Is lorazepam (Ativan) safe to use in a woman in her third trimester of pregnancy?

Use of Lorazepam in Third Trimester of Pregnancy

Lorazepam should be avoided during the third trimester of pregnancy unless the potential benefit to the mother clearly outweighs the risks to the fetus. The FDA drug label specifically warns about potential adverse effects on the fetus and newborn.

Risks of Lorazepam in Late Pregnancy

Lorazepam use in the third trimester poses several significant risks:

• Neonatal withdrawal syndrome: Infants whose mothers used benzodiazepines for several weeks or more before delivery may experience withdrawal symptoms during the postnatal period 1
• Neonatal complications: Symptoms reported in newborns include:
  • Hypoactivity
  • Hypotonia
  • Hypothermia
  • Respiratory depression
  • Apnea
  • Feeding problems
  • Impaired metabolic response to cold stress 1
• Placental transfer: Blood levels from umbilical cord blood confirm placental transfer of both lorazepam and lorazepam glucuronide 1

Evidence from Guidelines

While limited specific guidance exists for lorazepam in pregnancy, some guidelines mention its use in specific contexts:

• The National Comprehensive Cancer Network (2010) mentions lorazepam as part of antiemetic regimens for chemotherapy during pregnancy 2, but this is in a very specific context for cancer treatment
• The Toronto Consensus Statements (2016) note that benzodiazepines generally should be avoided, particularly in the first trimester, due to a possible 2-fold increased risk of oral cleft 2

Alternative Approaches

If anxiolytic treatment is absolutely necessary during the third trimester:

1. Consider non-pharmacological interventions first
2. If medication is required:
   • Use the lowest effective dose for the shortest possible duration
   • Divide the daily dosage to avoid high peak concentrations 3
   • Monitor the pregnancy closely with appropriate fetal surveillance
   • Plan for potential neonatal complications after delivery

Special Considerations

• Breastfeeding: Lorazepam has been detected in human breast milk and should not be administered to breastfeeding women unless the benefit outweighs the risk 1
• Neonatal monitoring: If lorazepam is used in the third trimester, the newborn should be monitored for sedation, respiratory depression, and withdrawal symptoms 1
• Tapering: If a pregnant woman is already taking lorazepam, abrupt discontinuation should be avoided to prevent withdrawal symptoms 4

Conclusion

The risks of lorazepam use in the third trimester are significant and well-documented. Unless there is a compelling medical necessity where the benefits clearly outweigh these risks, lorazepam should be avoided during this critical period of fetal development.