What are the risks of using clonazepam (as needed) during pregnancy?

Risks of Using Clonazepam As Needed During Pregnancy

Clonazepam should be used with caution during pregnancy, with as-needed use preferred over regular dosing to minimize fetal exposure, as limited data suggests it is likely not associated with major congenital malformations but carries risks of neonatal adaptation issues. 1

Safety Profile During Pregnancy

Clonazepam use during pregnancy presents several considerations:

Congenital Malformations

• Limited studies suggest clonazepam is likely not associated with increased risk of major or minor malformations when used for conditions like hypertension or hyperemesis gravidarum 1
• One case report noted a possible association with Roberts syndrome, but this appears to be an isolated finding 1
• A surveillance study of 33 infants exposed to first-trimester clonazepam monotherapy found only one (3.0%) with dysmorphic features and a heart malformation (tetralogy of Fallot) 2

Neonatal Effects

• Risk of poor neonatal adaptation syndrome, which may include:

  • Drowsiness and hypotonia
  • Respiratory distress
  • Jitteriness
  • Sedation
  • Potential seizures 1, 3

• One case report described an infant developing drowsiness, hypotonia, suspected generalized seizures, and episodes of apnea when the mother took clonazepam 0.15 mg daily during pregnancy and postpartum 1

• When combined with SSRIs (particularly paroxetine), the risk of neonatal symptoms increases to approximately 39% compared to 25% with SSRIs alone 3

Long-term Outcomes

• A recent large, well-controlled study demonstrated no increased risks for long-term outcomes including:
  • Neurodevelopmental psychiatric disorders
  • Impairments in vision or hearing
  • Epilepsy or seizures
  • Growth impairment 1

Risk Factors and Considerations

Dosage and Timing

• Lower doses are preferred - typical starting dose is 0.05-0.1 mg at bedtime, with maximum 0.4 mg per day 1, 4
• As-needed use rather than regular dosing may reduce total exposure
• Avoid abrupt discontinuation as it may induce withdrawal symptoms in both mother and fetus 5

Concurrent Medications

• Combined use with other CNS depressants (especially opioids) significantly increases risks 5
• Combination with SSRIs may increase risk of neonatal adaptation issues 3

Third Trimester Considerations

• Use near delivery increases risk of neonatal withdrawal symptoms
• May contribute to "floppy infant syndrome" characterized by hypotonia and respiratory depression 6

Breastfeeding Considerations

• Clonazepam is found in human milk and is detectable in infant serum 1
• The milk-to-plasma ratio has been reported as 2 with a relative infant dose up to 7.1% 1
• Breastfed infants should be monitored for:
  • Drowsiness and hypotonia
  • Poor feeding
  • Weight loss
  • Sedation 1, 6

Recommendations for Clinical Practice

1. Risk-Benefit Assessment: Use clonazepam only when benefits clearly outweigh risks
2. Dosing Strategy:
   • Use lowest effective dose for shortest duration
   • Consider as-needed rather than scheduled dosing
   • Avoid high peak concentrations by dividing daily dosage 6
3. Monitoring:
   • Monitor maternal response and adjust dosage as needed
   • Consider tapering dose before delivery to minimize neonatal adaptation issues
4. Delivery Planning:
   • Alert pediatric team about maternal clonazepam use
   • Monitor neonate closely for withdrawal symptoms for at least 48-72 hours after birth

Common Pitfalls to Avoid

1. Abrupt Discontinuation: Never stop clonazepam suddenly during pregnancy as this may precipitate withdrawal symptoms or seizures 5
2. Polypharmacy: Avoid combining with other sedatives or CNS depressants when possible 5
3. Inadequate Monitoring: Failure to monitor neonates for potential adaptation issues after delivery
4. Ignoring Alternative Treatments: Non-pharmacological approaches for anxiety should be considered first-line when appropriate

While the data on clonazepam use in pregnancy is limited, the current evidence suggests cautious use with as-needed dosing is preferable to regular scheduled dosing to minimize fetal exposure while managing maternal symptoms.