Are buspirone, pantoprazole, quetiapine, sertraline, and trazodone safe to use during pregnancy?

Safety of Buspirone, Pantoprazole, Quetiapine, Sertraline, and Trazodone During Pregnancy

These medications have varying safety profiles in pregnancy: sertraline and trazodone appear relatively safe with some caveats; quetiapine shows no increased malformation risk; buspirone has limited but reassuring data; pantoprazole lacks sufficient evidence in the provided sources but is generally considered low-risk for PPIs as a class.

Sertraline (SSRI Antidepressant)

Sertraline can be continued during pregnancy when clinically necessary, though it carries specific cardiac and skeletal risks that require informed decision-making.

• Sertraline exposure in the first trimester is associated with increased risk of atrial/ventricular septal defects (RR 1.34,95% CI 1.02-1.76) and craniosynostosis (RR 2.03,95% CI 1.09-3.75) 1
• However, the overall major malformation rate is not significantly elevated compared to depressed women not taking antidepressants 1
• The broader evidence suggests that associations between prenatal antidepressant exposure and neurodevelopmental problems (ASD, ADHD) are largely due to confounding factors rather than the medications themselves 2
• Critical consideration: Untreated depression during pregnancy carries substantial risks including gestational diabetes, ongoing pregnancy depression, postpartum depression, and decreased breast milk production 3

Trazodone (Sedating Antidepressant)

Trazodone can be used during pregnancy when benefits outweigh risks, with no consistent evidence of major malformations.

• FDA labeling states that published data over several decades have not identified drug-associated risks of major birth defects, miscarriage, or adverse maternal/fetal outcomes 4
• A 2025 systematic review found no consistent evidence linking trazodone to increased risks of congenital malformations, stillbirths, or low birth weight 5
• Some studies suggest possible association with increased spontaneous/therapeutic abortions, though data are limited 5
• Animal studies showed fetal toxicity at 7-11 times human doses, but human data are reassuring 4

Quetiapine (Atypical Antipsychotic)

Quetiapine can be used during pregnancy with appropriate monitoring, as it shows no increased malformation risk but requires awareness of neonatal adaptation issues.

• FDA labeling indicates no major malformations in limited published literature (63 exposed pregnancies reviewed) 6
• A 2015 systematic review of 443 first-trimester exposures found a malformation rate of 3.6% with relative risk of 1.0 (95% CI 0.6-1.7), indicating no increased risk 7
• Important caveat: Neonates exposed in the third trimester are at risk for extrapyramidal and/or withdrawal symptoms (agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, feeding disorders) that may require ICU support 6
• Use only if potential benefit justifies potential fetal risk 6

Buspirone (Anxiolytic)

Buspirone appears safe based on limited but rigorously collected prospective data showing zero malformations in 72 infants.

• The most rigorous prospective study (MGH National Pregnancy Registry) found zero major malformations among 72 infants exposed to buspirone in the first trimester 8
• This represents the only prospectively ascertained sample with rigorous outcome verification 8
• While the sample size is small, the complete absence of malformations is reassuring 8

Pantoprazole (Proton Pump Inhibitor)

No specific evidence provided in the sources for pantoprazole. Based on general medical knowledge, PPIs as a class are considered relatively safe in pregnancy, but individual risk-benefit assessment is needed.

Clinical Decision-Making Algorithm

When maternal psychiatric illness requires treatment:

1. Assess severity of untreated illness: Untreated depression/anxiety carries documented risks (gestational diabetes, postpartum depression, decreased lactation) 3

2. For depression/anxiety:

   • Sertraline: Use with awareness of small increased cardiac/craniosynostosis risk (absolute risk remains low) 1
   • Trazodone: Preferred for insomnia/anxiety with reassuring safety profile 4, 5

3. For psychosis/bipolar disorder:

   • Quetiapine: No increased malformation risk; plan for neonatal monitoring if third-trimester exposure 6, 7

4. For anxiety:

   • Buspirone: Limited but reassuring data; reasonable option 8

Critical Pitfalls to Avoid

• Do not discontinue effective psychiatric treatment without weighing maternal risks: Women who discontinued antidepressants had significantly higher relapse rates and pregnancy complications 3
• Third-trimester antipsychotic exposure requires neonatal monitoring: Plan delivery at facility capable of managing neonatal adaptation syndrome 6
• Counsel about specific risks: For sertraline, discuss cardiac defects; for quetiapine, discuss neonatal withdrawal 1, 6