Why is it necessary to discontinue taking Lorazepam (Ativan) during pregnancy?

From the Guidelines

Lorazepam should be discontinued during pregnancy whenever possible due to significant risks to the developing fetus. This benzodiazepine medication crosses the placental barrier and can cause harm, particularly when used in the first and third trimesters. Potential risks include increased chances of birth defects (particularly cleft lip and palate), neonatal withdrawal syndrome, respiratory depression in the newborn, and developmental delays. If a pregnant woman is currently taking lorazepam, she should not stop abruptly but should consult her healthcare provider immediately to develop a safe tapering schedule, as sudden discontinuation can cause dangerous withdrawal symptoms. Alternative treatments for anxiety or insomnia during pregnancy might include cognitive behavioral therapy, mindfulness techniques, or medications with better safety profiles as determined by a healthcare provider. The decision to discontinue lorazepam balances the mother's mental health needs against the potential risks to the developing baby, with the goal of minimizing harm to both.

Key Considerations

• The provided evidence does not directly address the use of lorazepam during pregnancy, but general knowledge in the field suggests that benzodiazepines can pose significant risks to the fetus 1.
• The potential for harm, including birth defects and neonatal withdrawal syndrome, necessitates careful consideration and monitoring by a healthcare provider.
• Alternative treatments for anxiety and insomnia during pregnancy should be explored to minimize risks associated with lorazepam use.

Recommendations for Clinical Practice

• Pregnant women taking lorazepam should be closely monitored by their healthcare provider.
• A safe tapering schedule should be developed to minimize the risk of withdrawal symptoms.
• Alternative treatments, such as cognitive behavioral therapy or medications with better safety profiles, should be considered.
• The decision to discontinue lorazepam should prioritize the health and well-being of both the mother and the developing fetus.

From the FDA Drug Label

Although all of these anomalies were not present in the concurrent control group, they have been reported to occur randomly in historical controls At doses of 40 mg/kg and higher, there was evidence of fetal resorption and increased fetal loss in rabbits which was not seen at lower doses. 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 Infants of mothers who ingested benzodiazepines for several weeks or more preceding delivery have been reported to have withdrawal symptoms during the postnatal period Symptoms such as hypoactivity, hypotonia, hypothermia, respiratory depression, apnea, feeding problems, and impaired metabolic response to cold stress have been reported in neonates born of mothers who have received benzodiazepines during the late phase of pregnancy or at delivery

It is necessary to discontinue taking Lorazepam (Ativan) during pregnancy because:

• Congenital malformations: There is a suggested increased risk of congenital malformations associated with the use of minor tranquilizers, including lorazepam, during the first trimester of pregnancy.
• Fetal resorption and loss: High doses of lorazepam have been shown to cause fetal resorption and increased fetal loss in rabbits.
• Withdrawal symptoms: Infants born to mothers who took benzodiazepines, including lorazepam, during pregnancy may experience withdrawal symptoms.
• Neonatal risks: Neonates may experience symptoms such as respiratory depression, apnea, and feeding problems if exposed to benzodiazepines during the late phase of pregnancy or at delivery. It is recommended to avoid the use of lorazepam during pregnancy, especially during the first trimester, and to discontinue the drug if pregnancy occurs 2.

From the Research

Risks Associated with Lorazepam Use During Pregnancy

• The use of lorazepam during pregnancy may pose risks to the fetus, including the potential for congenital defects, neonatal withdrawal symptoms, and developmental delays 3, 4.
• Studies have shown that benzodiazepines, including lorazepam, can cross the placenta and affect fetal development, with potential risks increasing in the third trimester 5.
• Neonatal withdrawal symptoms, such as floppy infant syndrome, have been reported in infants exposed to lorazepam during pregnancy, particularly when used in high doses or in combination with other medications 6, 4.

Pharmacokinetic Considerations

• Lorazepam is lipophilic and can readily penetrate membranes, allowing for rapid placental transfer and significant fetal uptake of the drug 5.
• The pharmacokinetics of lorazepam during pregnancy are not well understood, but it is known to be excreted into breast milk, potentially posing risks to nursing infants 4, 5.

Management of Benzodiazepine Withdrawal During Pregnancy

• Managing benzodiazepine withdrawal during pregnancy requires careful consideration of the potential risks and benefits, with guidelines suggesting a gradual tapering of the medication to minimize withdrawal symptoms 7.
• The use of lorazepam during pregnancy should be carefully monitored, with consideration given to alternative treatments and the potential need for detoxification 7.