What are the recommendations for a patient with Attention Deficit Hyperactivity Disorder (ADHD) on stimulants who plans to become pregnant in the next 4 to 6 months?

Managing ADHD Medications During Pregnancy Planning

For patients on stimulant medication for ADHD who are planning pregnancy within 4-6 months, consider a trial of gradually discontinuing the medication before conception if it will not severely impact daily functioning. 1

Preconception Planning for ADHD Medication

Risk-Benefit Assessment

• The safety data for ADHD medications in pregnancy is largely reassuring, but requires careful consideration 1
• Methylphenidate has not been associated with major birth defects according to FDA data 2
• The risks of untreated ADHD during pregnancy must be weighed against potential medication risks

Recommended Approach

1. Medication Management Options:

   • If ADHD is mild to moderate: Consider non-pharmacologic treatments including:

     • Cognitive Behavioral Therapy (CBT)
     • Self-management strategies
     • Mindfulness-Based Interventions (MBIs)
     • Dialectical Behavior Therapy (DBT) 1

   • If ADHD is moderate to severe with significant functional impairment:

     • Option 1: Trial discontinuation before conception if feasible
     • Option 2: Continue at lowest effective dose
     • Option 3: Consider intermittent use during pregnancy
     • Option 4: Switch to a non-stimulant option 1

2. If continuing medication is necessary:

   • Reduce to lowest effective dose
   • Consider intermittent use (as-needed basis)
   • Monitor closely during pregnancy 1

Potential Risks and Benefits

Medication Risks

• Small increased risk of pregnancy complications with stimulants:

  • Preeclampsia (adjusted risk ratio 1.29) 3
  • Preterm birth (adjusted risk ratio 1.06) 3
  • Special care unit admittance for newborns 4

• However, recent evidence shows:

  • No increased risk of major birth defects with methylphenidate 2
  • No increased risk of long-term neurodevelopmental disorders in children 5, 6

Risks of Untreated ADHD

• Impaired daily functioning
• Potential for poor self-care during pregnancy
• Increased risk of impulsive behaviors
• Possible exacerbation of ADHD symptoms during pregnancy 1

Monitoring During Pregnancy

If medication is continued during pregnancy:

• Monitor pregnancy carefully
• Regular blood pressure checks
• Ensure appropriate weight gain
• Monitor fetal growth 1

Important Considerations

• Register with the National Pregnancy Registry for Psychostimulants (1-866-961-2388) 2
• Consider referral to a reproductive psychiatrist for specialized management 1
• Develop an individualized treatment plan for the perinatal period 1

Breastfeeding Considerations

• Limited data on ADHD medications during breastfeeding
• For methylphenidate: May maintain therapeutic dose during breastfeeding
• For amphetamine derivatives: Discuss safety and consider timing feedings to minimize exposure 1
• Monitor infant for appropriate weight gain and development 1

The decision to continue or discontinue ADHD medication before and during pregnancy should be made collaboratively, weighing the individual's need for treatment against the small but potential risks to pregnancy outcomes. The absolute increases in risks are small, and women with significant ADHD should not automatically suspend their treatment based on these findings 3.