pregnant women suggest that birth defects are unlikely. Supplementation may be considered if benefits of treatment are greater than risk to the baby.
  • Non-medication options: sleep hygiene, cognitive behavioral therapy for insomnia
• May be considered, especially after the first trimester:
  • Brompheniramine, chlorpheniramine, and diphenhydramine: These medications are sometimes found in cold preparations.Some studies have found an increased risk of birth defects with use during the first trimester, but other studies do not support these findings. Other medications with more evidence of safety in pregnancy may be preferred. These medications may be considered, particularly after the first trimester, if benefits of use outweigh risk to the fetus.

COVID-19

• Recommended:
  • COVID-19 vaccine: The COVID-19 vaccine appears to be safe in pregnant women based on available data. The American College of Obstetricians and Gynecologists recommends that all pregnant women be vaccinated against COVID-19 as soon as possible. When administered during pregnancy, the vaccine can protect the baby in addition to the mom.
• May be considered throughout pregnancy:
  • Nirmatrelvir/ritonavir: Case studies do not suggest that there is a risk of birth defects with the use of nirmatrelvir/ritonavir during pregnancy, but data are limited and controlled trials are not available. According to the American College of Obstetricians and Gynecologists, if a pregnant woman tests positive for SARS-CoV-2, treatment with nirmatrelvir/ritonavir should be considered. Although limited data are available, benefits of treatment may be greater than risk to the baby.

Influenza

• Recommended:
  • Flu vaccine: The flu vaccine appears to be safe in pregnant women based on clinical trials, observational studies, and adverse event reporting systems. The American College of Obstetricians and Gynecologists and Centers for Disease Control and Prevention recommend that all adults, including pregnant women, receive an annual flu vaccine. When administered during pregnancy, the vaccine can protect the baby in addition to the mom. Pregnant women should receive an inactivated or recombinant form of the vaccine as soon as one is available during flu season.
• May be considered throughout pregnancy:
  • Oseltamivir: Studies in humans have not found an increased risk of birth defects with the use of oseltamivir during pregnancy. Treating the flu with oseltamivir during pregnancy is likely to be more beneficial than risky for the baby. The American College of Obstetricians and Gynecologists recommends that pregnant women who are thought to have the flu should receive antiviral treatment, regardless of specific test results or vaccination history. It’s best to start treatment within the first 48 hours of feeling sick, but if that’s not possible, treatment can still be beneficial. Oseltamivir is the preferred drug for when the flu is suspected or confirmed during pregnancy, as long as the flu is not thought to be resistant to oseltamivir. Compared to other similar medications, more is known about the risks and benefits of using oseltamivir during pregnancy.
  • Peramivir: There is not a lot of data on the safety of peramivir during pregnancy. Treating the flu with peramivir during pregnancy is likely to be more beneficial than risky for the baby. The American College of Obstetricians and Gynecologists recommends that pregnant women who are thought to have the flu should receive antiviral treatment, regardless of specific test results or vaccination history. It’s best to start treatment within the first 48 hours of feeling sick, but if that’s not possible, treatment can still be beneficial. Other similar medications with more evidence for safety during pregnancy may be preferred, but peramivir may be considered if benefits of use are greater than risk to the baby.
  • Zanamivir: Studies in humans have not found an increased risk of birth defects with the use of zanamivir during pregnancy. Treating the flu with zanamivir during pregnancy is likely to be more beneficial than risky for the baby. The American College of Obstetricians and Gynecologists recommends that pregnant women who are thought to have the flu should receive antiviral treatment, regardless of specific test results or vaccination history. It’s best to start treatment within the first 48 hours of feeling sick, but if that’s not possible, treatment can still be beneficial.
• Not preferred due to limited data:
  • Baloxavir: The American College of Obstetricians and Gynecologists recommends against using baloxavir during pregnancy due to the absence of efficacy and safety data.

Respiratory Syncytial Virus

• Recommended:
  • Respiratory syncytial virus vaccine: The Centers for Disease Control recommended administration of the Abrysvo vaccine to women who are 32-36 weeks pregnant, when seasonally indicated, and when standard contraindications are not present. Vaccination offers protection to the baby for up to 6 months after birth, which wanes over time. Arexvy is another RSV vaccine available and is not indicated for use during pregnancy.

Supplements

• May be considered:
  • Echinacea: Available data in pregnant women do not show an increased risk of birth defects with echinacea in pregnancy. Short-term use (for 7 days or less) may be okay if the benefits of use are greater than risk to the baby.
  • Vitamin D: Some data suggest benefit with vitamin D dosages beyond the dietary reference intake during pregnancy, and available data show limited risk to the baby with dosages below 4,000 international units or 100 mcg per day. Use of vitamin D may be considered if benefits of use are greater than risk to the baby. Total daily dosages should be less than 4,000 international units or 100 mcg per day when accounting for intake from all possible sources (e.g., prenatal vitamins, food, etc.).
• Not preferred due to limited data:
  • Elderberry: Human pregnancy data are not available for elderberry and risk to the baby cannot be ruled out. Small amounts of elderberry in foods are probably okay, but there is not enough data with dosage references for supplementation of elderberry beyond this in pregnant women. Other options with more data should be used instead when possible.
  • Propolis: Small amounts via throat spray are ok to use for sore throat, however, alternatives with a larger body of evidence for safety during pregnancy may be preferred.
  • Eucalyptus: Birth defects have not been seen with eucalyptus in pregnant animals, but human data are not available. Other options with more data should be used instead if the benefits of treatment outweigh risk.
  • Vitamin C and zinc: Supplementation with vitamin C and Zinc is not a preferred strategy for prevention or treatment of the common cold in pregnancy. There is not enough data to support the use of this remedy; and while prenatal vitamins often contain the recommended daily requirements of vitamin C and zinc for pregnant women, cold remedies tend to contain much larger dosages that have not been studied in pregnancy.
  • Oscillococcinum: Studies have shown that it this supplement is unlikely to be helpful. Human pregnancy data are not available for oscillococcinum and risk to the baby cannot be ruled out.

Brittany Finocchio, PharmD, BCPP

Nichole Campbell, MSN, APRN, NP-C

Kaytlin Krutsch, PharmD, MBA, BCPS

References

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2. The REPROTOX System. Georgetown University Medical Center and Reproductive Toxicology Center, Columbia Hospital for Women Medical Center, Washington, D.C. (electronic version). Thomson Reuters, Greenwood Village, Colorado, USA.
3. Teris: The Teratogen Information System. University of Washington, Seattle, WA. (electronic version). Thomson Reuters, Greenwood Village, Colorado, USA.
4. Shephards: A catalog of teratogenic agents. The John’s Hopkins University Press, Baltimore, MD. (electronic version). Thomson Reuters, Greenwood Village, Colorado, USA.
5. MotherToBaby. Fact Sheets. (https://mothertobaby.org/fact-sheets). Acccessed 28 January 2024.
6. Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol. 2020;146(4):721-767.
7. U.S. Food and Drug Administration. FDA recommends avoiding use of NSAIDs in pregnancy at 20 weeks or later because they can result in low amniotic fluid. (https://www.fda.gov/drugs/drug-safety-and-availability/fda-recommends-a…). Updated 1 September 2022. Accessed 28 January 2024.
8. Centers for Disease Control and Prevention. Recommendations for Obstetric Healthcare Providers Related to Use of Antiviral Medications in Treatment and Prevention of Influenza. (https://www.cdc.gov/flu/professionals/antivirals/avrec_ob.htm). Last Reviewed 15 September 2022. Accessed 20 January 2024.
9. Abdullahi H, Elnahas A, Konje JC. Seasonal influenza during pregnancy. European Journal of Obstetrics and Gynecology and Reproductive Biology. 2021;258:235-329.
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12. Natural Medicines. (2023, November 27). Elderberry [monograph]. Accessed 28 January 2024.
13. The American College of Obstetricians and Gynecologists. COVID-19 Vaccines and Pregnancy: Key Recommendations and Messaging for Clinicians. (https://www.acog.org/-/media/project/acog/acogorg/files/pdfs/clinical-g…). Written September 2023. Accessed 21 January 2024.
14. Bednarek A and Laskowska M. Vaccination Guidelines for Pregnant Women: Addressing COVID-19 and the Omicron Variant. Med Sci Monit. 2024;30:e942799.
15. Kang D, Choi A, Park S, et al. Safety of COVID-19 Vaccination During Pregnancy and Lactation: A VigiBase Analysis. J Korean Med Sci. 2024;39(1):e3.
16. Centers for Disease Control and Prevention. Respiratory Syncytial Virus Infection (RSV). (https://www.cdc.gov/rsv/clinical/index.html). Last Reviewed 18 January 2024. Accessed 21 January 2024.
17. Centers for Disease Control and Prevention. When and How to Wash Your Hands. (https://www.cdc.gov/handwashing/when-how-handwashing.html). Reviewed 15 November 2022. Accessed 29 January 2024.
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20. Fikri AM, Sulaeman A, Handharyani E, Marliyati SA, Fahrudin M. The effect of propolis administration on fetal development. Heliyon. 2019;5(10):e02672. Published 2019 Oct 23. doi:10.1016/j.heliyon.2019.e02672

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