In utero exposure to antibiotics and risk of congenital malformations: a population-based study

Am J Obstet Gynecol. 2019 Dec;221(6):648.e1-648.e15. doi: 10.1016/j.ajog.2019.06.050. Epub 2019 Jun 28.


Background: Antibiotics are commonly prescribed during pregnancy. Although the safety of most penicillins is well established, some controversy and uncertainty are associated with the use of other commonly prescribed antibiotics.

Objective: To determine the risk of congenital malformations following first-trimester in utero exposure to 10 commonly prescribed antibiotics in Denmark.

Materials and methods: This was a cohort study comprising all singleton liveborn children in Denmark between 2000 and 2015. Data on malformations were collected through 2016. Merging validated and comprehensive populationwide Danish healthcare and civic registries, we merged data on pregnancy, prescription drugs purchases during first trimester and congenital malformations. Using logistic regression, we calculated the odds ratio for congenital malformations (any), major congenital malformations, and cardiac congenital malformations for the 10 most commonly prescribed antibiotics (excluding 4 penicillins that served as control). In the primary analysis, the exposed cohort was compared to a cohort exposed to any of 4 penicillins considered safe during pregnancy (ampicillin, pivampicillin, benzylpenicillin, and phenoxymethylpenicillin). In sensitivity analysis, the exposed cohort was compared to an unexposed cohort. Covariate adjustments were made for maternal age at delivery, year of delivery, parity, pre-pregnancy body mass index, smoking, educational status, employment status, and annual personal income.

Results: We found no increased risk of congenital malformations to be related to first-trimester in utero exposure to the 10 most commonly prescribed antibiotics in Denmark compared to a cohort of pregnant women exposed to penicillins that are considered safe during pregnancy. Compared to unexposed pregnancies, small increased risks for major malformations and cardiac malformations were apparent for pivmecillinam (odds ratio, 1.13; confidence interval, 1.06-1.19; and odds ratio, 1.15; confidence interval, 1.04-1.28, respectively), sulfamethizole (odds ratio, 1.15; confidence interval, 1.07-1.24; and odds ratio, 1.22; confidence interval, 1.07-1.39, respectively), and azithromycin (odds ratio, 1.19, confidence interval, 1.03-1.38; and odds ratio, 1.29, confidence interval, 0.99-1.67, respectively).

Conclusion: In this large populationwide cohort study, we found, with a high degree of precision, no increased risk of congenital malformations following first-trimester exposure to 10 commonly prescribed systemic antibiotics.

Keywords: antibiotics; congenital malformations; pregnancy.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Amdinocillin Pivoxil / therapeutic use
  • Anti-Bacterial Agents / therapeutic use*
  • Azithromycin / therapeutic use
  • Case-Control Studies
  • Cohort Studies
  • Congenital Abnormalities / epidemiology*
  • Denmark / epidemiology
  • Educational Status
  • Employment
  • Female
  • Heart Defects, Congenital / epidemiology
  • Humans
  • Logistic Models
  • Maternal Age
  • Maternal Exposure / statistics & numerical data*
  • Obesity, Maternal / epidemiology
  • Odds Ratio
  • Penicillins / therapeutic use
  • Pregnancy
  • Pregnancy Trimester, First
  • Smoking / epidemiology
  • Sulfamethizole / therapeutic use
  • Young Adult


  • Anti-Bacterial Agents
  • Penicillins
  • Amdinocillin Pivoxil
  • Sulfamethizole
  • Azithromycin