Is it safe to take lorazepam (Ativan) during pregnancy?

From the Guidelines

Lorazepam should be avoided during pregnancy, especially in the first trimester, due to the potential risks of congenital malformations and other adverse effects on the fetus. The medication is classified as FDA Pregnancy Category D, indicating evidence of fetal risk 1. Although the provided study does not directly focus on lorazepam, it mentions that guidelines generally recommend avoiding benzodiazepines during pregnancy, particularly in the first trimester 1.

Key Considerations

• The study suggests that benzodiazepines, including lorazepam, may be associated with an increased risk of oral cleft and other congenital malformations 1.
• If medication is necessary, midazolam is preferred over other benzodiazepines, but this does not imply that lorazepam is safe 1.
• The need for periprocedural fetal monitoring should be discussed with an obstetrician due to the risk of fetal sedation or respiratory depression 1.

Clinical Implications

• Pregnant women taking lorazepam should not stop abruptly, as this can cause withdrawal symptoms; instead, they should consult their healthcare provider to discuss safer alternatives 1.
• Non-medication approaches, such as cognitive behavioral therapy, may be recommended as safer alternatives for managing anxiety or other conditions during pregnancy.
• The risks of untreated severe anxiety or seizures must be balanced against the medication risks in each individual case, and healthcare providers should weigh these risks carefully when making treatment decisions 1.

From the FDA Drug Label

The clinical significance of the above findings is not known However, an increased risk of congenital malformations associated with the use of minor tranquilizers (chlordiazepoxide, diazepam, and meprobamate) during the first trimester of pregnancy has been suggested in several studies. Because the use of these drugs is rarely a matter of urgency, the use of lorazepam during this period should be avoided The possibility that a woman of childbearing potential may be pregnant at the time of institution of therapy should be considered. Patients should be advised that if they become pregnant, they should communicate with their physician about the desirability of discontinuing the drug In humans, blood levels obtained from umbilical cord blood indicate placental transfer of lorazepam and lorazepam glucuronide. Infants of mothers who ingested benzodiazepines for several weeks or more preceding delivery have been reported to have withdrawal symptoms during the postnatal period

Key Points:

• Pregnancy Risk: There is a suggested increased risk of congenital malformations associated with the use of minor tranquilizers, including lorazepam, during the first trimester of pregnancy.
• Use During Pregnancy: The use of lorazepam during pregnancy should be avoided, especially during the first trimester, unless absolutely necessary.
• Placental Transfer: Lorazepam and its glucuronide are transferred across the placenta, and infants of mothers who ingested benzodiazepines may experience withdrawal symptoms.
• Recommendation: Patients who become pregnant should communicate with their physician about the desirability of discontinuing the drug 2, 2.

From the Research

Safety of Lorazepam During Pregnancy

• The safety of lorazepam during pregnancy is a concern due to its potential effects on the fetus and neonate 3, 4, 5, 6.
• Studies suggest that benzodiazepines, including lorazepam, can cross the placenta and may cause fetal uptake of the drug, leading to potential risks such as the "floppy infant syndrome" 3, 6.
• The use of lorazepam during the first trimester of pregnancy is not recommended due to the potential risk of birth defects, although the evidence is inconsistent 4, 6.
• Late third trimester use and exposure during labor may be associated with greater risks to the fetus/neonate, including neonatal withdrawal symptoms and altered transmitter synthesis and function 6.

Risks and Precautions

• The therapeutic value of lorazepam must be weighed against theoretical adverse effects on the fetus before and after birth 4.
• To minimize risks, physicians should use benzodiazepines with established safety records at the lowest dosage for the shortest possible duration, avoiding use during the first trimester and multidrug regimens 4.
• Women taking lorazepam during pregnancy should be aware of the potential risks and discuss alternative treatments, such as antidepressants or psychotherapy, with their healthcare provider 5, 7.
• Abrupt discontinuation of lorazepam during pregnancy should be avoided due to the risk of discontinuation syndrome, and gradual tapering off is recommended instead 7.

Breastfeeding Considerations

• Lorazepam is excreted into breast milk, although the levels detected are low, and the suckling infant is unlikely to ingest significant amounts of the drug 6.
• However, problems may arise if the infant is premature or has been exposed to high concentrations of the drug during pregnancy or at delivery 6.