List of Medications Pregnant Nurses Should Not Handle

Pregnant nurses face documented reproductive risks from occupational contact with certain medications, and the drugs of greatest concern are antineoplastic agents, commonly known as chemotherapy drugs. Beyond that well-established category, a broader list includes specific antivirals, hormone analogues, immunosuppressants, and some newer targeted therapies. The risk comes not from a single dramatic exposure but from repeated low-level contact through skin absorption, inhalation of aerosolized particles, or accidental ingestion during routine tasks like mixing, administering, or even disposing of these drugs.

Why Certain Drugs Are Labeled Hazardous

The National Institute for Occupational Safety and Health (NIOSH) maintains a list of drugs it considers hazardous based on whether they have shown any of the following properties in human, animal, or laboratory studies: the ability to cause cancer, the ability to cause birth defects or developmental harm, reproductive toxicity, organ damage at low doses, or genetic damage.

NIOSH divides these drugs into groups. Group 1 contains drugs with confirmed cancer-causing properties, which largely overlaps with antineoplastic agents. Groups 2 and 3 capture non-antineoplastic drugs that still pose reproductive or organ-level hazards. For a pregnant nurse, the drugs flagged for teratogenicity (the ability to cause birth defects) and reproductive toxicity are the ones that matter most, but in practice, many of the cancer-causing agents in Group 1 also carry reproductive risks because the same mechanism that damages DNA in tumor cells can damage a developing embryo.

Antineoplastic Drugs Are the Highest Priority

Chemotherapy drugs sit at the top of every hazardous-handling list, and the evidence behind this is the most robust of any medication category. A meta-analysis of studies on nurses found that occupational exposure to antineoplastic agents raises the risk of spontaneous abortions, stillbirths, and congenital abnormalities.

A large prospective study of nurses who handled antineoplastic drugs before becoming pregnant found that the risk of miscarriage after 12 weeks of gestation more than doubled compared to nurses who never handled those drugs. That elevated risk was even more pronounced among nurses who did not consistently use protective equipment like gloves and gowns.

A broader review of the epidemiological evidence confirmed the pattern: while effect sizes varied across studies, occupational exposure to antineoplastic drugs appears to raise the risk of both congenital malformations and miscarriage, and studies on fertility suggested an increased risk for difficulty conceiving as well.

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The specific drugs in this category that pregnant nurses encounter most frequently in hospital settings include cyclophosphamide, ifosfamide, 5-fluorouracil, paclitaxel, docetaxel, doxorubicin, methotrexate, and cisplatin. These are among the most commonly detected on workplace surfaces in contamination studies, which means they are the ones most likely to result in skin contact even when a nurse is not directly preparing or administering them.

Non-Antineoplastic Drugs That Still Pose Reproductive Risk

The hazardous drug conversation often stops at chemotherapy, but several other medication categories carry documented teratogenic or reproductive risks. These drugs do not get the same institutional attention as antineoplastics, and the handling guidelines around them tend to be less clear-cut, which is itself a problem.

Antivirals

Ribavirin, used to treat certain viral infections including hepatitis C and respiratory syncytial virus, is a confirmed teratogen in animal studies. Nurses and respiratory therapists can be exposed to aerosolized ribavirin during administration to patients, and research has measured detectable drug uptake in healthcare workers as a function of the concentration of aerosol in the room.

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Ganciclovir, another antiviral, appears on NIOSH’s hazardous drug list because of its known mutagenic and teratogenic properties. Pregnant nurses should avoid handling either of these drugs, and anyone administering aerosolized ribavirin should be doing so in negative-pressure rooms with appropriate engineering controls regardless of pregnancy status.

Immunosuppressants

Mycophenolate (sold as CellCept or Myfortic) is a well-known teratogen when taken by patients. What is less widely appreciated is that it also poses an occupational hazard to the person handling it. A workplace survey found that nurses and pharmacists reported highly variable practices when handling mycophenolate, and many found existing guidance about hazardous non-cytotoxic medicines confusing or unclear.

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Other immunosuppressants that warrant caution include tacrolimus and cyclosporine. While these are less potently teratogenic than mycophenolate, they still appear on hazardous drug lists and should be handled with gloves and care by anyone who is pregnant.

Hormones and Uterotonic Agents

Misoprostol, widely used in obstetrics and gynecology, is teratogenic when a fetus is exposed to it in early pregnancy. Documented birth defects from prenatal exposure include skull defects, facial malformations, limb defects, and cranial nerve palsies, with the absolute risk of congenital malformations estimated at roughly 1% after exposure.

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For a pregnant nurse, the risk with misoprostol comes primarily from skin absorption when handling tablets without gloves or from accidentally inhaling dust if a tablet is crushed. Finasteride, diethylstilbestrol, and certain other hormonal agents also carry reproductive hazards and should be handled with the same precautions. The common thread is that these drugs are designed to interact with hormone pathways or uterine tissue, making even tiny exposures biologically meaningful during pregnancy.

How Exposure Actually Happens on the Job

Many nurses assume that if they are not mixing chemotherapy in a pharmacy hood, they are not at risk. This is wrong. Exposure happens through multiple pathways during routine nursing tasks, and the evidence for surface contamination in hospitals is striking.

A contamination surveillance program at a large community hospital found that 15 out of 25 sampled sites tested positive for hazardous drug residue, resulting in 37 positive results over 16 weeks of monitoring.

⁸ A UK hospital study found contamination with 5-fluorouracil and cyclophosphamide on isolator surfaces, bench tops, trays, and prepared products, with lower but still measurable levels detected on administration-area surfaces including trays, trolley arms, and nurses’ gloves.⁹ Another study that tested 28 surfaces in a hospital found 22 of them contaminated with at least one antineoplastic drug, with residue detected even in patient toilets, where the highest contamination level was from ifosfamide.¹⁰

This means a nurse can be exposed simply by touching a bed rail, a toilet handle, or an IV pole that a patient on chemotherapy has used. Patient excreta (urine, feces, vomit) contain metabolized drug, and handling linens, bedpans, or diapers is a common route of secondary exposure that gets overlooked.

Pill Crushing Is a Hidden Risk

When oral medications need to be crushed for patients who have difficulty swallowing, the act of crushing generates airborne particles that can be inhaled. Research has confirmed that different sizes of inhalable, respirable, and thoracic particles are released into the air during medication crushing.

¹¹ A separate study found that more vigorous crushing significantly increased the number of aerosolized drug particles, with the method and type of crusher both influencing exposure levels.¹²

If the drug being crushed is hazardous, this task should be performed inside a ventilated enclosure such as a fume hood, not at the bedside or in an open medication room. A pregnant nurse should avoid crushing any hazardous drug entirely.

Antibody-Drug Conjugates and Newer Targeted Therapies

A relatively new category of concern involves antibody-drug conjugates (ADCs). These drugs link a targeted antibody to a potent cytotoxic payload, delivering chemotherapy directly to tumor cells. While their clinical precision is a benefit for patients, the handling risk for staff is substantial because the payloads can be extraordinarily potent, with cytotoxic activity sometimes in the low picomolar range.

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ADCs are becoming more common in oncology, and their increasing use introduces handling challenges that go beyond what traditional chemotherapy protocols were designed for. The combination of antibody stability concerns and extreme cytotoxic potency means that ADCs require strict controls during preparation and administration.

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For pregnant nurses, the message is straightforward: these drugs should be treated with the same or greater caution as traditional antineoplastics. The payloads they carry include tubulin inhibitors and DNA-damaging agents, both of which are capable of harming a developing fetus.

What About Inhalational Anesthetics?

Waste anesthetic gases (sevoflurane, desflurane, nitrous oxide) have long been a concern for pregnant operating room nurses, but the evidence here is more reassuring than many people expect. A systematic review found that the studies with the strongest methodology do not show an association between occupational exposure to inhalational anesthetics and miscarriage or congenital malformations.

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This does not mean exposure is entirely risk-free; it means that modern scavenging systems in operating rooms appear to keep waste gas concentrations low enough to avoid measurable reproductive harm. The older studies that did find associations were typically conducted in settings with poor ventilation and no scavenging equipment. A pregnant nurse working in a well-ventilated, modern operating room is in a different situation from one working in a facility from the 1970s. Still, minimizing unnecessary exposure remains good practice.

Protective Equipment and Its Limits

The standard protective measures for hazardous drug handling include chemotherapy-tested gloves (double-gloving is recommended), disposable gowns, eye protection, and respiratory protection when there is a risk of aerosolization. For drug preparation, biological safety cabinets and closed-system transfer devices (CSTDs) are used to contain the drug during mixing and transport.

However, the evidence for how much CSTDs actually reduce worker exposure is surprisingly thin. A Cochrane review found that the available evidence was of very low certainty and insufficient to determine whether CSTDs make a meaningful difference in the proportion of workers with detectable drug in their urine or in the amount of surface contamination. None of the studies reviewed reported on downstream health outcomes like fertility, pregnancy complications, or cancer development.

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This does not mean CSTDs are useless. It means the trials have been too small and too short to prove their benefit in a statistically rigorous way. The theoretical mechanism is sound, and most occupational health experts still recommend them. But the takeaway for a pregnant nurse is that you should not rely solely on protective equipment as your safety net. Engineering controls reduce exposure; they do not eliminate it. The more cautious approach is to avoid handling hazardous drugs altogether during pregnancy.

Workplace Policies and Reassignment

Major professional organizations, including the Oncology Nursing Society, have recommended that employees who are actively trying to conceive, pregnant, or breastfeeding should be offered alternative work assignments that keep them away from antineoplastic drugs. Data from one study suggest this is already happening to some degree: only about 7% of pregnant nurses in the study administered antineoplastic drugs during the first 20 weeks of pregnancy, compared to 27% of non-pregnant nurses who had handled them within the past month.

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In the United States, no federal law explicitly mandates reassignment for pregnant nurses handling hazardous drugs. The Pregnancy Discrimination Act requires employers to treat pregnant employees the same as others with similar ability or inability to work, and the more recent Pregnant Workers Fairness Act (2023) requires reasonable accommodations for pregnancy-related limitations. In practice, a pregnant nurse who requests reassignment away from hazardous drug handling has strong grounds to receive it, particularly when professional guidelines already support the request. Some hospitals have written policies requiring reassignment; others handle it informally and case by case.

The challenge is that non-antineoplastic hazardous drugs often fall through the cracks. A nurse reassigned away from oncology may still encounter mycophenolate on a transplant unit, ribavirin in a respiratory unit, or misoprostol on a labor and delivery floor. A well-designed policy accounts for all NIOSH-listed drugs, not just the ones with “chemo” in their description.

The Contamination Problem That Cleaning Cannot Fully Solve

Even with decontamination protocols, hazardous drug residue persists in healthcare environments. The hospital surveillance study mentioned earlier found that after an initial positive surface test, decontamination successfully cleared the site about 93% of the time. But three sites remained positive even after the first cleaning and required a formal investigation and a second round of decontamination before they tested negative.

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The fact that contamination was found on patient toilet surfaces at particularly high levels has implications for nurses on any unit where patients receive oral or IV chemotherapy, not just nurses who work in dedicated infusion centers.

¹⁰ A nurse helping a patient to the bathroom, changing bed linens, or emptying a urinal could be handling drug-contaminated materials without realizing it. This kind of secondary exposure is especially easy to miss because it does not look like “handling medication.”

A Practical Reference List

While the full NIOSH list includes hundreds of drugs, the following categories and specific agents are the ones pregnant nurses are most likely to encounter and should avoid handling:

Antineoplastics: cyclophosphamide, ifosfamide, 5-fluorouracil, methotrexate, doxorubicin, cisplatin, paclitaxel, docetaxel, vincristine, etoposide, and all other cytotoxic chemotherapy agents
Antibody-drug conjugates: trastuzumab emtansine (Kadcyla), enfortumab vedotin (Padcev), sacituzumab govitecan (Trodelvy), and other ADCs carrying cytotoxic payloads
Antivirals: ribavirin, ganciclovir, valganciclovir
Immunosuppressants: mycophenolate mofetil (CellCept), mycophenolic acid (Myfortic)
Hormones and related agents: misoprostol, finasteride, dutasteride, diethylstilbestrol, oral contraceptives (when crushed), tamoxifen, raloxifene
Retinoids: isotretinoin (Accutane), acitretin, tretinoin (oral form used in leukemia)
Other reproductive hazards: thalidomide, lenalidomide, pomalidomide (all classified as known teratogens with restricted distribution programs)

The complete and current NIOSH hazardous drug list, updated periodically, should be the final reference. Hospital pharmacy departments typically maintain a facility-specific version that maps to their formulary. If you are pregnant and unsure whether a drug you are asked to handle is on the list, ask your pharmacy before touching it.

The Pre-Conception Window

One finding that surprises many nurses is that the risk is not limited to the weeks after a positive pregnancy test. The study on antineoplastic handling and miscarriage measured exposure before pregnancy and still found elevated risk, particularly for later pregnancy losses.

³ A separate review noted that studies of fertility and time-to-pregnancy also suggested increased risk of subfertility among nurses with antineoplastic exposure.⁴

This means that nurses who are actively trying to conceive may also benefit from reassignment away from hazardous drug handling. The Oncology Nursing Society’s recommendation includes this group explicitly. If your workplace policy only covers nurses who are already pregnant, the evidence suggests it should also cover those planning pregnancy. Bringing this up with an occupational health department, ideally with supporting literature, is the most practical path toward a broader policy where one does not already exist.

1
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