Safe Medications for Sleep Disturbances During Pregnancy
Non-pharmacological approaches should be the first-line treatment for sleep disturbances during pregnancy, as most sleep medications carry potential risks to the developing fetus.
First-Line Approach: Non-Pharmacological Interventions
Sleep Hygiene Education
- Regular morning or afternoon exercise (avoid evening exercise)
- Daytime exposure to bright light
- Keep bedroom dark, quiet, and comfortable
- Avoid heavy meals, alcohol, and nicotine near bedtime
- Maintain a regular sleep-wake schedule
Behavioral Therapies
- Cognitive Behavioral Therapy for Insomnia (CBT-I) has shown effectiveness for sleep disturbances and is the safest first-line approach
- Components include stimulus control, sleep restriction, progressive muscle relaxation, and cognitive restructuring of sleep-related thoughts
Pharmacological Options (When Non-Pharmacological Approaches Fail)
Low-Risk Options
Trazodone (25-100 mg) may be considered for persistent insomnia when benefits outweigh risks 1
- Start at 25 mg and titrate as needed
- Non-habit forming and addresses both sleep initiation and maintenance
Mirtazapine (7.5-30 mg) is an alternative option 1
- Particularly beneficial for pregnant women with comorbid depression and anxiety
- Has the added benefit of potentially helping with pregnancy-related nausea
Medications to Avoid or Use with Extreme Caution
- Diphenhydramine (Benadryl) - FDA label specifically states to ask a healthcare professional before use during pregnancy 2
- Doxylamine - FDA label requires consultation with a healthcare professional before use during pregnancy 3
- Benzodiazepines - Associated with risk of dependence and should be avoided, especially in long-term use 4
- Zolpidem and other "Z-drugs" - Limited safety data in pregnancy; use only when benefits clearly outweigh risks
Special Considerations
Underlying Conditions
- Rule out other sleep disorders that may present or worsen during pregnancy:
- Obstructive sleep apnea (OSA) - Consider polysomnography if indicated
- Restless legs syndrome (RLS) - Check ferritin levels; levels below 45-50 ng/mL may indicate treatable cause
Trimester-Specific Approach
- Sleep disturbances are most prevalent during the third trimester 5
- Interventions should be adjusted based on stage of pregnancy and severity of symptoms
Monitoring
- Reassess sleep symptoms after 2 weeks of any intervention
- Monitor for daytime sedation, especially with medications like trazodone
- If insomnia persists despite interventions, referral to a sleep specialist is warranted
Important Cautions
- The American Academy of Sleep Medicine notes that there is insufficient data to make specific recommendations for pregnant and lactating women 4
- Any medication use during pregnancy requires careful risk-benefit assessment
- Untreated severe insomnia itself may pose risks to maternal and fetal health
Remember that sleep disturbances during pregnancy are common and often temporary. When possible, time-limited interventions with the lowest risk profile should be prioritized until delivery.