Furosemide in pregnancy and breastfeeding


Risk Factor: CM*
Class: Diuretics

Contents of this page:
Fetal Risk Summary
Breast Feeding Summary

Fetal Risk Summary

Furosemide is a potent diuretic. The drug has caused maternal deaths and abortions in rabbits at doses 2, 4, and 8 times the maximum recommended human dose of 600 mg/day (1). An increase in the incidence and severity of hydronephrosis (distention of the renal pelvis and in some cases of the ureters) has also been observed in the offspring of mice and rabbits (1). Wavy ribs and some skeletal defects have been observed in the offspring of rats given furosemide during organogenesis (2). These effects appeared to be caused directly or indirectly by the diuretic action of the drug (2).

Cardiovascular disorders, such as pulmonary edema, severe hypertension, or congestive heart failure, are probably the only valid indications for this drug in pregnancy. Furosemide crosses the placenta (3). Following oral doses of 2540 mg, peak concentrations in cord serum of 330 ng/mL were recorded at 9 hours. Maternal and cord levels were equal at 8 hours. Increased fetal urine production after maternal furosemide therapy has been observed (4,5). Administration of furosemide to the mother has been used to assess fetal kidney function by provoking urine production, which is then visualized by ultrasonic techniques (6,7). Diuresis was found more often in newborns exposed to furosemide shortly before birth than in controls (8). Urinary sodium and potassium levels in the treated newborns were significantly greater than in the nonexposed controls.

In a surveillance study of Michigan Medicaid recipients involving 229,101 completed pregnancies conducted between 1985 and 1992, 350 newborns had been exposed to furosemide during the 1st trimester (F. Rosa, personal communication, FDA, 1993). A total of 18 (5.1%) major birth defects were observed (15 expected). Specific data were available for six defect categories, including (observed/expected) 2/4 cardiovascular defects, 1/1 oral clefts, 0/0 spina bifida, 1/1 polydactyly, 1/1 limb reduction defects, and 3/1 hypospadias. Only with the latter defect is there a suggestion of an association, but other factors, including the mother’s disease, concurrent drug use, and chance, may be involved.

After the 1st trimester, furosemide has been used for edema, hypertension, and toxemia of pregnancy without causing fetal or newborn adverse effects (9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30 and 31). Many investigators now consider diuretics contraindicated in pregnancy, except for patients with cardiovascular disorders, since they do not prevent or alter the course of toxemia and they may decrease placental perfusion (32,33,34 and 35). A 1984 study determined that the use of diuretics for hypertension in pregnancy prevented normal plasma volume expansion and did not change perinatal outcome (36). Thus, diuretics are not recommended for the treatment of pregnancy-induced hypertension because of the maternal hypovolemia characteristic of this disease.

Administration of the drug during pregnancy does not significantly alter amniotic fluid volume (30). Serum uric acid levels, which are increased in toxemia, are further elevated by furosemide (37). No association was found in a 1973 study between furosemide and low platelet counts in the neonate (38). Unlike the thiazide diuretics, neonatal thrombocytopenia has not been reported for furosemide.

[*Risk Factor D if used in pregnancy-induced hypertension.]

Breast Feeding Summary

Furosemide is excreted into breast milk (1,39). No reports of adverse effects in nursing infants have been found. Thiazide diuretics have been used to suppress lactation (see Chlorothiazide).



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