Acetaminophen (Tylenol) is the safest over-the-counter pain reliever during pregnancy, and calcium-based antacids like Tums are fine for heartburn when used as directed. Beyond those two staples, several other OTC medications are considered low-risk for specific symptoms, while a handful of common drugs should be avoided entirely. Here’s what the evidence says, organized by the symptom you’re trying to treat.
Pain and Fever: Acetaminophen Only
Acetaminophen remains the only recommended OTC pain reliever and fever reducer during pregnancy. The FDA has noted it is the safest over-the-counter option among all painkillers and fever reducers, and in 2021, the American College of Obstetricians and Gynecologists affirmed that prudent use has not been clearly linked to developmental problems in children.
That said, “prudent” is the key word. Some research has raised concerns about chronic, daily use throughout pregnancy and a possible association with neurological conditions like ADHD in children. The practical takeaway: use it when you genuinely need it, at the lowest effective dose, for the shortest time necessary. Don’t take it preventively or for minor discomfort you can manage without medication. The standard maximum for adults is 3,000 mg per day, though many providers recommend staying under that ceiling during pregnancy.
Medications to Avoid for Pain
Ibuprofen (Advil, Motrin) and naproxen (Aleve) belong to a class of drugs called NSAIDs, and the FDA has issued a specific warning against using them at 20 weeks of pregnancy or later. After that point, NSAIDs can impair the baby’s kidney function, which leads to dangerously low amniotic fluid levels. This problem has been reported in as little as 48 hours after starting an NSAID. In severe cases, babies have needed dialysis after birth.
Low amniotic fluid, if it persists, can cause complications including restricted limb development and delayed lung maturation. The fluid levels often recover once the medication is stopped, but the risk makes NSAIDs a clear “no” in the second half of pregnancy. Earlier in pregnancy, the evidence is less definitive, but most providers recommend avoiding them altogether when acetaminophen is available.
Aspirin is also an NSAID, but there’s one important exception: low-dose aspirin (81 mg daily) is sometimes deliberately prescribed starting between 12 and 28 weeks for women at increased risk of preeclampsia. Consistent trial data shows it significantly reduces the risk of preeclampsia, preterm birth, and fetal growth restriction. This is a specific medical use, not something to start on your own.
Allergies: Second-Generation Antihistamines
For seasonal allergies or allergic rhinitis, cetirizine (Zyrtec) and loratadine (Claritin) are the best-studied options. Both are classified as pregnancy category B, meaning animal studies have shown no risk and human data has not identified birth defects. Earlier concerns that loratadine might increase the risk of a genital birth defect called hypospadias have been ruled out by more recent studies.
The main guidance from ACOG and the American College of Allergy, Asthma and Immunology is to try first-generation antihistamines like chlorpheniramine first, then move to cetirizine or loratadine if those don’t work. In practice, many women go straight to the second-generation options because they don’t cause drowsiness. If possible, it’s best to avoid any antihistamine during the first trimester, when the baby’s organs are forming, and start them after that window if you need ongoing relief.
Fexofenadine (Allegra) has less safety data in pregnant women. Animal studies showed reduced pup weight and survival, and it carries a less reassuring pregnancy classification. Stick with cetirizine or loratadine when you have the choice.
Colds and Coughs
Dextromethorphan, the cough suppressant found in many Robitussin and Delsym products, has not been linked to increased rates of miscarriage, birth defects, stillbirth, or low birth weight. A study of 128 women who took it in the first trimester found no increase in miscarriage, and a larger study of 184 women who used it at various points in pregnancy found no problems at delivery.
Two practical rules apply. First, choose single-ingredient products rather than combination cold medicines. Multi-symptom formulas often bundle in ingredients you don’t need, some of which may not be safe. Second, check the label for alcohol content. Some liquid cough syrups contain alcohol, which you should avoid during pregnancy.
Oral Decongestants: Use With Caution
Pseudoephedrine (Sudafed) and phenylephrine are more complicated. All oral decongestants work by constricting blood vessels, and that same mechanism can constrict the blood vessels supplying the uterus, potentially reducing oxygen flow to the baby. A study published in the American Journal of Epidemiology found that phenylephrine was associated with an eightfold increased risk of a specific heart defect, and phenylpropanolamine (now largely off the market) was linked to ear defects and a stomach condition called pyloric stenosis.
For nasal congestion during pregnancy, saline nasal sprays or saline rinses are the safest first step. If you need something stronger, talk to your provider before reaching for an oral decongestant, especially during the first trimester.
Heartburn and Acid Reflux
Calcium carbonate antacids (Tums, Rolaids, Maalox) are not expected to increase the risk of miscarriage, birth defects, preterm delivery, or low birth weight when used at recommended doses. Heartburn affects the majority of pregnant women, particularly in the third trimester, and these antacids have a long safety record.
You get a side benefit, too: calcium carbonate provides supplemental calcium, which most pregnant women need more of. Just stay within the dosing instructions on the label, since excessive calcium intake can cause its own problems, including constipation and kidney stones.
Constipation
Constipation is extremely common in pregnancy due to hormonal changes that slow the digestive tract. The good news is that most OTC laxatives are minimally absorbed into the bloodstream, so they pose little risk to the baby.
Fiber supplements like psyllium (Metamucil) are the gentlest first option. If those aren’t enough, osmotic laxatives such as polyethylene glycol (MiraLAX) and lactulose are poorly absorbed and have not been associated with adverse effects. Stimulant laxatives like bisacodyl and senna also appear safe but can cause abdominal cramping. With any laxative type, keep use occasional or short-term rather than daily for extended periods, since prolonged use can lead to dehydration or electrolyte imbalances.
Nausea and Morning Sickness
Doxylamine succinate, the antihistamine sold as Unisom SleepTabs, has one of the strongest safety records of any OTC medication in pregnancy. Combined with vitamin B6, it is the active ingredient in prescription anti-nausea medication specifically approved for morning sickness. Studies involving hundreds of thousands of women have found no increased risk of birth defects, preterm delivery, or low birth weight. Follow-up studies tracking children to age 7 found no higher rates of behavioral or learning problems.
Many women use the OTC version (doxylamine plus a vitamin B6 supplement) as a first-line treatment for nausea. This combination is also what makes doxylamine a reasonable sleep aid during pregnancy, since drowsiness is its primary side effect.
Skin Issues and Acne
Pregnancy hormones can trigger or worsen acne, and several OTC topical treatments are considered acceptable. ACOG suggests that topical products containing benzoyl peroxide, azelaic acid, salicylic acid, or glycolic acid can be used during pregnancy if needed. Because the skin acts as a barrier, only small amounts of these ingredients are absorbed into the bloodstream, and none have been associated with increased birth defect risk when applied topically as directed.
The one topical category to avoid is retinoids. Over-the-counter products containing adapalene (Differin) or tretinoin (Retin-A) should be stopped during pregnancy. Oral retinoids are known to cause serious birth defects, and while topical forms deliver much lower doses, the general recommendation is to stay away from them entirely until after delivery.
For itching or minor skin irritation, low-potency topical hydrocortisone cream (1%) is generally considered low-risk for short-term, localized use. It treats the same small-area concerns it would outside of pregnancy: bug bites, mild rashes, and contact irritation.
General Principles for OTC Use
A few guidelines apply across every category. Choose single-ingredient products over combination formulas so you’re only taking what you actually need. Use the lowest effective dose for the shortest time that helps. The first trimester, when organs are developing, is the most sensitive window for any medication exposure, so delaying non-urgent OTC use until the second trimester reduces risk when that’s practical.
Read labels carefully. Many “multi-symptom” cold, flu, and PM-formula products contain overlapping ingredients, and it’s easy to accidentally double up on acetaminophen or take a decongestant you didn’t realize was in the mix. If a product lists more than two active ingredients, take a closer look at each one before assuming the whole formula is safe.