Key Counseling Points for OTC Medications During Pregnancy

Counseling pregnant patients regarding OTC products is extremely important. Physicians oversee prescription medications the patient is taking, but OTC products bypass this system, and patients are often unaware of what can and cannot be taken. The general rule of thumb is for patients to use the safest regimen, at the lowest effective dose, for the shortest duration of time necessary, per a physician’s direction.¹

However, patients should also be aware that there is a higher probability of increased adverse effects in the first and third trimesters. Furthermore, 2 through 8 weeks after conception is when organogenes, the development of organs, occurs; this is a vital time to limit drug exposure.¹ Providing these educational points is a crucial role for pharmacists.

OTC Options for Nausea & Vomiting

Nausea and vomiting are extremely common during pregnancy, affecting an estimated 70% to 80% of all patients.² Safe options for nausea and vomiting in pregnancy are vitamin B6 and pyridoxine (specifically, a dose of <100 mg daily as initial treatment). Another option is first-generation antihistamines, such as doxylamine and diphenhydramine. These are safe to use throughout pregnancy.¹

For patients seeking herbal supplements, ginger is safe to use only in the first trimester. Per a 2014 meta-analysis involving 12 randomized controlled trials, a total daily dose of 1000 mg to 1500 mg of ginger given in 2 to 4 separate doses is just as effective as pyridoxine and superior to placebo in early pregnancy. Ginger should be avoided in the second and third trimester as it has been associated with vaginal bleeding, premature birth, and reduced fetal head circumference.¹

Managing Acid Reflux

Like nausea, acid reflux is nearly ubiquitous in pregnancy.³ Regarding gastroesophageal reflux disease (GERD), calcium carbonate up to its usual dose limits is the recommended antacid in pregnancy. If symptoms are not controlled with calcium carbonate, H2 antihistamines are a safe alternative.¹

Sodium bicarbonate, seen in some antacid products, should be avoided because it can cause metabolic alkalosis and fetal fluid overload. Bismuth subsalicylate can cross the placenta and should not be used after 20 weeks’ gestation. It can cause kidney dysfunction, low amniotic fluid volume, premature closing of the ductus arteriosus.¹

OTC Medications for Constipation

Up to half of pregnant patients experience constipation at some point during their pregnancy.⁴ Light exercise and increased water and dietary fiber intake may reduce symptoms of constipation. Osmotic laxatives, such as polyethylene glycol 3350 or magnesium hydroxide, are safe and effective in pregnancy. However, caution patients against long-term use because this can lead to electrolyte imbalances.¹

Constipation can lead to hemorrhoids, especially in the second or third trimesters. It is important to educate patients about diet and stool habits early in pregnancy to avoid hemorrhoids at delivery. In the second or third trimester, a thin layer of topical 1% hydrocortisone can be used 2 times per day for up to 10 consecutive days.¹

Acne and Eczema in Pregnancy

Pregnancy-related acne is typically caused by the surge in hormones, particularly during the first trimester, which causes increased oil production.⁵ Acne treatment in pregnancy involves avoiding oily cosmetics, decreasing dairy and high glycemic index foods, and facial cleansing twice a day. Benzoyl peroxide and azelaic acid are safe to use in pregnancy. In contrast, retinoids are known teratogens. Educate patients to avoid adapalene, as this is a topical OTC retinoid.¹

A safe option for treating eczema-related itching and inflammation is either 0.5% or 1% hydrocortisone cream to be applied once or twice daily. Treatment of tinea skin infection can with azole antifungals, such as clotrimazole 1% applied twice a day for 2 to 4 weeks.¹

Treating Nasal Congestion During Pregnancy

Nasal congestion can occur in pregnant patients and is often called “pregnancy rhinitis.”⁶ Hypertonic saline rinse is safe and effective for decreasing rhinitis symptoms. Several cohort and case control studies have shown birth defects with first trimester sympathomimetic decongestant exposure. As such, clinicians should advise patients to avoid OTC stimulant decongestants in early pregnancy. Specific examples of products to avoid include pseudoephedrine, phenylephrine, and intranasal oxymetazoline. Dextromethorphan use is generally considered safe in early pregnancy. It has been used in the past and did not show any major malformations or harms to the fetus.¹

Headache and Migraine Management

The first-line OTC treatments for headaches in pregnancy are acetaminophen and acetaminophen with caffeine. The total caffeine intake from medications, food, and beverages should not be greater than 200 mg daily in pregnant patients.¹

To decrease migraine frequency, severity, and duration during pregnancy, prophylactic magnesium oxide 400 mg to 800 mg daily can be used. Findings of a 5-year retrospective cohort study showed evidence in favor of magnesium oxide. For treatment of uncontrollable and unmanageable migraines, nonsteroidal anti-inflammatory drugs (NSAIDs) can be considered in the second trimester only.¹

Reducing Pain and Fever in Pregnant Patients

Reducing fever during pregnancy is critical. High temperatures can cause dehydration, lead to premature labor, and have been shown to slightly increase the risk of fetal organ defects or neurodevelopmental problems.⁷ If medications are needed for pain and fever management, acetaminophen is the first-line option. There is no evidence of increased malformations in human observations, and lidocaine has not been shown to be teratogenic in animal studies. Lidocaine patches or creams should only be used when safer options have not worked.¹

Although acetaminophen is safe to use in pregnancy, the maximum total daily dose is 4000 mg. There is an increased risk of asthma in the exposed infant with maternal use of acetaminophen. Acetaminophen should be used minimally, as needed, and only after speaking with a health care provider.¹

Use of OTC NSAIDs should be limited in the second trimester. Per a National Birth Defects Prevention Study, the results of approximately 29,000 cases over 14 years demonstrated an increased risk of 10 major congenital abnormalities. There is an increased risk of fetal kidney injury and build-up of low amniotic fluid with NSAID use after 20 weeks’ gestation. After 30 weeks’ gestation, use of NSAIDs can cause premature ductus arteriosus closure. Additionally, topical NSAIDs should be avoided in late pregnancy, as they have shown similar complications in case reports.¹

Alternatively, patients at increased risk of preeclampsia can take low-dose aspirin. Per the US Preventative Services and American College of Obstetricians and Gynecologists, 81 mg per day of aspirin should be initiated between 12 and 28 weeks’ gestation for patients at increased risk of preeclampsia.¹

The preferred treatment for fever is acetaminophen because the use of NSAIDs is dangerous in pregnancy. Pregnant patients with a fever should be counseled to avoid NSAIDs and take the minimum amount of acetaminophen.¹

Sleep Aides in Pregnancy

Sleep during pregnancy—typically 7 to 9 hours per night—regulates blood pressure, supports fetal development, and lowers the risk of complications.⁸ Any outside factors affecting sleep patterns should be addressed. However, if someone is still having trouble sleeping, first-generation antihistamines taken as needed are acceptable. First-generation antihistamines have shown benefit over placebo in reducing depression related to insomnia during pregnancy.

Counseling Points for Pharmacists

When a patient asks whether a certain product is safe to use during pregnancy, the pharmacist must educate them regarding what to avoid and what is acceptable. Pharmacists serve to fill the gap by providing safe OTC product recommendations for pregnant patients. Being a resource for the public is a vital role that must be prioritized. Pharmacists must focus on teaching patients what to avoid, what drugs can be taken, and appropriate dose and duration.

REFERENCES

1. Powers EA, Tewell R, Bayard M. Over-the-counter medications in pregnancy. Am Fam Physic. 2023;108(4):360-369.

2. Lee NM, Saha S. Nausea and vomiting of pregnancy. Gastroenterol Clin North Am. 2011;40(2):309-vii. doi:10.1016/j.gtc.2011.03.009

3. Heartburn during pregnancy. Cleveland Clinic. Updated April 26, 2024. Accessed July 7, 2026. https://my.clevelandclinic.org/health/diseases/12011-heartburn-during-pregnancy

4. Constipation during pregnancy. American Pregnancy Association. Updated February 20, 2026. Accessed July 7, 2026. https://americanpregnancy.org/pregnancy/constipation-during-pregnancy/

5. Pregnancy acne: what’s the best treatment? Mayo Clinic. October 10, 2025. Accessed July 7, 2026. https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/expert-answers/pregnancy-acne/faq-20058045

6. Pregnancy rhinitis. Cleveland Clinic. Updated June 3, 2024. Accessed July 7, 2026. https://my.clevelandclinic.org/health/diseases/pregnancy-rhinitis

7. Fever/Hyperthermia. MotherToBaby Fact Sheets [Internet]. February 2025. Accessed July 7, 2026. https://www.ncbi.nlm.nih.gov/books/NBK582757/

8. Get a good night’s sleep during pregnancy. Johns Hopkins Medicine. Accessed July 7, 2026. https://www.hopkinsmedicine.org/health/conditions-and-diseases/staying-healthy-during-pregnancy/get-a-good-nights-sleep-during-pregnancy