A Rational Approach to Pharmacotherapy in Pregnancy

Most pregnant individuals are exposed to at least one medication, whether prescription or over the counter, during pregnancy. Despite the ubiquity of medication use in pregnancy, there remains no standardized framework to guide clinicians in selecting the most appropriate pharmacotherapy that balances maternal needs with fetal safety. This gap contributes to variability in prescribing practices and uncertainty in clinical decision making. In this article, we propose a structured schema for evaluating and selecting drug therapy during pregnancy. Our approach emphasizes careful consideration of maternal and fetal factors, integration of the unique physiologic changes of pregnancy, and systematic appraisal of the best available evidence. Recognizing the frequent absence of robust pharmacokinetic and safety data, we also provide pragmatic principles and rules of thumb to guide clinicians in estimating the likelihood of placental transfer and potential fetal exposure. This framework is designed to support clinicians in making more informed, transparent, and evidence-based decisions while also identifying areas for future research.