ADHD, Medication and Pregnancy: Questions and Answers

 

Dear Dr Quinn,
For the past 2 years I have been taking 20 mg of Adderall daily for adult ADD and seem to have been doing fine. It helps me control outbursts of anger and aided primarily in anxiety management. Recently, however, I learned that I am pregnant so I stopped taking the Adderall altogether. However, I find that my temper seems to flare up and the anxiety and depression have been over-whelming at times.

While I am under the impression that a class “C” drug is not advisable to take during the first trimester, I find that taking just 10mg every 3rd day seems to make coping much easier. Is taking Adderall during pregnancy totally forbidden? What has been the experience and or clinical test results been of others taking this medication before and or during pregnancy? Can you direct me to more details regarding my issue?

Thank You,
HH

 

Dear Dr. Quinn,
I am a 33-year old woman with ADD and am now 3 months pregnant. I have been taking Ritalin for 6 years, and my obstetrician says, “Ritalin is just for children,” and does not want me to take it. My dosage was 3 10-mg tablets a day. I am an accountant, among many other things, and find it very difficult to function without it.

I am completely for doing whatever is best for my unborn child, but I want to do what needs to be done with the best information. I am not one who does something, “just because.” I have been able to find no research on the effects of taking Ritalin during pregnancy, and my obstetrician tells me he has never had a patient who took Ritalin during pregnancy. His sole reason for telling me not to take it is because there have been no studies done, and it is “not in the books.”

Is it safe to take Ritalin while you’re pregnant? Thanking you in advance for your reply,
DK

 

ARE STIMULANTS SAFE TO USE DURING PREGNANCY?

With more and more women being diagnosed and treated for AD/HD, the question of safe use of stimulant medications during pregnancy has become more critical. I am now receiving letters like those above several times a month. I have decided to answer them here and provide a little more information on safety of not only stimulants, but also other medications during pregnancy.

The NCGI website contains an article that I wrote on Medication Use during Pregnancy (pdf 76k). In general, stimulants (either amphetamines like Adderall or methyphenidate like Ritalin, Concerta, and Metadate CD) are all considered “Category C” teratogens. That means that they should only be used when the risk to the mother outweighs the risk to the fetus.

To date, the effects of stimulants during pregnancy have only been studied in animals, where defects were seen in the offspring when the mothers were given very high doses of the stimulants. The doses of stimulants given to animals for these studies have been 41x and 12x the usual human dose. The literature contains individual case reports of women who have taken stimulants during their pregnancy and, clinically, there have been many other women who have taken stimulants and have had normal babies.

The important questions for a woman who is being treated for AD/HD and who is thinking about getting pregnant or who recently learned that she is pregnant are the following:

  • Should she discontinue stimulants prior to becoming pregnant?
  • Should she continue stimulants during her first 3 months?
  • Should she discontinue medication during the entire pregnancy?
  • What are the risks both to the mother and the baby if her disorder goes untreated?

Each woman needs to decide for herself after considering all of the available information and discussing the issue with both the child’s father and her physician. The problems with the stimulants have to do with cardiac defects, which usually occur because of problems during the formation stages of each organ system during the first trimester. To date, there are no large-scale studies to provide us with answers. The National Center for Gender Issues and ADHD would like to address this issue and collect information that would help women of childbearing age and their physicians better answer these questions armed with more data.

In the near future, NCGI will establish a birth registry on which physicians can report outcomes of women who have taken stimulants during pregnancy.

CAN A WOMAN WITH AD/HD TAKE OTHER MEDICATIONS WHILE PREGNANT?

While the stimulants remain the most effective treatment for AD/HD, other medications that are approved for use during pregnancy might also be considered to address associated symptoms such as the anxiety and depression reported in the first letter above.

  • The tricyclic antidepressants (Clonidine and Tenex) are second line treatments for AD/HD and are no longer considered a risk during pregnancy as a result of studies that have shown no significant association between exposure during pregnancy and defects or behavior changes in infants.
  • The SSRI antidepressants also have been studied and have a large database on pregnancy exposure.
  • After considerable monitoring, Prozac, Luvox, Paxil, and Zoloft are considered to have no increased risk of major malformations in the infant when used within recommended dosage levels during the pregnancy. There was also no increased risk of miscarriage, stillbirth, or premature delivery noted.
  • Wellbutrin does not yet have enough data, but has been labeled a Category B as a result of studies done in rabbits. A pregnancy database to monitor its safety was established in 1997 to further investigate its safety in humans.

SHOULD ANXIETY AND DEPRESSION BE TREATED DURING PREGNANCY?

We have already discussed the safety of the antidepressants during pregnancy, but are there risks to not treating these disorders? A recent study in Canada has looked at this question. Dr. Shaila Misri, medical director of the reproductive psychiatry program at B.C. Women’s hospital Vancouver has just completed a groundbreaking study. Investigators found that in studying 46 women:

  • psychiatric illnesses escalated during pregnancy without medications such as antidepressants
  • women diagnosed later in the pregnancies needed more medications and were more likely to give birth to babies that required longer observation (48 hours) in the nursery
  • babies of mothers taking medication during the pregnancy were released from the hospital at the same time as babies of mothers who were not taking medication for psychological illness

Dr. Misri noted that panic attacks or anxiety in pregnant women can stress their unborn babies triggering uterine contractions that cause fetal distress. She further reported that studies done on rats and monkeys stressed during pregnancy found that the offspring were very nervous and jittery.

While no other studies like this one have been conducted, Dr. Misri does not feel that her findings are controversial. She emphasizes that it is important to educate family practitioners and obstetricians of these findings in order to improve early diagnosis and treatment of anxiety and depression in pregnant women.

In addition, it is important to note that a study conducted at Harvard suggested that decreased or discontinuation of antidepressants during pregnancy leaves mothers extremely vulnerable to relapses.

 

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